The Care Quality Commission
  • Doctor
  • GP practice

Archived: Church View Practice

103-107, High Street, Rainham, Gillingham, ME8 8AA (01634) 337642

Provided and run by:
Dulwich Medical Centre

Important: The provider of this service changed. See new profile

All Inspections

8 April 2021

During an inspection looking at part of the service

We carried out a focused inspection of Church View Practice on 6 November 2020 and found breaches of regulations. We took enforcement action and issued warning notices against Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. We issued a requirement notice against Regulation 18 (Staffing).

We carried out this inspection of Church View Practice to confirm that the practice now met the legal requirements in relation to those breaches of regulations and to ensure sufficient improvement had been made. This report only covers findings in relation to those requirements. The practice was not rated as a consequence of this inspection.

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:

  • 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 site visit.

We conducted clinical searches and a remote review of patient records on 30 March 2021 at short notice to the provider and an unannounced site visit on 8 April 2021. Following our site visit on 8 April 2021 we requested supporting evidence and documents from the provider which we reviewed remotely.

At this inspection we found the practice had made the following improvements:

  • Patient group directions, to ensure the safe administration of medicines to patients, were complete and up to date.
  • Arrangements were in place to ensure the safe storage of medicines.
  • The practice kept all medicines required for dealing with medical emergencies.
  • Staff had been supported to complete all required training.
  • Clinical staffing levels were maintained via the use of two long term locum GPs.
  • Safeguarding arrangements and responsibilities were clearly defined.
  • Governance and local clinical leadership arrangements had been reviewed and updated.
  • Infection prevention and control monitoring processes had been improved but required further development.

The clinical searches undertaken at this inspection identified a small number of minor issues outside of the warning notice compliance review which the provider resolved at the time of inspection.

The areas where the provider should make improvements are:

  • Review and develop infection prevention and control auditing processes and use of the enhanced auditing tool not yet fully implemented.
  • Monitor and review clinical staffing levels and continue to seek to recruit to vacant salaried GP position.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

6 November 2020

During an inspection looking at part of the service

We carried out an announced focussed inspection (at short notice to the provider) at Church View Practice on 6 November 2020. The practice was not rated as a consequence of this inspection.

Following the inspection in August 2020 of another location where services were also delivered by the provider Dulwich Medical Centre, we found breaches of regulation and the risk of patient harm. As a result, we took enforcement action and issued a Section 29 Warning Notice. As the provider Dulwich Medical Centre is also delivering regulated activities at Church View Practice, we carried out this inspection to assure ourselves that the breaches of regulation and risk of patient harm found during the inspection of the other location in August 2020 were not being repeated at this location.

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 on-site inspection activity took place on 6 November 2020 followed by inspection activities carried out remotely thereafter.

At this inspection we found:

  • The practice’s systems, practices and processes did not always keep people safe.
  • Risks to patients, staff and visitors were not always assessed, monitored or managed in an effective manner.
  • The practice learned and made improvements when things went wrong.
  • Staff had the information they needed to deliver safe care and treatment.
  • The arrangements for medicines management did not always help to keep patients safe.
  • Local clinical leadership (including on-site clinical supervision) was unclear.
  • Governance arrangements were not always effective.
  • The practice involved the public, staff and external partners to help sustain high-quality sustainable care.
  • Systems and processes for learning and continuous improvement were effective.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • 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 their duties.

The areas where the provider should make improvements are:

  • Continue to follow up patients who are prescribed high-risk medicines that are overdue relevant blood tests.
  • Consider recording all complaints, including verbal complaints, in line with organisational policy.

We are mindful of the impact of COVID-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering what enforcement action was necessary and proportionate to keep people safe as a result of this inspection. We will continue to discharge our regulatory enforcement functions required to keep people safe and to hold providers to account where it is necessary for us to do so.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care