The Care Quality Commission
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  • GP practice

Archived: Church View Medical Centre

Overall: Good read more about inspection ratings

Silksworth Terrace, Sunderland, Tyne and Wear, SR3 2AW (0191) 521 1753

Provided and run by:
City Hospitals Sunderland NHS Foundation Trust

All Inspections

24 October 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at Church View Medical Centre on 24 October 2016.

We had previously carried out an inspection of the practice on 8 September 2015 when a breach of legal requirements was found. The practice could not demonstrate their approach to audit supported them to improve either clinical outcome for patients or improved clinical practice.

After the inspection on 8 September 2015 the practice wrote to us to say what they would do to meet the legal requirements set out in the Health and Social Care Act (HSCA) 2008.

In October 2016 we undertook a focused inspection where we asked the Trust to send us information to evidence that they now met legal requirements. This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Church View Medical Centre on our website at www.cqc.org.uk.

Our key findings were as follows:

  • The practice had taken action in relation to the requirement notice we issued at the last inspection and were no longer in breach of regulations. The practice had increased focus on clinical audit. There was a clinical audit plan in place and there was evidence this was discussed regularly through clinical and team meetings. The Trust provided us with several examples of completed clinical audit cycles.
  • The practice had also addressed those areas we told them they should consider improving. They had carried out a formal legionella risk assessment. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings). They had updated their complaints leaflet to detail the arrangements for external resolution.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church View Medical Centre on 8 September 2015. Overall the practice is rated as good.

We had previously carried out an inspection of the practice on 16 September 2014 when breaches of legal requirements were found;

  • Regulation 10 HSCA 2008 (Regulated Activities) Regulations 2010 Assessing and monitoring the quality of service (which corresponds to Regulation 17 of the HSCA 2008 (Regulated Activities) Regulations 2014);
  • Regulation 22 HSCA 2008 (Regulated Activities) Regulations 2010 Staffing (which corresponds to Regulation 18 (1) of the HSCA 2008 (Regulated Activities) Regulations 2014);

After the inspection on 16 September 2014 the practice wrote to us to say what they would do to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008.

We undertook this comprehensive inspection to check that they had followed their plan and to confirm that they now met legal requirements.

Our key findings were as follows:

  • The practice had addressed all of the issues identified during the previous inspection with the exception that they could not demonstrate on going quality improvement and effective care through completed clinical audit cycles.
  • Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Staff had received training appropriate to their roles.
  • 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.
  • Patients said they were able to get an appointment with a GP when they needed one with urgent appointments available the same day. However, they thought continuity of care was difficult. We saw the provider had taken steps to improve this since the previous inspection in September 2014, with the recruitment of another GP, which still needed time to become effective.
  • The practice offered open access practice nurse clinics and phlebotomy clinics every day. There was also access to a CCG initiative of extended hours which the practice participated in 6pm until 8pm.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure in place and staff felt supported by management. The practice sought feedback from staff and patients, which they acted on.
  • Staff throughout the practice worked well together as a team.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Improve the system for clinical audit. There were no two cycle completed audits which could demonstrate changes resulting in improvements of outcomes for patients since the initial audit.

In addition the provider should:

  • Carry out a formal legionella risk assessment.
  • Update the leaflet given to patients who wish to make a complaint to specifically contain information regarding taking a complaint further than the practice, for example to NHS England or the Parliamentary and Health Service Ombudsman.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

16 September 2014

During a routine inspection

Church View Medical Centre is a GP practice located in the Silksworth area in the City of Sunderland. The provider of the service is City Hospitals Sunderland NHS Foundation Trust (the trust). It is housed in purpose built premises and has a list of approximately 6,000 patients.

During our inspection we spoke with GPs (two salaried and one locum), the practice manager and deputy practice manager, a nurse practitioner, practice nurse and reception and administration staff.

We found further improvements were required for safety as some safety concerns were not dealt with quickly. There were not enough GPs to ensure continuity of care to patients.

There were systems in place to identify risks to patients and staff in terms of safeguarding, health and safety, fire and infection control.

Further improvements were needed for the practice to be effective as there were limited audits of patient outcomes to drive improvement. There were no formal arrangements to follow National Guidelines.

All of the patients we spoke with said they were treated with respect and dignity by the practice staff.

Further improvements were needed for the practice to be responsive to people’s needs. Patients said they were satisfied with the appointment systems operated by the practice, however, continuity of care suffered because of only one salaried GP being employed there from January 2014. There was an accessible complaints system but the system for dealing with this or learning from complaints was unclear.

Further improvements were needed for the practice to be well-led. There was no clear leadership or lines of accountability. There was no clear vision or strategy for the practice to move forward. Policies and procedures were not specific to the practice.

The practice was in breach of the Regulation 10 of Health & Social Care Act 2008 (Regulated Activities) Regulations 2010 relating to assessing and monitoring the quality of service and in breach of Regulation 22 of Health & Social Care Act 2008 (Regulated Activities) Regulations 2010 relating to staffing.