Chapelthorpe Medical Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm. At our last assessment, we rated this key question as Good. Following this assessment, the rating remains the same.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. There were systems in place to ensure people were safe and safeguarded from abuse. The facilities and equipment met the needs of people, were clean and well-maintained, however we found that risks identified were not always acted upon within a timely manner.

There were enough clinical staff with the right skills, qualifications and experience. However, at the time of our assessment the practice was recruiting additional administerial staff to support the existing workforce. Managers made sure staff received training to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

This service scored 69 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice encouraged a positive culture of safety, based on openness and honesty. Leaders and managers explained how they had adopted 2 processes for documenting when things went wrong, significant events (for serious concerns) and learning events (for incidents deemed less critical). Staff we spoke with and received feedback from were able to explain how they would escalate an incident. However, feedback from non-clinical staff, regarding significant/learning events they had been involved in, was limited. We reviewed minutes of meetings where significant events had been discussed, however feedback from staff confirmed that information such as themes, trends and learning was not routinely shared with the wider practice team. We discussed this with the provider during our site visit and were informed that learning events were an area they were looking to improve.

The practice had a policy in place to manage complaints, and information was easily accessible for staff and patients. We reviewed a sample of complaints as part of our assessment and found that appropriate action had been taken.

The practice worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The practice worked with other providers to deliver shared care and when patients moved between services. Referrals and test results were managed in a timely way; there was a process in place for monitoring urgent cancer referrals to ensure patients were offered an appointment within appropriate timescales. However, there was no process in place to follow up patients who did not attend their allocated appointment.

The practice had systems in place to identify, record and act upon on concerns. There was a dedicated GP lead for safeguarding adults and children. All the staff we spoke with or received feedback from knew who the lead was and what steps they should take if they had any concerns.

Records demonstrated that staff had completed safeguarding adults and children training, however we noted that nursing staff had only completed this to level 2. This was not in line with intercollegiate guidance.

Staff had also completed initial training to support interactions with patients with a learning disability or autism. We were advised that further training would be undertaken when this was available.

The practice utilised the safeguarding node on the clinical system to identify vulnerable patients. Information stored within the safeguarding node was then available for other teams involved in the patients’ care, for example district nurses and health visitors.

We saw evidence of multidisciplinary team meetings with input from midwives and health visitors. The practice had a dedicated district nursing team who attended palliative care meetings and shared any additional safeguarding information with the practice via the clinical system.

The practice worked with people to understand and manage risks and provided care to meet patients’ needs. During our site visit we saw that the practice had appropriate equipment and medicines to support patients in the event of an emergency. For example, oxygen, a defibrillator and adrenalin. However, we noted that access to these was not immediately accessible as they were stored behind a locked door.

Staff we spoke with and received feedback from, knew how to identify patients presenting with ‘red flag’ symptoms and we heard examples of steps taken to support such patients.

We reviewed training records and saw that staff had completed basic life support training. All of the staff we spoke with also confirmed they had attended the training.

The practice took steps to detect and control potential risks in the environment.

During our site visit, we observed the premises to be well-maintained. Services were offered from purpose-built premises and treatment rooms were available on the ground floor. There was a large car park with dedicated disabled spaces, and the building had level access entrance with automated doors.

Contracts were in place to ensure the premises were maintained, and appropriate risk assessments were in place. However, we found that actions identified in the risk assessments had not always been addressed. For example, there were no records of fire drills being carried out at regular intervals (as identified in the 2023 and 2024 Fire Risk Assessment) and none of the staff we spoke with or received feedback from had been involved in a fire drill within the last 12 months. There was no risk assessment for Dangerous Substances and Explosive Atmosphere Regulations 2002 to cover gases under pressure and substances that are corrosive to metals (as identified in the 2023 and 2024 Health and Safety Risk Assessment) and no evidence of action taken to address water temperatures not reaching 55 degrees within 1 minute (as identified in the Legionella Risk Assessment 2024).

In preparation for our assessment, the provider produced an improvement plan to address some of the issues identified.

The practice made sure there were enough qualified, skilled and experienced staff, who received effective support, supervision and development. They worked together well to provide safe care that met people’s individual needs.

There were a range of clinical and non-clinical roles within the practice. We found training was up to date in most cases and staff were working within their agreed areas of competence. However, we noted that nursing staff within the practice had only completed safeguarding training to level 2, this was not in line with intercollegiate guidance.

There was a recruitment policy in place which outlined the necessary checks required during the recruitment process. We reviewed 3 staff files during our site visit (2 clinical and 1 non-clinical), there was no evidence that the recruitment process had been followed in all cases. For example, 2 files only contained 1 document as proof of identification. However the provider sent this information to us immediately following our site visit.

None of the staff we spoke with, or received feedback from, had received an appraisal within the previous 12 months. We discussed this with leaders and managers who confirmed that steps were being taken to address this.

The practice assessed and managed the risk of infection. There was a dedicated infection prevention and control (IPC) lead, and all staff were aware of who this was and how to raise concerns.

We found the premises to be clean and well maintained. Cleaning was undertaken by a contracted company, and who worked to appropriate cleaning schedules.

There were arrangements in place for the collection of clinical and non-clinical waste.

Risk assessment and audits were completed, and actions taken to mitigate risks.

The practice made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened.

As part of this assessment, a Care Quality Commission (CQC) GP Specialist Advisor (SpA) conducted a series of remote clinical searches of patient records to assess the practice’s procedures around prescribing and medicines management. We found that the practice had systems in place to ensure patients prescribed disease-modifying antirheumatic drugs (DMARDs) and medicines requiring monitoring were appropriately managed. We noted that 4 of the 5 patients prescribed the DMARD Methotrexate, did not have the day of the week that the medication should be taken in line with guidance. However, the practice contacted these patients during our assessment and planned to review at each monitoring blood test going forward.

We reviewed the systems and processes in place to receive, disseminate and act upon patient safety alerts. Overall, the findings of our clinical search indicated a structured approach. We highlighted 4 patients from the search for further review and received written feedback from the practice in response to this.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Staff managed prescription stationery appropriately and securely. Staff followed protocols to ensure they prescribed all medicines safely, and ensured people received all recommended medicines reviews and monitoring. Medicines were stored securely and at appropriate temperatures. Staff regularly checked the stock levels and expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs.

Data showed that the practice had systems in place to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. We saw the practice was in line with or better than national averages in all 6 prescribing outcome areas. For example, the average daily quantity of Hypnotics prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU) was 0.11 (expected 0.45), the total items prescribed of Pregabalin or Gabapentin per 1,000 patient was 122.2 (expected 132.2) and the percentage of antibiotic items prescribed that are Co-amoxiclav, Cephalosporins or Quinolones was 5.8 (expected 7.9).