Chapel Group Medical Centre

We carried out an announced inspection at Chapel Group Medical Centre on 26 May 2022. Overall, the practice is rated as inadequate.

Set out the ratings for each key question

Safe - Inadequate

Effective – Requires Improvement

Caring - Good

Responsive – Requires Improvement

Well-led - Inadequate

Why we carried out this inspection.

This inspection was a comprehensive inspection of all five key questions as part of our routine inspection programme.

How we carried out the inspection/review

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:

• Conducting staff interviews using video conferencing
• 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
• Asking staff to fill out a feedback form

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 have rated this practice as Inadequate overall

Following this inspection, we have rated the practice inadequate for providing safe services. We identified the following areas of concern:

• Recruitment checks were not always carried out in accordance with regulations.
• There were gaps in systems to assess, monitor and manage risks to patient safety.
• Due to a backlog of patient note summarising, staff did not always have the information they needed to deliver safe care and treatment.
• The practice did not have effective systems for the appropriate and safe use of medicines, including medicines optimisation.
• The practice did not have a clear system to learn and make improvements when things went wrong.

Following this inspection, we have rated the practice requires improvement for providing effective services. We identified the following areas of concern:

• The practice could not demonstrate how they assured the competence of staff.
• Patients’ needs were not always assessed.
• There was not an effective system in place for monitoring thyroxine treatment.
• Patients who had experienced acute exacerbation of asthma had not always been followed up appropriately.

Following this inspection, we have rated the practice good for providing caring services.

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

Following this inspection, we have rated the practice requires improvement for providing responsive services. We identified the following area of concern:

• Complaints were not used to improve the quality of care.

Following this inspection, we have rated the practice inadequate for providing safe services. We identified the following areas of concern:

• There were not clear arrangements to deal with any behaviour inconsistent with the vision and values.
• Leaders did not always demonstrate an understanding of the challenges to quality of care and identify the actions needed to address these challenges.
• There was no credible strategy to provide high quality sustainable care.
• The overall governance arrangements were ineffective.
• The practice did not have clear and effective processes for managing risks, issues and performance.
• The practice did not always act on appropriate and accurate information.

We found three breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation. Ensure that there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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