- GP practice
Church Lane Surgery
All Inspections
29 March 2018
During a routine inspection
This practice is rated as Good overall. (Previous inspection October 2017 – requires improvement )
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) – Good
We carried out an announced comprehensive inspection at Church Lane Surgery on 3 October 2017. The overall rating for the practice was requires improvement. The practice was found good in providing safe, effective and well led services but required improvement for caring and responsive services. The full comprehensive report on the October 2017 inspection can be found by selecting the ‘all reports’ link for Church Lane Surgery on our website at www.cqc.org.uk.
A desk-based review was carried out on 29 March 2018. This was to confirm that the practice had carried out their plan to make improvements in respect to the breach of the Health and Social Care Act 2008 identified in our previous inspection on 3 October 2017. We found the practice to be good in providing caring and responsive services.
Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- The practice had appointed salaried GPs providing stability and onsite leadership to the clinical team.
- The practice and their patient participation group were working together to better understand and respond to patient needs.
- The practice had improved the support provided to carers.
- The practice was working with a local charity to improve their services to patients with hearing loss.
- The practice had reviewed their disease registers to accurately reflect patient’s needs.
- We found the practice had revised their coding of the resuscitation status of patients within their care plans. Therefore, ensuring the wishes of patients were appropriately represented and shared with out of hour’s services.
- The practice had a system to identify where safety alerts had not been consistently actioned.
- The practice had followed up on children who failed to attend appointments with the practice and secondary care.
- The practice identified patients who had not responded to national screening programme requests and provided them with information and support to access services should they so wish.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
3 October 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Church Lane Surgery (also known as Church Lane Health Centre) on 3 October 2017. Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
- We found there was a system for reporting, recording, investigating and learning from significant events.
- The practice had defined systems, processes and practices to minimise risks to patient safety including, infection prevention control audits and health and safety assessments.
- We found medicines were prescribed and monitored appropriately.
- The practice were reviewing their disease registers to ensure they were reflective of their patients clinical needs.
- The practice were currently reviewing the needs of their patient population and were diversifying their clinical team to improve their responsiveness.
- The practice had reviewed the findings of the national GP patient survey and had an action plan to address the concerns and to improve the care provided to patients and their families.
- All patients we spoke with told us they found it difficult to make an appointment, online, in person or on phone. They were concerned there was little continuity of care with the practice employing sessional GPs and recent changes to the practice nursing team.
- The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
- There was a clear leadership structure and staff welcomed greater stability to the team with the recent appointment of the interim practice manager.
- A programme of continuous clinical and internal audit was used to monitor quality and to make improvements.
- Staff had received inductions, annual performance reviews and attended staff meetings and training opportunities.
- The practice sought feedback from staff and patients. The patient participation group and practice agreed their relationship had improved over the past three months.
The areas where the provider must make improvement are:
- Ensure the care and treatment of patients is appropriate, meets their needs and reflects their preferences
The areas where the provider should make improvement are:
- Strengthen systems to identify where safety alerts had not been consistently actioned, follow up on children who fail to attend appointments with the practice and secondary care and patients who failed to attend national screening programmes.
- Improve the identification and services provided to carers.
- Ensure staff are confident in using the hearing loop.
- Embed changes to disease registers to accurately reflect patients needs.
- Ensure consistent coding of the resuscitation status of patients within their care plans.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice