The Care Quality Commission
  • Doctor
  • GP practice

Chapel Lane Surgery

Overall: Good read more about inspection ratings

13 Chapel Lane, Formby, Liverpool, Merseyside, L37 4DL (01704) 876363

Provided and run by:
Chapel Lane Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Chapel Lane 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 Chapel Lane Surgery, you can give feedback on this service.

25 January 2020

During an annual regulatory review

We reviewed the information available to us about Chapel Lane Surgery on 25 January 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.

30 June 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chapel Lane Surgery on 17 November 2016. The overall rating for the practice was requires improvement with requires improvement for safe, effective and responsive services, inadequate for well led and good for providing a caring service. The full comprehensive report on the 17 November 2016 inspection can be found by selecting the ‘all reports’ link for Chapel Lane Surgery on our website at www.cqc.org.uk.

This inspection was an announced follow up inspection carried out on 30 June 2017 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 inspection on 17 November 2016. This report includes our findings in relation to those requirements.

Overall the practice is now rated as good for providing services.

The practice had made significant improvements and addressed the issues identified in the previous inspection. The practice engaged all staff in driving forward improvements and utilised new technology. Improvements included:

  • A review of the governance systems in place to ensure the quality and safety of the service. All policies and protocols had been revised. The practice now utilised a computer software programme to help monitor systems.
  • All staff had received mandatory training relevant to their role and had received an appraisal. There was now a system in place to monitor the training and appraisals staff received.
  • Recruitment checks were in place for all staff. Staff were asked to update their DBS checks at annual appraisals.
  • There were increased monitoring systems now in place for cleaning and the safety of the premises. This included having a fixed electrical wiring safety certificate for the premises.
  • Improvements in the content of patient specific directions for nursing staff to administer medicines safely.
  • A system to review any abnormal screening checks for patients.
  • Responding to patient feedback about making appointments and waiting to be seen beyond their allocated time by engaging with the PPG and Healthwatch and working towards the national New Ways of Working programme. The practice had implemented a system of triaging patient calls and trained staff to become care navigators to signpost patients to the most appropriate service instead of automatically being booked in with a GP. To support this, the practice had recruited a variety of new staff such as a phlebotomist and an advanced nurse practitioner.
  • Clinical meetings were now documented.
  • The practice had correctly registered with us to carry out the regulated activity of family planning.

In addition:-

  • The practice had a new carers’ policy and actively sought ways to identify carers by utilising a carer’s questionnaire available in the waiting room and offer tailored support.
  • The practice had reviewed its safeguarding registers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chapel Lane Surgery on November 17 2016. Overall the practice is rated as Requires Improvement.

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

  • There was an open and transparent approach to clinical safety. There was an effective system in place for reporting and recording significant events.
  • The practice was delivering family planning services, a regulated activity that they were not registered for.
  • There were a number of governance issues that could adversely impact on patient safety. For example, all required staff checks had not been undertaken. There was a lack of monitoring of cleaning. Water temperature checks had not been consistently carried out, in line with the risk assessment on Legionella control. There was no evidence of an electrical safety certificate for the building or that the provider had requested a copy of this from the landlord.
  • Staff training and appraisals were not being delivered as required.
  • The practice did not have a system in place to ensure that any abnormal results from screening programmes were followed up.
  • Staff meetings were in place and were minuted.
  • Information documented on Patients Specific Directions was insufficient.
  • Only seven staff had been appraised since 2012.
  • Housekeeping issues required attention, for example cleaning and premises checks.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said it was not easy to make an appointment with a named GP but this could be done if they were prepared to wait several weeks to see that GP. There was continuity of care, if patients needed it.
  • Urgent appointments were available the same day.
  • Common themes and cause for complaint in patient feedback had not been effectively addressed by the practice. An action plan detailing how improvements would be made lacked appropriate detail.
  • Staff felt supported by management. However clear leadership which followed governance processes to support the practice was lacking.
  • The provider was aware of and complied with the requirements of the duty of candour.

There were areas where the provider must make improvements. The provider must:

  • Ensure information required by nurses when administering ongoing care and treatment is sufficient for purpose.

  • Ensure that any abnormal results from screening programmes are tracked to ensure each patient is followed up.

  • Have governance systems in place to ensure:

  • patient feedback is acted upon and areas requiring improvement are addressed; and

  • that all buildings and premises checks are in place.

  • Ensure that all staff receive the training required to deliver their duties effectively and are regularly appraised and monitored.

  • Ensure that all recruitment checks as required by the regulations are taken up and held on record.

There were also areas where the provider should make improvements. The provider should

  • Develop and maintain a carer’s register.

  • Ensure staff know what the protocol is for handling requests for safeguarding reports and that the safeguarding register for the practice is up to date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

22 August 2013

During a routine inspection

We spoke with three patients on the day of our visit, including a member of the practice patient participation group (PPG). They told us they were very happy with the care they received. One patient told us; 'You can usually get an appointment when you need one. I like the consistency of seeing the same doctor, unless they're on holiday.' Another patient said 'Monday mornings are difficult to get through on the phone. You can usually get an appointment when you want one on other days.' One patient told us the staff were, in the main, very helpful.

The practice had electronic records in place to accurately describe the contact patients had with the service and the actions taken to provide appropriate care and treatment. Patients' records included GP and nurse consultations, test results, current and past medication and referral letters as well as contact with other professionals, such as hospital consultants and community nurses.

We were shown around the practice and saw it provided spacious waiting, reception and consultation/treatment rooms. All rooms were accessible on the ground floor. Car parking was at the rear of the building. We found the building clean and tidy, and well maintained.

The practice had a range of policies and procedures for staff to access, which supported the safe running of the service. The practice completed audits/reports following significant events, in order to learn and make changes as required.