During an assessment under our new approach
Date of Inspection: 26 to 28 August 2025. Chapel St Surgery is a GP practice delivering services to around 5,200 people under a contract held with NHS England. We carried out this inspection to follow-up on previous breaches of regulation.
The National General Practice Profiles show that the age profile of the service population is similar to that of England generally but with a higher proportion of people aged over 65 and a lower proportion of younger adults. Information published by the Office for Health Improvement and Disparities shows that deprivation in the service’s population group is in the 4th decile (4 of 10). The lower the decile, the more deprived the service population is relative to others. The majority of the service population is white (94%). This inspection considered the demographics of the people using the service, the context the service was working in and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
The service had a positive learning culture and people could raise concerns. The service had improved its process for reporting and learning from incidents. People were protected from abuse. The facilities and equipment met the needs of people, were clean and well-maintained and were risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.
Staff reviewed people’s needs taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. The service involved people coming to the end of life and their families in decisions about their care and took decisions in people’s best interests where they did not have capacity.
We received positive feedback about the way people were treated at the service. We received comments with examples of kindness and compassion. We found staff protected people’s privacy and dignity. The service supported staff wellbeing.
The service provided information people could understand. People knew how to give feedback, and the service took feedback seriously and acted on it. The service had taken action to improve access for people, however feedback remained mixed and further action was planned. People received fair and equal care and treatment. The service worked to reduce health and care inequalities.
Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. There was a developing culture of continuous improvement with increasing focus and resources to try new ideas.
Since the last inspection, the service had made improvements and is no longer in breach of legal regulation for safe care and treatment; good governance; staffing; and fit and proper persons employed.