The Care Quality Commission
  • Doctor
  • GP practice

Churchtown Medical Centre

Overall: Good read more about inspection ratings

137 Cambridge Road, Churchtown, Southport, Merseyside, PR9 7LT (01704) 224416

Provided and run by:
Churchtown Medical Centre

All Inspections

24 May 2023

During a routine inspection

We carried out an announced comprehensive inspection at Churchtown Medical Centre on 22 and 24 May 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive – requires improvement

Well-led - good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Churchtown Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

We inspected the key questions of:

Safe, effective, caring, responsive and well led.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • 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 found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Responsive is rated requires improvement because:

  • Patients reported less satisfaction with access to the practice in the National GP Patient Survey, directly to CQC and the practice. As a result, the provider had an action plan to improve the appointment system. The changes made were yet to be evaluated over time and sustained.

Whilst we found no breaches of regulations, the provider should:

  • Take more timely action in response to all safety alerts.
  • Improve documentation in patient records including medication reviews and information provided to patients during consultations.
  • Take action to address monitoring and follow up action required for patients with long term conditions.
  • Improve uptake for cervical screening.
  • Continue to take action to improve patient satisfaction regarding access to the service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

03 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Churchtown Medical Centre on 26 May 2016. The overall rating for the practice was requires improvement. The practice was required improvement for safe and well-led services. Requirement notices were made as improvements were needed in the safety and suitability of the premises, staffing and staff recruitment and to governance systems. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Churchtown Medical Centre on our website at www.cqc.org.uk.

This inspection was undertaken on 3 October 2017 and was an announced comprehensive inspection.

Overall the practice is rated as good.

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

  • There were systems in place to reduce risks to patient safety, for example, equipment checks were carried out, there were systems to protect patients from the risks associated with insufficient staffing levels and to prevent the spread of infection.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Staff were aware of procedures for safeguarding patients from the risk of abuse.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff felt supported. They had access to training and development opportunities appropriate to their roles.
  • Patients said they were treated with compassion, dignity and respect. We saw staff treated patients with kindness and respect.
  • Services were planned and delivered to take into account the needs of different and diverse patient groups.
  • Access to the service was monitored and steps taken to ensure access was improved.
  • There was a system in place to manage complaints.
  • There were systems in place to monitor and improve quality and identify individual risks however the service did not ensure there was an overview of significant events that had taken place.

Areas of practice where the provider had improved since the previous inspection were:

  • A range of policies and procedures for infection prevention and control were now in place and staff could access them on the practice intranet site.
  • Certificates and maintenance records indicated that all clinical and general equipment was cleaned, calibrated and serviced in keeping with the manufacturer’s instructions. We saw for example the gas and fixed electrical wiring safety certificates for the premises and legionella risk assessment and water temperature checks.
  • The practice had implemented a quality improvement programme which included clinical audits being undertaken in response to local and national priorities.
  • A patient participation group had been actively encouraged and supported.
  • Processes were in place to report and review serious incidents. Reports indicated that lessons learnt were discussed with staff and action taken to prevent a repeat incident. The practice did not have a process in place however, to review all incidents at the same time so that possible themes and trends could be identified.
  • A detailed business continuity plan had been developed this provided information for staff to follow in the case of events that could cause the service to stop. For example flue pandemics; cyber-attacks or damage to the premises.
  • A mandatory training plan had been implemented and the records indicated all staff had completed the courses required.
  • Staff appraisals had been implemented and most staff had received appraisals.
  • A staff recruitment policy was now in place and appropriate pre-employment checks were completed and records kept.

However, there were areas of practice where the provider should make improvements and the provider should:

  • Review significant events and complaints periodically in order to identify themes and trends and learn from these.
  • Review the system for documenting action taken in response to patient safety alerts.
  • Review whether actions taken to reduce risks have worked.
  • Review systems in order to identify more patients who are carers so that appropriate timely support can be offered.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Churchtown Medical Centre on 26 May 2016. Overall the practice is rated as requires improvement.

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

  • There was a system at the practice for reporting and recording significant events. However, this was ineffective.
  • Risks to patients were assessed and managed but there was a lack of clear protocols that were embedded within the practice, which affected the quality of governance.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. We saw a number of audits had been completed and results were used to drive improvement.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had plans to utilise technology to make its services more accessible to patients, having introduced the use of telemedicine and planning to introduce intelligent telephony to deal with incoming telephone calls more effectively.
  • Patients said they were able 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 equipped to treat patients and meet their needs.
  • Staff felt supported by management. The practice 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.

However, there were areas where the provider must make improvements. The provider must:

  • Ensure all significant events are recorded, reported and discussed and learning from them shared.

  • Ensure all staff recruitment checks as required by Schedule 3 are carried out on staff.

  • Ensure that the premises are regularly checked to maintain safety for all people that use the building.

  • Ensure that water testing as required by the risk assessment on Legionella, carried out in respect of the building, is performed as required.

  • Ensure there is an effective procedure in place for the receipt, dissemination and discussion of MHRA alerts relevant to the practice.

  • Ensure all staff have annual appraisal including reception and administrative staff, practice nurses and healthcare assistants.

  • Ensure all clinicians have access to and time to complete the training necessary for their role, for example, training in the Mental Capacity Act 2005.

  • Ensure an up to date business continuity plan is in place.

There are areas where the provider should make improvements. The provider should:

  • Maintain equipment registers to help identify and assure that all equipment has been tested regularly.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice