23 May 2022
Chelsfield surgery operates from 62 Windsor Drive Chelsfield Orpington Kent BR6 6HD. The service is open Monday to Friday 8am to 6.30pm
The practice is registered with the Care Quality Commission (CQC) to provide the regulated activities of treatment of disease, disorder or injury, maternity and midwifery services, family planning services, surgical procedures and diagnostic and screening procedures.
The practice is situated within the Bromley Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 9497. This is part of a contract held with NHS England.
Local enhanced services provided by the practice included Sexual Health Clinic- Level 2, Minor Surgery- Level- 3, Phlebotomy, 24-hour BP Hub and Cardiology.
The practice has a male and a female GP partner. They employ five female long term locum GPs. Chelsfield Surgery is an accredited training practice, and at the time of our inspection there was one GP registrar in training at the practice. There is also a nursing team which comprises a female nurse practitioner, three female practice nurses and a female healthcare assistant completing the clinical team. The practice has a full time practice manager, 11 reception staff, five administrative staff and two secretaries. The practice provides 38 GP and advanced nurse practitioner sessions per week.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
23 May 2022
We carried out an announced inspection at Chelsfield Surgery between 4 and 8 April 2022. Overall, the practice is rated as requires improvement.
Set out the ratings for each key question
Safe - Requires improvement.
Effective - Requires improvement.
Caring - Not inspected
Responsive - Not inspected
Well-led - Requires improvement.
Following our previous inspection on 11 July 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 Chelsfield Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused inspection to follow up on information of concerns which involved a site visit: We looked at the Safe, Effective and Well-led key questions.
How we carried out the inspection/review
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 inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
- Conducting staff interviews using video conferencing.
- 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 short site visit.
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.
We found that:
- Policies were monitored, reviewed and updated.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The way the practice was led and managed did not always promote the delivery of high-quality, person-centre care.
We found breach of regulations. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Whilst we found no breaches of regulations, the provider should:
- Review all legacy valid MHRA alerts.
- Ensure all staff undertansd and complete Sepsis awareness training.
- Continue to work and and review process in place for using DOCMAN.
- Continue to take action to improve cervical screening uptake.
- Continue to review and monitor staff recruitment documents.
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