Archived: Church View Surgery

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church View Surgery on 13 June 2017. The overall rating for the practice was good with requires improvement for being effective. The full comprehensive report from the June 2017 inspection can be found by selecting the ‘all reports’ link for Church View Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 23 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified in our previous inspection on 13 June 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is rated as good.

Our key findings were as follows:​

• The minor surgery protocol had been reviewed and updated to reflect NHS England Service Specification for Minor Surgery Direct Enhanced Services guidance. T
• An audit had been undertaken to review all minor surgery procedures and we saw four skin samples were sent for histology and the results followed up by practice staff.
• The locum staff pack had been updated to include the practice chaperone procedure. Chaperones were routinely offered to patients.
• Staff had access to online fire safety training modules and in addition completed weekly fire safety checks with the fire marshalls.

​Following our June 2017 inspection we recommended the provider should review of relevant policies and procedures during incident investigation processes. During this inspection we reviewed a recent significant event and the relevant procedure had been reviewed and updated and shared with all practice staff.

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 View Surgery on 13 June 2017. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.

• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Patients told us they 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.
• The process to book appointments had recently been reviewed and patients we spoke with said they found it easy to make an appointment with urgent appointments available the same day.  However, we received six CQC comment cards that reported that there was a long wait for routine appointments with a preferred GP.
• 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.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

• Ensure the process for sending skin/tissue samples for histological examination reflects NHS England Service Specification for Minor Surgery Direct Enhanced Services.

The areas where the provider should make improvement are:

• Include review of relevant policies and procedures during incident investigation processes.
• Update all locum staff on the chaperone procedure to confirm compliance with the process.
• Monitor attendance at and provide access to regular fire safety training for all staff.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice