- GP practice
Chapel Street Medical Centre
Report from 1 May 2025 assessment
Contents
Ratings
Our view of the service
Date of Assessment: 10 July 2025 to 16 July 2025. Chapel Street Medical Centre is a GP practice and delivers service to 3,456 under a contract held with NHS England. The practice is operated and managed by The Dudley Group NHS Foundation Trust, which oversees its governance, strategic direction, and clinical service delivery. The Trust became the registered provider for Chapel Street Medical Centre on 16 December 2024, with practice staff formally transferred as part of the transition. The National General Practice Profiles states that 39.3% of patients registered at Chapel Street Medical Centre are Pakistani, 12%; Asian other, 19.3% are white other including Roma, 25.1% are white British and 4.3% are other ethnic groups. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 2nd decile (2 of 10). The lower the decile, the more deprived the practice population is relative to others. The practice provides care for a significant number of care homes across the Dudley area, serving an elderly and vulnerable patient population. Additionally, the practice provides services to a diverse demographic, including Pakistani, Romanian, and other ethnic backgrounds, some of whom experience challenges related to language barriers. The provider also hosts face to face appointments for the Special Allocation Scheme on behalf of the Other Dudley Group Foundation Trust practice High Oak Surgery. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report. The service had a good learning culture and people could raise concerns. The provider investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were staff with the right skills, qualifications and experience and recruitment was kept under review. The provider made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice, however some areas required strengthening. 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. Staff involved family members, carers, or advocates in decision making processes for those who lacked capacity, ensuring that all actions taken were in the person's best interests. People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing. People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service demonstrated a proactive approach to reducing health and care inequalities through training, feedback, and collaborative engagement with the local community. Particular emphasis was placed on reaching underserved populations, with efforts focused on education and improving timely access to appropriate care. People were involved in planning their care and understood options around choosing to withdraw or not receive care. 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. Managers worked with the local community to deliver the best possible care and were receptive to new ideas.
People's experience of this service
The practice encouraged and used feedback from patients who used the service to make improvements. As part of this assessment, we reviewed patient feedback data available from the National GP Patient Survey and the NHS Friends and Family Test (FFT).
Feedback from the National GP Patient Survey was above national averages in the majority of outcomes. For outcomes in relation to kindness, compassion and dignity, we found 88% responded positively to the overall experience of the practice (national average 75%), 94% felt the healthcare professional was very good or fairly good at listening to them (national average 87%), 97% had confidence and trust in the healthcare professional they saw or spoke to (national average 93%), 91% felt the healthcare professional was good at treating them with care and concern (national average 86%); 96% felt they were involved as much as they wanted to be in decisions about their care and treatment (national average 91%) and 88% felt the reception and administrative team were helpful (national average 83%). Feedback regarding access showed that 79% responded positively to the overall experience of contacting their GP practice (national average 70%) and 70% responded positively to how easy it was to contact their GP practice by phone (national average 53%).
The Friends and Family Test data for May 2025 showed that 80% of patients rated their overall experience of the service as ‘very good’.
We also invited patients to share their experience of the service they received via the Give Feedback on Care form on the Care Quality Commission’s website. We received comments from 10 people who provided feedback about the practice at the time of the assessment. Most of these comments (90%) were wholly positive about the service. While some feedback noted concerns around delays in diagnosis, others praised the service for being accessible and commended staff for their helpfulness, kindness, and supportive approach.
Feedback from local care homes whose residents received GP services from the practice was largely positive. The homes highlighted the provider’s responsiveness and level of care, which included regular ward rounds, medication reviews, and access to a dedicated communication channel for urgent requests. However, we did receive feedback regarding some concerns regarding delays in responsiveness. The provider was committed to working collaboratively with care home staff and residents.