You are here

Church Lane Medical Centre Good

Inspection Summary


Overall summary & rating

Good

Updated 28 May 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Lane Medical Centre on 4 February 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive services and for being well led. It was also good for providing services for the older people and families, children and younger people.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

  • People told us they were treated with professionalism and respect, and that the practice responded well to patients that were visiting the area for patient care and support.

  • Incidents and complaints were appropriately investigated and responded to.

  • The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand.

  • The practice had an effective governance system in place, was well organised and actively sought to learn from performance data, complaints, incidents and feedback.

  • The practice showed a patient centred approach to delivering care and treatment.

The practice was proactive in improving health and access to services and engaged with other health and social care agencies to improve access and patients health.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 28 May 2015

The practice is rated as good for providing safe services. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons were learned and communicated widely to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed. Risks to patients were assessed and well managed. There were enough staff to keep people safe.

Effective

Good

Updated 28 May 2015

The practice is rated as good for providing effective services. Data showed patient outcomes were at or above average for the locality. Staff referred to guidance from National Institute for Health and Care Excellence (NICE) and used it routinely. People’s needs were assessed and care was planned and delivered in line with current legislation. This included assessing the capacity of patients and promoting good health. Staff had received training appropriate to their roles and any further training needs had been identified and planned. The practice could identify all appraisals and the personal development plans for all staff. The practice had developed good supervision and support for all staff which included weekly and monthly reviews with the manager. Staff worked effectively with multidisciplinary teams and agencies.

Caring

Good

Updated 28 May 2015

The practice is rated as good for providing caring services. Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. Information to help patients understand the services available was easy to understand. We also saw that staff treated patients with kindness and respect, and maintained confidentiality.

Responsive

Good

Updated 28 May 2015

The practice is rated as good for providing responsive services. It reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified. Patients said they generally found it easy to make an appointment. However, some patients commented they found arranging an appointment could be challenging at times. Urgent appointments were available the same day. The practice had a range of facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand and evidence showed that the practice responded quickly to issues raised.

Well-led

Good

Updated 28 May 2015

The practice is rated as good for being well-led. It had a clear vision and strategy. Staff were clear about the vision and their responsibilities in relation to this. There was a clear leadership structure and staff felt well supported by management. The practice had a number of policies and procedures to govern activity and held regular staff meetings. Governance and performance management arrangements had been proactively reviewed and took account of current models of best practice. There were systems in place to monitor and improve quality and identify risk. The practice proactively sought feedback from staff and patients, which it acted on. The practice promoted a two minute patient survey including friends and family test which patients were encouraged to complete on attendance at the practice. The patient participation group (PPG) was currently being re-established. Staff had received inductions, had regular performance reviews and attended staff meetings and training events.

Checks on specific services

People with long term conditions

Good

Updated 28 May 2015

The practice is rated as good for the care of people with long-term conditions. There were emergency processes in place and regular reviews took place for patients whose health deteriorated suddenly. Longer appointments and home visits were available when needed. Patients in this group had a named GP and a structured annual review to check that their health and medication needs were being met. For those people with the most complex needs, the named GP and or specialist nurses worked with relevant health and care professionals to deliver a multidisciplinary package of care. The staff had received appropriate training in the management of long term conditions.

Families, children and young people

Good

Updated 28 May 2015

The practice is rated as good for the care of families, children and young people. There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations. Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this. Appointments were available outside of school hours when it was convenient for children and teenagers to attend the surgery.

Older people

Good

Updated 28 May 2015

The practice is rated as good for the care of older people. Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. There were a number of care homes in the practice area and all patients 75+ have a named GP. GPs made regular visits to patients in the care homes to provide care & support. Protected time was allocated to the GP to ensure continuity of care was delivered consistently and in line with older patient’s needs. The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example, in dementia and end of life care. It was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs.

Working age people (including those recently retired and students)

Good

Updated 28 May 2015

The practice is rated as good for the care of working-age people (including those recently retired and students). The needs of this group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. The practice was proactive in offering services as well as a full range of health promotion and screening that reflected the needs for this age group. We saw that the practice provided a range of services patients could access at times that best suited them.

People experiencing poor mental health (including people with dementia)

Good

Updated 28 May 2015

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia). People experiencing poor mental health had received an annual physical health check. The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. It also carried out advance care planning for patients with dementia.

The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. It had a system in place to follow up and review patients’ needs who had attended A&E who had been experiencing poor mental health. Staff had received training on how to care for people with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 28 May 2015

The practice is rated as good for the care of people whose circumstances may make them vulnerable. The practice held a register of patients living in vulnerable circumstances including those with a learning disability. It carried out annual health checks for people with a learning disability and longer appointments were offered to them, and also for other patients’ who required it.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. Information was given to vulnerable patients about how to access various support groups and voluntary organisations. Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.