This practice is rated as Good overall. (Previous rating July 2016 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Church Street Practice on 3 July 2018 as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

The building that the practice was located in was destroyed in a large fire in July 2017. Through strong team work and by working with external stakeholders the practice provided a basic service to their patients for the first 48 hours following the fire. A full service was provided by the practice based in a local community hospital for six months before moving back to the original location in temporary modular buildings. The practice worked to ensure that a service was provided to patients throughout this period minimising impact to patients and staff. Feedback we received from patients praised the practice for the service provided following the fire.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

• Review and improve the monitoring of patients prescribed high risk medicines.
• Review and improve engagement with patients, including monitoring and acting on patient feedback.
• Improve the awareness of red flag symptoms and signs of sepsis for non-clinical staff.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

Following an announced comprehensive inspection of The Church Street Practice in December 2015 the practice was given an overall rating of good.

At our inspection we identified concerns relating to equipment safety checks.

After the comprehensive inspection, the practice wrote and provided an action plan to tell us what they would do in respect of our inspection report findings and to meet legal requirements.

Our previous inspection in December 2015 found the following area where the practice must improve:

• Ensure that safety testing of electrical equipment was up to date.

We also identified some areas in which the practice should improve:

• Continue to ensure the regular review and monitoring of patients experiencing poor mental health.
• Review the waiting area to ensure that there is a sufficient seating for patients to wait.
• Ensure that patient confidentiality is maintained.

We undertook this focused inspection on 24 June 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. The provider was now meeting all requirements and was rated as Good under the Safe domain. Overall the practice is rated as Good.

Our key findings across the areas we inspected for this focused inspection were as follows:

• Risks to patients were assessed and well managed including equipment safety checks.
• The practice ensured that patient confidentiality was maintained. At this inspection we saw that the practice has reviewed how patient confidentiality was maintained, shared this learning with all staff and provided refresher training.The practice had reviewed the waiting area in conjunction with other services who shared the area and had put measures in place to ensure there was sufficient seating for all patients.
• The practice was reviewing and monitoring patients experiencing poor mental health. At this inspection we saw evidence that patients experiencing poor mental health were having regular reviews and monitoring and we saw unverified data which indicated the practice performance in this area was in line with other practices locally and nationally.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

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 Church Street Practice on 8 December 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a GP with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must

• Ensure that safety testing of electrical equipment is up to date.

Importantly the provider should

• Continue to ensure regular review and monitoring of patients experiencing poor mental health.
• Review the waiting area to ensure that there is sufficient seating for patients to wait.
• Ensure that patient confidentiality is maintained.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice