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Church Lane Surgery Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 10 April 2019

We carried out an announced comprehensive inspection at Church Lane Surgery on 6 March 2019 as part of our inspection programme.

At the last inspection in April 2018, we rated the practice as requires improvement overall and specifically requires improvement for providing safe and well-led services because:

  • There were inconsistent arrangements in how risks were assessed and managed. For example, during the inspection, we found risks relating to health and safety of the premises and patients including fire safety arrangements, management of legionella and management of blank prescription forms.
  • There was a lack of good governance in some areas.

Previous reports on this practice can be found on our website at: 

At this inspection, we found that the provider had demonstrated improvements in some areas, however, they were required to make further improvements in some areas and are rated as requires improvement for providing safe and well-led services.

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 requires improvement overall and good for all population groups.

We rated the practice as requires improvement for providing safe services because:

  • Risks to patients were assessed and well managed in some areas, with the exception of those relating to safety alerts, infection control procedures and recruitment checks.
  • The provider did not have a second thermometer which could log all the data and provide assurance that temperatures had been within the required range, nor was the existing thermometer calibrated at least monthly, as recommended in Public Health England guidance.
  • Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes.

We rated the practice as requires improvement for providing well-led services because:

  • There was a lack of good governance in some areas.
  • The practice had not had an effective system to identify and monitor who was collecting the repeat prescriptions for controlled drugs from the reception.
  • The practice had failed to take appropriate action in a timely manner to address the risk identified during the previous inspection in April 2018, regarding the rear fire exit door, which required to be fitted with a panic or push bar.
  • The practice had not had a system to follow up women (after 12 weeks) who were prescribed contraceptive depot injections.
  • There were no failsafe systems to follow up women who were referred as a result of abnormal results after the cervical screening.
  • The practice was aware of and complied with the requirements of the Duty of Candour.
  • There was a clear leadership structure and staff felt supported by the management.

We rated the practice as good for providing effective, caring and responsive services because:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • Patients could access care and treatment in a timely way. Patients were able to ring a duty GP directly (bypassing the reception) for a telephone consultation between 8.30am to 9am and 11.30am to 12pm Monday to Friday.
  • The practice was encouraging patients to register for online services and 30% of patients were registered to use online Patient Access.
  • Information about services and how to complain were available and easy to understand.

The areas where the provider must make improvements as they are in breach of regulations are:

  • 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.

The areas where the provider should make improvements are:

  • Review and improve the current arrangements to monitor effectively the use of blank prescription forms for use in printers and handwritten pads.
  • Consider ways to improve the identification of carers to enable this group of patients to access the care and support they need.
  • Continue to review and monitor the outcomes of patients with diabetes.
  • Continue to review, monitor and encourage uptake of bowel cancer screening.
  • Review ways to improve patients’ satisfaction with care and treatment, telephone access and refurbishment of the premises.

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

Inspection areas


Requires improvement








Requires improvement
Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable