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Church Hill Surgery Inadequate

The provider of this service changed - see old profile


Inspection carried out on 29 July 2021

During an inspection looking at part of the service

We carried out an announced inspection at Church Hill Surgery on 29 July 2021. Overall, the practice is rated as Inadequate.

The ratings for each key question were:

Safe - Inadequate

Effective - Inadequate

Well-led – Inadequate

Following our previous inspection on 2 May 2017, 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 Hill Surgery on our website at

Why we carried out this inspection

This inspection was a focused inspection in response to concerns raised in relation to the management of medicines and care and treatment delivered to patients. The inspection focused on specific areas of the following key questions;

  • Are services safe?
  • Are services effective?
  • Are services well-led?

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 included:

  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A site visit

Our findings

This was a focused inspection responding to specific areas of concern. Due to the seriousness of the concerns identified and the need to take urgent action, not all areas within the safe, effective and well-led key questions were reviewed or reported upon. 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 have rated this practice as Inadequate overall and for all population groups.

At this inspection, the practice was rated as inadequate for providing safe services because:

  • We found the practice process did not evidence that all the relevant information or checks were in place to ensure staff were recruited safely.
  • We found the practice’s system for managing patient and medicines safety alerts did not ensure medicines were prescribed safely.
  • The practice did not evidence a safe system to ensure patients on high risk medicines were appropriately monitored in a timely way.
  • The practice did not evidence that all patients had a structured and comprehensive medicines review. We identified reviews had been coded on the clinical system but there was no evidence in the clinical records of a structured medicines review or consultation with the patient.
  • We reviewed patient consultation records and found discrepancies with the coding of medical records.
  • The practice did not ensure all staff had vaccinations in line with current Public Health England guidance.
  • The practice did not evidence clear supervision and competency checks for all staff.
  • The process for recording, investigating and learning from significant events did not ensure safe care and treatment.
  • The practice stored securely but did not monitor all prescription stationery in line with national guidance.
  • The risk assessment for medicines remote collection sites and deliveries lacked detail to be assured it mitigated all risks.
  • The practice did not ensure the safe storage of medicines in the dispensary fridges.

At this inspection, the practice was rated as inadequate for providing effective services and for all population groups because:

  • The practice failed to evidence patients’ needs were adequately assessed. We found care and treatment was not always delivered in line with current legislation, standards and evidence-based guidelines.
  • We found examples where clinical coding was missing from patient records or the clinical coding applied was not wholly accurate. This meant that patients’ needs were not always identified and therefore they were not always given appropriate or necessary care and treatment.
  • The practice performance in relation to the quality and outcomes framework (QOF) 2019/2020 was below Clinical Commissioning Group (CCG) and national averages in some indicators. The practice had experienced some unexpected staff shortages, which had affected their ability to deliver care. However, the practice did not show us a clear documented plan to address the lower performance.
  • The practice failed to have an effective system in place for recalling, monitoring or treating patients with a potential diagnosis of diabetes and chronic kidney disease. This did not ensure these patients received proactive care and advice to make informed choices and lifestyle changes to prevent further deterioration of their health.
  • The practice’s limited quality improvement program did not reliably identify or respond to patients’ needs to ensure they received appropriate or proactive care in line with guidelines. This was further impacted by inappropriate, incorrect or missing coding.

At this inspection, the practice was rated as inadequate for providing well-led services because:

  • We found there was a lack of leadership and oversight from the provider to ensure services were delivered in a safe and effective way to patients.
  • The practice performance in relation to the quality and outcomes framework was below CCG and national averages. The practice did not have a regular program or plan of quality improvements to address this.
  • The practice did not operate effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • We found a lack of clinical oversight was in place from the provider to fully support staff to deliver safe care and treatment to patients.

We found breaches of regulations and therefore the provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

  • Continue to encourage patients to attended for childhood immunisations and for encourage patients to attend for the national cervical screening programme.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take 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 or to varying the terms of their registration within six months if they do not improve.

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 a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal 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.

As a result of the findings from our focused inspection, as to non-compliance, but more seriously, the risk to service users’ life, health and wellbeing, the Commission decided to issue an urgent notice of decision to impose conditions on the provider’s CQC registration. For further information see the enforcement section of this report.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Review carried out on 25 March 2020

During an annual regulatory review

We reviewed the information available to us about Church Hill Surgery on 25 March 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 2 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Hill Surgery

on 2 May 2017. Overall the practice is rated as good.

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

  • Since November 2016, the registered provider of Church Hill Surgery had changed and the principal GP was the sole provider. Practice staff we spoke with told us significant changes had been made, including the employment of three GPs who had previously worked as long term locums in the practice.

  • There was a clear leadership structure, practice staff we spoke with told us that the principal GP and practice manager had involved them in developing their business plan to encourage future developments and offer greater services to their patients.
  • The practice proactively sought feedback from staff and patients, which it acted on. The Patient Participation Group had recently been reformed and the members we spoke with were passionate about the changes and the greater involvement of patients.
  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had systems to minimise risks to patient safety. However, the practice had undergone extensive building works to extend the practice and a qualified person had not reviewed the previous risk assessment for the prevention of legionella disease. The previous risk assessment deemed the building to be low risk. The practice took immediate action and arranged for a qualified person to undertake a review.
  • Practice staff were aware of current evidence based guidance, and had been trained to provide them with the skills and knowledge to deliver effective care and treatment. The clinical staff discussed these and patient cases at regular meetings. Clinical staff told us they always had access to a GP for advice. We noted the practice did not undertake formal one to one peer meetings with clinicians in protected time to review consultations and share learning. The practice told us with the addition of three new GPs in post, protected time would be given to formalise clinical supervision to enhance the support already in place. The practice took immediate action and arranged protected sessions for clinical staff to enhance the supervision already in place..
  • Results from the national GP patient survey, published in July 2016, showed patients were treated with compassion, dignity, and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it very easy to make an appointment and there was continuity of care, with urgent appointments available the same day. The practice offered 12 minute appointments as standard and longer appointments if appropriate.
  • The practice had achieved 100% for the standard childhood immunisations.
  • In 2015, the practice had extended the premises providing additional clinical rooms had upgraded other clinical rooms to a high standard and provided more car parking. The practice was well equipped to treat patients and meet their needs.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

We saw one area of outstanding practice:

The practice directly employed an outreach team to manage patients that were vulnerable and needed additional care. The team consisted of a GP and three nurses, one community based, one nurse practitioner and a practice nurse. The team worked closely with other health professionals such as a care co-ordinator and social worker. All practice staff were engaged with this team, including the dispensary drivers who delivered medicines five days per week to patients that needed them. Other local charities and support groups such as the Cinnamon Trust (a local charity that cared for patients dogs when needed) support the team to ensure patients were support to remain at home. The CCG had supported the project and data they provided showed a significant reduction of the number of avoidable admissions. The CCG planned to roll out this model of care to other practices in the locality.

We saw areas where the practice should make the following improvements:

  • Embed the practice plan to provide protected time to undertake formal clinical supervision of all clinical staff enhancing the supervision already in place.

  • Review and monitor the system used to record the results from regular safety checks undertaken and ensure that they are updated timely and any actions are investigated and completed.

  • Update the risk assessment for the management of Legionella’s disease and ensure any actions are completed in a timely way including those related to water temperature management.

  • Collate the practice registers to identify all patients who are vulnerable to ensure there is comprehensive oversight enabling practice staff to be informed of patients with more complex needs.

  • Review the system for recording all feedback including verbal to ensure trends can be identified and improvement encouraged.

  • Review the systems and processes in place to ensure consistent coding of medical records is used to provide accurate performance data.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice