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Inspection Summary

Overall summary & rating


Updated 23 August 2019

We carried out an announced focused inspection at Church Street Practice on 31 July 2019. This was to follow up on a breach of regulations identified at our previous inspection on 3 July 2018, the practice was rated good overall and requires improvement for providing safe services. The details of these can be found by selecting the ‘all reports’ link for Church Street Practice on our website at

During the inspection looked at the following key questions

  • Is it Safe

Our judgement of the quality of care at this service is based 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.

The practice remains rated as good overall and for all the population groups.

The key question remains rated as:

Are services safe? – Requires improvement

At this inspection we found some improvements:

  • The procedure for monitoring patients prescribed high risk medicines had been improved and was reviewed by a clinical pharmacist and GPs.
  • Health and safety risk assessments had been completed.
  • Non-clinical staff had received training in sepsis awareness.
  • Recruitment procedures were established and operated effectively to ensure only fit and proper persons are employed and specified information is available regarding each person employed, including locum staff.
  • The practice had reviewed patient feedback from all sources and improved their engagement with patients. Patient satisfaction was in line with local and England averages.

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

  • Staff training was not up to date, including infection control, hand hygiene, information governance, fire training and safeguarding.
  • The recording of fridge temperatures where vaccines were stored had been improved however action taken and recording of action when temperatures were out of range was not sufficient.
  • The practice system for storing and monitoring prescription stationary had been improved but did not maintain clear and unambiguous records of prescription forms that were distributed to prescribers and prescription forms were not stored securely once distributed to prescribers.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review and improve how staff immunisation status is monitored in line with current Public Health England guidance.

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








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