Church View Medical Centre

We carried out an announced comprehensive inspection at Church View Medical Centre on 19 & 23 October 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection on 2 July 2015, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Church View Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection in line with our inspection priorities and this inspection was comprehensive covering all key questions.

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 (this was with consent from 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 short 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 found that:

• The practice demonstrated that safety systems in place were working effectively, including those in relation to the environment, recruitment, and medicines management. Although we found limited examples of patients that had not been monitored fully in line with national guidance, the risk of these were low and the practice addressed these immediately.
• Cervical screening and childhood immunisation data was lower than average or target in some areas, but the practice was able to demonstrate the actions they had taken to address this and provided unverified data that indicated that some improvements were occurring.
• GP Patient survey data in relation to both the caring and responsive key questions was in line with local and national averages, but the practice continued to survey patients and consider ongoing feedback to ensure that they could identify and address patient concerns. This also included complaints that were managed well and were used for learning.
• Governance systems and leadership were in place and working effectively to ensure a good standard of care and treatment delivery, along with effective management of the workforce.

Whilst we found no breaches of regulations, the provider should:

• Take action to continue to improve cervical screening and childhood immunisation uptake.
• Implement actions gained from assessing patient feedback to ensure that satisfaction remains high and continues to improve.
• Incorporate CQC clinical searches to audit systems to ensure all areas of medicine management are reviewed for outliers and address these on an ongoing basis.
• Improve systems in place to ensure formal review of DNACPRs, ensuring a consistent approach.
• Embed and strengthen clinical audit systems to ensure quality improvement.

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 Health Care