The Care Quality Commission
  • Doctor
  • GP practice

Chelsfield Surgery

Overall: Requires improvement read more about inspection ratings

62 Windsor Drive, Chelsfield, Orpington, Kent, BR6 6HD (01689) 852204

Provided and run by:
Chelsfield Surgery

All Inspections

06 April 2022

During an inspection looking at part of the service

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.

This included

  • 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.

Our findings

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

11 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chelsfield Surgery on 15 December 2015. The overall rating for the practice was Good, but the Safe domain was rated requires improvement. The full comprehensive report on the December 2015 inspection can be found by selecting the ‘all reports’ link for Chelsfield Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 11 July 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 15 December 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

.Overall the practice is now rated as Good.

Our key findings were as follows:

  • At our previous inspection on 15 December 2015, we rated the practice as requires improvement for providing safe services as we found that the provider had not ensured staff had appropriate support and training to carry out their duties, and some equipment used in treating certain medical emergencies was not fit for use. These arrangements had significantly improved when we undertook this inspection.

  • 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.
  • Results from the national GP patient survey 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 easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • 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.

We saw this area of outstanding practice:

The practice had made particularly strong efforts to engage its practice population in the running of the service. They held a patient participation week in June 2017, to raise awareness about the patient participation group (PPG) and inform people about how they could get involved. During the awareness week, 189 questionnaires were completed by patients providing feedback to the PPG.

The areas where the provider should make improvements are:

  • to review processes for monitoring and following up uncollected prescriptions in a timely manner.

  • consider ways to improve patient satisfaction with access to appointments

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

15 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chelsfield Surgery on 15 December 2015. 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 an effective system in place for reporting and recording significant events.

  • Risks to patients were assessed and well managed, with the exception of those relating to chaperoning arrangements.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • 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 they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. However some patients told us that they experienced delays at times before being seen for their scheduled appointments.
  • 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 and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are:

  • Ensure staff who carry out chaperoning duties have suitable training and background checks.
  • Ensure Patient Group Directions and Patient Specific Directions are in place for the nursing staff.
  • Ensure equipment used for treating medical emergencies is fit for use.

The areas where the provider should make improvement are:

  • Ensure policies and procedures available in the practice are complete and up to date.
  • Ensure an action plan is completed for the improvement areas identified in the infection prevention and control audit.
  • Ensure they respond and make improvements to the long waits experienced by patients for their appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice