Chapel St Surgery

We carried out an announced comprehensive inspection at Chapel St Surgery between 28 September 2022 and 10 October 2022. Overall, the practice is rated as requires improvement.

Safe - Requires improvement

Effective - Requires improvement

Caring - Good

Responsive - Requires improvement

Well-led – Requires improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Chapel St Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

Chapel St Surgery was registered as a new location of a new provider on 19 August 2020. This is the first rated inspection of the practice.

Our inspection included all key questions; safe, effective, caring, responsive, and well-led.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall

We found that:

• The practice had some systems to review patients prescribed high risk medicines and who were diagnosed with long term conditions. These systems were not always safe and effective.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

We rated the practice as requires improvement for providing safe services because:

• Whilst most medicines were managed safely, some concerns were identified around the monitoring and prescribing of patients’ medicines, including those that were high risk.
• Staff vaccination was not maintained in line with current national guidance relevant to their role.
• Action plans for health and safety, fire and legionella risks assessments were not in place in the practice.
• Significant events were not always recorded and learning from events could not be demonstrated.

We rated the practice as requires improvement for providing effective services because:

• Improvements were needed to the management of long-term conditions.
• Staff did not always receive appropriate inductions and a programme of clinical supervision was not in place.

We rated the practice as requires improvement for providing responsive services because:

• Complaints were not always managed in a timely and appropriate way.

We rated the practice as requires improvement for providing well-led services because:

• Leaders had demonstrated that they had a credible strategy to develop sustainable care. However, at this inspection we identified concerns around clinical governance.
• Health and safety risk assessments were not always accurate and managed in a way that provided appropriate reassurances that actions had been taken.

We found breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Review and respond to patient feedback and experiences relating to access to services.
• Continue to embed the reintroduction of the patient participation group (PPG).
• Continue to monitor the uptake of childhood immunisations and cervical screening.
• Review and maintain staffing levels.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services