We carried out a review of the data available to us about Chatham Street Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Chatham Street Surgery, you can give feedback on this service.
We carried out an announced inspection at Chatham Street Surgery in Reading, Berkshire on 4 August 2021.
Following our previous inspection in December 2019, the practice was rated Requires Improvement overall with three key questions (the provision of safe, effective and well-led services) rated as Requires Improvement. The remaining key questions (the provision of caring and responsive services) were rated as Good.
At this inspection (August 2021), we found improvements had been made and the provider is now compliant with the regulations. We have re-rated this practice as Good overall and Good for all population groups, specifically we have rated the practice as:
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Chatham Street Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
Given continued concerns from a previous inspection in February 2019 and new concerns reported at the December 2019 inspection, we issued a requirement notice for Regulation 12 ‘Safe care and treatment’ and a warning notice for Regulation 17 ‘Good governance’.
A further announced focused inspection was undertaken in October 2020. That inspection reviewed the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements. We were not able to re-rate the practice as a result of this type of remote focused inspection. We used that approach because we wanted to find evidence that confirmed improvements had been made whilst being aware of COVID-19 restrictions in primary care. We saw a variety of evidence which demonstrated improvements had been made, sustained and the practice had complied with the warning notice issued, and the conditions previously imposed on the provider registration.
We carried out an announced inspection on 4 August 2021 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 inspections in February 2019 and December 2019.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
Our findings
We based our judgement of the quality of care at this service on a combination of:
We found that:
Whilst we found no breaches of regulations, the provider should:
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic. This was conducted with the consent of the provider. Unless the report says otherwise, we obtained the information in it without visiting the provider.
We inspected Chatham Street Surgery on 23 July 2019. Following this focussed inspection, we did not rate the practice. However, conditions were applied to the provider’s registration and, a Warning Notice was issued due to the levels of risk identified.
We carried out a comprehensive inspection at Chatham Street Surgery on 11 December 2019 to check the progress made against the enforcement action. This report was published on 2 April 2020. The full comprehensive report following the inspection on December 2019 can be found by selecting the ‘all reports’ link for Chatham Street Surgery on our website at www.cqc.org.uk. The outcome of the inspection was that the practice was rated Requires Improvement.
A further announced GP focused inspection was undertaken on 27th, 28th and 29th October 2020. We focussed our inspection to review the actions taken by the practice to improve the quality of care and to confirm that the practice was now meeting legal requirements. As a result of the remote focused inspection, the ratings awarded to the practice were not updated.
We used this approach because we wanted to find evidence that could confirm what the provider had told us, earlier in 2020. The provider sent us reports at that time to show us that they had complied with the warning notice issued, and the conditions previously imposed on the provider registration.
During this remote inspection we found that:
We found no further breaches of regulations. Based on the improvements identified above, the provider had achieved compliance with the Regulation 17 Warning Notice and we are also able to lift the conditions previously imposed on the provider’s registration.
However, there were areas of practice where the provider needs to continue to make improvements. The provider should:
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Chatham Street Surgery on 27 February 2019 as part of our inspection programme. Following this inspection, the practice was rated as follows:
Are services safe? – Good
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Requires Improvement
Consequently, the practice was rated as requires improvement overall.
At the February 2019 inspection we rated the practice as requires improvement for providing effective services because:
We rated the practice as requires improvement for providing well-led services because:
We then undertook a focused inspection in response to concerns reported to the commission in July 2019. We did not rate the practice at this inspection, as not all key lines of enquiry were covered.
At the inspection on 23 July 2019 we found:
This inspection was a comprehensive inspection to check whether the provider had made the necessary improvements.
At this inspection we found:
The area where the provider must make improvements are:
A further comprehensive inspection will be undertaken to check the progress made against our enforcement action.
(Please see the specific details on action required at the end of this report).
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BS BM BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
We carried out an announced comprehensive inspection at Chatham Street Surgery on 27 February 2019 as part of our inspection programme. Following this inspection, the practice was rated as follows:
Are services safe? – Good
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Requires Improvement
Consequently, the practice was rated as requires improvement overall.
This inspection was a focused inspection which we undertook in response to concerns reported to the commission. We have not rated the practice at this inspection, as not all key lines of enquiry were covered.
At the February 2019 inspection we rated the practice as requires improvement for providing effective services because:
We rated the practice as requires improvement for providing well-led services because:
At the inspection on the 23 July 2019 we found:
The area where the provider must make improvements are:
A further comprehensive inspection will be undertaken to check the progress made against our enforcement action.
(Please see the specific details on action required at the end of this report).
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BS BM BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
We carried out an announced comprehensive inspection at Chatham Street Surgery on 27 February 2019 as part of our inspection programme.
At the last inspection in February 2017 we rated the practice as Good overall.
At this inspection we found the practice had not sustained the improvements we found at our last inspection. It is now rated as requires improvement in provision of both effective and well led services. Consequently, the practice is now rated as requires improvement overall.
We rated the practice as requires improvement for providing effective services because:
We rated the practice as requires improvement for providing well-led services because:
We rated the practice as good for providing safe, caring and responsive services because:
The area where the provider must make improvements are:
(Please see the specific details on action required at the end of this report).
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BS BM BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
We carried out an announced comprehensive inspection at Chatham Street Surgery on 13 July 2017. The overall rating for the practice was good with provision of a caring service rated as requires improvement. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Chatham Street Surgery on our website at www.cqc.org.uk.
This inspection was a desk-based review carried out on 19 February 2018 to confirm that the practice had carried out their plan to improve provision of caring services to their patients.
When we carried out the inspection on 13 July 2017 we identified that the practice had not breached regulations but should improve the delivery of compassionate and caring services.
This report covers our findings in relation to the provision of caring services and also additional improvements made since our last inspection.
Overall the practice remains rated good overall and delivery of caring services is now rated good.
Our key findings were as follows:
At our previous inspection on 13 July 2017, we rated the practice as requires improvement for providing caring services as patient feedback indicated the practice staff were not providing care and treatment in a caring way. The information provided by the practice showed an improvement in patient feedback which has resulted in a rating of good for provision of caring services.
Chief Inspector of General Practice
We carried out a comprehensive inspection of Chatham Street Practice in August 2015 when the practice was rated as inadequate for providing safe and well led services and requires improvement for effective, caring and responsive services. Overall the practice was rated as inadequate and placed into special measures. The service was re-inspected on 5 April 2016 where we found the ratings had not changed and the practice remained in special measures. We carried out a further comprehensive inspection of the practice on 30 September 2016. The overall rating for the practice was requires improvement (safe, effective, caring and responsive) with provision of well-led services rated as inadequate. The practice remained in special measures and was issued with a warning notice for breach of good governance regulations. We returned to conduct a focused inspection on 9 February 2017. At that time the practice had made sufficient improvement to comply with regulations and fulfil the requirements of the warning notice. Both the comprehensive and focused reports of these inspections can be found by selecting the ‘all reports’ link for Chatham Street Surgery on our website at www.cqc.org.uk.
This inspection was an announced comprehensive inspection carried out on 13 July 2017 to confirm that the practice had sustained the improvements and requirements in relation to the breaches of regulation that we identified in our previous inspection on 30 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
The practice is now rated as good for the provision of safe, effective, responsive and well led services and requires improvement for providing caring services. The six population groups have also been re-rated as good following this inspection. Overall the practice is now rated as good.
Our key findings across all the areas we inspected were as follows:
The areas where the provider should make improvement are:
Ensure fire marshals are appropriately trained to carry out their role.
Review the practice business continuity plan at appropriate intervals.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Chatham Street Surgery on 30 September 2016. The overall rating for the practice at that time was requires improvement. Specifically the practice was rated requires improvement for provision of safe, effective and caring services, good for provision of responsive services and inadequate for the provision of well led services. The practice had previously been rated as inadequate overall in April 2016 and remains in special measures. The full comprehensive report of the September 2016 inspection can be found by selecting the ‘all reports’ link for Chatham Street Surgery our website at www.cqc.org.uk .
This inspection was an announced focused inspection carried out on 9 February 2017 to follow up on a warning notice the Care Quality Commission served following the comprehensive inspection on 30 September 2016. The warning notice was served relating to regulation 17, Good Governance. The timescale given to meet the requirements of the warning notices was 12 January 2017. The practice had submitted an action plan detailing the actions they were taking to meet legal requirements. This report covers our findings in relation to those requirements. Due to the focussed nature of this inspection the ratings for the practice have not been updated. We will conduct a further comprehensive inspection within six months of publication of the report of the inspection undertaken in September 2016.
Our key findings were as follows:
The process to monitor cleaning standards was operated effectively.
The practice had implemented a secure system for holding blank prescriptions
Equipment and medicines were in date and fit for use.
The audit process and programme had been reviewed and an audit plan was in place.
The practice had implemented an effective system to identify and register patients with caring responsibilities.
A targeted approach was in place to encourage take up of cancer screening programmes.
The practice clinical governance structure had been reviewed and an additional partner had been appointed.
Environmental safety checks were carried out to reduce risk.
At our previous inspection on 30 September 2016, we rated the practice as requires improvement overall and the practice remained in special measures. At this inspection we found that the practice had taken action to address the breach of regulation set out in the warning notice issued in November 2016. However, the practice will remain in special measures until they receive a further inspection to assess the full extent of the improvements achieved since September 2016. If there is not enough improvement we will move to close the service.
Keeping the practice in special measures will give people who use the service the reassurance that the care they get should improve. The service will be kept under review and if needed could be escalated to urgent enforcement action.
Chief Inspector of General Practice
Chatham Street Surgery was first inspected on 5 August 2015. At that inspection the practice was found to have breached regulations and was rated inadequate. The practice was placed into special measures and issued with a warning notice in respect of Regulation 17 Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Good governance.
A second announced inspection was undertaken on 5 April 2016 to follow up the actions the practice stated it had taken to improve services for patients. Whilst improvements had been made the practice remained rated as inadequate. CQC instituted further enforcement action in accordance with our enforcement procedures. Because six months had elapsed we returned to assess the improvements the practice told us they would make.
Consequently we carried out a further unannounced comprehensive inspection at Chatham Street Surgery on 30 September 2016. Overall the practice is now rated as requires improvement. Specifically it is rated requires improvement for provision of safe, effective and caring services, good for provision of responsive services and inadequate for being well led. (CQC methodology includes for consideration of further enforcement action when a practice in special measures has any one rating of inadequate arising from an inspection).
During the inspection we found improvements made included:
Staff were clear about reporting incidents, near misses and concerns and there was evidence of learning and communication with staff.
Care plans were in place, or identified for updating, for those patients that needed additional help and support with their care and treatment.
A health and safety policy was in place and a range of risk assessments had been completed.
Appointment systems had been reviewed and updated. This had resulted in an improvement in patient feedback in regard of obtaining appointments at suitable times.
Patient feedback, from local surveys, had improved in relation to being treated with compassion, dignity and respect. Patients were also positive about seeing or speaking with their preferred GP.
Patient outcomes had improved and the practice had identified groups of patients who would benefit from additional support and review to better manage their medical conditions.
We also found that:
Monitoring had not identified risks found in two waiting rooms where trailing wires were present and a failure to secure blank prescriptions in one consulting room.
There was potential risk to patients because clinical governance systems were weak and relied heavily upon one GP. On call duties were not equitably shared between GPs and
There was a risk of patients not receiving appropriate advice, treatment and care because information provided from other health and social care providers was not entered in patient records in a timely manner.
The practice remained dependent on locum GPs which meant that the GP partners were responsible for the majority of management of clinical governance systems and processes.
Whilst the practice had identified the need to improve standards of cleanliness these had not been achieved. Inspectors found two areas of the practice where appropriate cleaning standards had not been met.
Staff understanding of the processes and procedures required by law to assess the capacity of patients to understand and consent to care and treatment was inconsistent.
Audits were undertaken but only one of these had resulted in follow up to check whether action had been taken to improve patient outcomes.
The areas where the provider must make improvements are:
Ensuring the systems in place to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users and others who may be at risk which arise from the carrying on of the regulated activities are operated effectively. Putting in place governance arrangements that enable systems to be managed and reviewed to ensure the needs of the registered patients are met.
Ensure the systems for assessing the risk of, and preventing, detecting and controlling the spread of, infections, including those that are health care associated are operated consistently.
Ensure that care provided is person centred taking account of the patients’ ethnicity, vulnerability and preferences.
Ensuring that patients are given opportunities to make informed choices regarding their care including the benefits of taking up health promotion and prevention of ill health opportunities.
The area where the provider should make improvement is:
To implement an effective system to promote the benefits of registering as a carer with a view to increasing the number of carers registered.
This service was placed in special measures in August 2015. Insufficient improvements have been made such that there remains a rating of inadequate for provision of well led services. However, improvements have been made in other areas of service provision. We are therefore keeping the practice in special measures. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by varying the provider’s registration to remove this location or cancel the provider’s registration.
Special measures will give people who use the service the reassurance that the care they get should improve.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Chatham Street Surgery on 5 April 2016. This comprehensive inspection was carried out to check that the practice was meeting the regulations and to consider whether sufficient improvements had been made.
Our previous inspection in August 2015 found breaches of regulations relating to the safe, effective, caring and responsive delivery of services. There were also concerns and regulatory breaches relating to the management and leadership of the practice, specifically in the well led domain. The overall rating of the practice in August 2015 was inadequate and the practice was placed into special measures for six months.
During the inspection in April 2016, we found evidence of minor improvements having been made. However, the practice continues to be rated as inadequate overall due to the unsatisfactory levels of improvement. Specifically it is rated inadequate for the provision of safe and well led services and requires improvement for provision of effective, caring and responsive services. Our rating of inadequate for the provision of well led services reflects the failure of leadership and management to deliver significant progress in improving services across the board for all patient groups.
Our key findings across all the areas we inspected were as follows:
The practice did not have a clear leadership structure. There was insufficient leadership capacity and limited formal governance arrangements. The practice did not have a culture of risk management and was reactive to improvement in services and failed to demonstrate a drive for constant and sustainable improvement.
Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment and systems to ensure action had been taken in regard to national safety alerts were ineffective.
Feedback from patients was encouraged but the response to feedback was limited. For example, the practice had appointed additional nursing staff to increase appointment capacity but did not demonstrate a commitment to address feedback relating to unhelpful reception staff or an inefficient appointment system.
Data showed patient outcomes, particularly for patients with long term conditions, had improved. However, we found care plans to support patient outcomes were not always in place or effective. In a number of cases, there was little evidence to confirm patients had been involved with the development of their care plan.
Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
Appointment systems were not working well so patients did not receive timely care when they needed it.
The areas where the provider must make improvements are:
Ensure all actions required in response to national safety alerts are completed and recorded.
Take action to address identified concerns with monitoring of cleaning standards throughout the practice premises.
Ensure recruitment arrangements include all necessary employment checks for all staff.
Ensure all risks to patient safety are identified and action taken to reduce risk. For example, in keeping liquid nitrogen at the practice and in assessing the risk of legionella and the safety of the practice premises.
Ensure the planned clinical audits, including re-audits, take place and inform improvements in patient outcomes.
Ensure care plans are appropriately recorded and involve the patient in the development of their care plan.
Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.
Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements
The areas where the provider should make improvements are:
Review and ensure carers are encouraged to register as such to enable them to access the support available via the practice and external agencies.
This service was placed in special measures in August 2015. Insufficient improvements have been made such that there remains a rating of inadequate for the delivery of safe and well led services. This led to a continued rating of inadequate. Therefore, we are taking action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration. The service will be kept under review whilst we complete our action and if needed this could be escalated to urgent enforcement action.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Chatham Street Surgery on 5 August 2015. Overall the practice is rated as inadequate.
Specifically, we found the practice inadequate for providing safe services and being well led. The population groups for older people, people with long term conditions, families children and young people, working age people, people whose circumstances may make them vulnerable and people experiencing poor mental health were rated as inadequate based on the overall rating of the practice. Improvements were also required for providing caring, responsive and effective services.
Our key findings across all the areas we inspected were as follows:
The areas where the provider must make improvements are:
In addition the provider should:
On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.
Chief Inspector of General Practice