Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chapel Lane Surgery on 17 November 2016. The overall rating for the practice was requires improvement with requires improvement for safe, effective and responsive services, inadequate for well led and good for providing a caring service. The full comprehensive report on the 17 November 2016 inspection can be found by selecting the ‘all reports’ link for Chapel Lane Surgery on our website at www.cqc.org.uk.

This inspection was an announced follow up inspection carried out on 30 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 17 November 2016. This report includes our findings in relation to those requirements.

Overall the practice is now rated as good for providing services.

The practice had made significant improvements and addressed the issues identified in the previous inspection. The practice engaged all staff in driving forward improvements and utilised new technology. Improvements included:

• A review of the governance systems in place to ensure the quality and safety of the service. All policies and protocols had been revised. The practice now utilised a computer software programme to help monitor systems.
• All staff had received mandatory training relevant to their role and had received an appraisal. There was now a system in place to monitor the training and appraisals staff received.
• Recruitment checks were in place for all staff. Staff were asked to update their DBS checks at annual appraisals.
• There were increased monitoring systems now in place for cleaning and the safety of the premises. This included having a fixed electrical wiring safety certificate for the premises.
• Improvements in the content of patient specific directions for nursing staff to administer medicines safely.
• A system to review any abnormal screening checks for patients.
• Responding to patient feedback about making appointments and waiting to be seen beyond their allocated time by engaging with the PPG and Healthwatch and working towards the national New Ways of Working programme. The practice had implemented a system of triaging patient calls and trained staff to become care navigators to signpost patients to the most appropriate service instead of automatically being booked in with a GP. To support this, the practice had recruited a variety of new staff such as a phlebotomist and an advanced nurse practitioner.
• Clinical meetings were now documented.
• The practice had correctly registered with us to carry out the regulated activity of family planning.

In addition:-

• The practice had a new carers’ policy and actively sought ways to identify carers by utilising a carer’s questionnaire available in the waiting room and offer tailored support.
• The practice had reviewed its safeguarding registers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chapel Lane Surgery on 17 November 2016. The overall rating for the practice was requires improvement with requires improvement for safe, effective and responsive services, inadequate for well led and good for providing a caring service. The full comprehensive report on the 17 November 2016 inspection can be found by selecting the ‘all reports’ link for Chapel Lane Surgery on our website at www.cqc.org.uk.

This inspection was an announced follow up inspection carried out on 30 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 17 November 2016. This report includes our findings in relation to those requirements.

Overall the practice is now rated as good for providing services.

The practice had made significant improvements and addressed the issues identified in the previous inspection. The practice engaged all staff in driving forward improvements and utilised new technology. Improvements included:

• A review of the governance systems in place to ensure the quality and safety of the service. All policies and protocols had been revised. The practice now utilised a computer software programme to help monitor systems.
• All staff had received mandatory training relevant to their role and had received an appraisal. There was now a system in place to monitor the training and appraisals staff received.
• Recruitment checks were in place for all staff. Staff were asked to update their DBS checks at annual appraisals.
• There were increased monitoring systems now in place for cleaning and the safety of the premises. This included having a fixed electrical wiring safety certificate for the premises.
• Improvements in the content of patient specific directions for nursing staff to administer medicines safely.
• A system to review any abnormal screening checks for patients.
• Responding to patient feedback about making appointments and waiting to be seen beyond their allocated time by engaging with the PPG and Healthwatch and working towards the national New Ways of Working programme. The practice had implemented a system of triaging patient calls and trained staff to become care navigators to signpost patients to the most appropriate service instead of automatically being booked in with a GP. To support this, the practice had recruited a variety of new staff such as a phlebotomist and an advanced nurse practitioner.
• Clinical meetings were now documented.
• The practice had correctly registered with us to carry out the regulated activity of family planning.

In addition:-

• The practice had a new carers’ policy and actively sought ways to identify carers by utilising a carer’s questionnaire available in the waiting room and offer tailored support.
• The practice had reviewed its safeguarding registers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with three patients on the day of our visit, including a member of the practice patient participation group (PPG). They told us they were very happy with the care they received. One patient told us; “You can usually get an appointment when you need one. I like the consistency of seeing the same doctor, unless they’re on holiday.” Another patient said “Monday mornings are difficult to get through on the phone. You can usually get an appointment when you want one on other days.” One patient told us the staff were, in the main, very helpful.

The practice had electronic records in place to accurately describe the contact patients had with the service and the actions taken to provide appropriate care and treatment. Patients' records included GP and nurse consultations, test results, current and past medication and referral letters as well as contact with other professionals, such as hospital consultants and community nurses.

We were shown around the practice and saw it provided spacious waiting, reception and consultation/treatment rooms. All rooms were accessible on the ground floor. Car parking was at the rear of the building. We found the building clean and tidy, and well maintained.

The practice had a range of policies and procedures for staff to access, which supported the safe running of the service. The practice completed audits/reports following significant events, in order to learn and make changes as required.