Chapel Street Medical Centre

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

This is the first inspection for this service since its registration with CQC. This key question has been rated as Good.

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

We found that staff involved people in decisions about their care and treatment and provided them advice and support. Staff worked together and collaboratively with other services to make sure people could access other services easily.

Patients received care and treatment that supported them to live healthier lives including being supported to undertake national screening programmes and vaccinations. Patients who required monitoring underwent regular checks on their health.

Multi-disciplinary meetings were held where the needs of patients with complex conditions or those approaching the end of life could be discussed, reviewed and planned for. The supporting documents and alerts where people had undergone an assessment for ‘Do Not Attempt Cardiopulmonary Resuscitation’ (DNACPR) were available on the patient record system.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service ensured that people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them; however, some records did not always provide sufficient detail. Feedback from people using the service felt that their needs were met and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community and staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had systems in place that effectively identified people with previously undiagnosed health conditions. Systems were in place to support mental health reviews, NHS health checks, immunisations, cervical screening, and the ongoing monitoring of individuals with long-term conditions. Despite these provisions, the practice acknowledged challenges in encouraging patient attendance for routine monitoring particularly among groups resistant to engagement or facing barriers to access. In response, the practice implemented outreach services to improve uptake and ensure that vulnerable and underserved populations received appropriate care. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had systems to identify people with previously undiagnosed conditions. However, during our remote clinical review, we carried out a clinical search to identify people who had potentially been missed as having diabetes. The search identified 3 people. We reviewed each clinical record and found 2 people had not been followed up within the timeframe and a code was not added. Following the clinical review, we spoke with the provider who confirmed that all patients identified were being reviewed. We found the provider held registers which were reviewed to prioritise care for their most clinically vulnerable patients. For example, we reviewed a sample of patients with a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) record to consider whether the DNACPR had been prepared and found this had been reviewed and agreed appropriately. Care home staff reported that the system of regular calls and visits to assess and review residents was largely consistent. The practice ensured that care home residents were able to register with the practice promptly to ensure continuity of care. Each care home had an allocated clinician who visited weekly. Care home staff had access to a direct telephone line to the practice to facilitate timely assessments and address prescription related queries. There were appropriate referral pathways to make sure that patients’ needs were addressed.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Most of the clinical records we saw demonstrated care was provided in line with current guidance, however we saw some areas where safety netting was not always in place.

We reviewed a safety alert for patients prescribed a medicine for epilepsy and migraines, which carries an increased risk of birth defects. We conducted a review of two relevant patient records. The review found that while one patient had appropriate safeguards in place, the other did not have a documented pregnancy prevention plan.

We saw that the service had a programme of regular searches of the patient clinical records system, to ensure patient care and monitoring was being actioned. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring and the service had designated staff members to support and co-ordinate this approach.

There were systems in place to ensure staff were up to date with relevant legislation, evidence-based practice and required standards. The remote clinical searches we undertook of the practice’s clinical records system included reviewing the monitoring of people with long-term conditions to assess if National Institute for Health and Care Excellence (NICE) recommendations were followed.

For example, we identified 63 patients with diabetes whose last blood glucose reading was over 75. We reviewed a random sample of 3 patient records and found all patients had their diabetes and diabetic medication reviewed following this blood glucose result.

One of our clinical records searches reviewed the number of patients with asthma who had been prescribed two or more courses of rescue steroids in the last 12 months. We identified a total of 8 patients and reviewed a random sample of 3 patient records and found all patients had been followed up appropriately and had received an adequate annual asthma review, however for some patient’s safety netting needed to be consistently in place for those at risk of an exacerbation.

For patients with hypothyroidism, our clinical records searches identified 9 patients who had not had thyroid function test monitoring for 18 months. We reviewed a patient record and found appropriate monitoring was in place.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

The practice provided care for a significant number of local care homes. An Enhanced Care Home team was in place to ensure effective coordination when individuals received care from multiple teams or services. Clinically vulnerable patients were prioritised, and the provider worked collaboratively with other professionals to deliver integrated care packages. We spoke to a number of care home representatives who was largely positive, highlighting levels of satisfaction with Chapel Street Medical Practice; however, some feedback reported issues with responsiveness and prescription errors.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

There were flags on patients records who were vulnerable and required ongoing monitoring and recalls in place to review patients and educate them to manage their health needs. There was regular engagement with community services and referral pathways in place. The practice website detailed information and links for health promotion, health conditions and common health questions.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

Staff actively signposted patients to local support services offering information, education, and tailored advice based on individual needs. This included referrals for diabetes education and dietary guidance. Patients were encouraged to participate in national health initiatives, such as cancer screening programmes and childhood immunisations.

The practice acknowledged challenges in their uptake for immunisations and cancer screenings and was working collaboratively to improve engagement. Follow up contact was made with patients who did not attend appointments, reinforcing the importance of participation and promoting continued access to preventative care.

The practice maintained close links with local voluntary organisations to foster community cohesion and carried out outreach activities to engage with hard to reach populations. This included attending community events such as the local carnival to raise awareness and educate people within the community.

The latest GP Patient Survey carried out, showed that 95% of respondents felt their needs had been met during their last general practice appointment which was higher than the national average of 90%.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes met both clinical expectations and the expectations of people themselves.

Cervical screening uptake at the practice was 34% in 24-49 year olds and 70% in 50-64 year olds, which was below the national target of 80%. In addition, national data showed that all five indicators for childhood immunisations fell short of the World Health Organisation’s minimum threshold of 90%. These areas had consistently underperformed over time. Having taken over the service within the past 12 months, the provider acknowledged that improving engagement with preventative care remained a significant challenge. Contributing factors included patient reluctance to participate in screening and immunisation programmes, as well as language barriers affecting many individuals within the local population. Despite these obstacles, the provider continued to review performance and actively worked with stakeholders and patients to identify ways to improve uptake. For example, strengthening community engagement and providing a range of multilingual literature and educational events were held to raise awareness and encourage participation in screening and immunisation programmes.

The practice had an established programme of clinical and non-clinical audits aimed at driving continuous improvement in patient care and operational efficiency. This included audits of clinical notes, clinical coding accuracy, medicines management and prescribing practices, as well as ethnicity data to support equitable service delivery.

Additional audits focused on care home residents, examining hospital admissions, the appropriateness and completion of ReSPECT forms, and strategies to prevent avoidable hospitalisations. Monthly mortality reviews were conducted to assess the quality of end-of-life care and identify opportunities for improvement. These reviews supported reflective learning and informed changes to enhance patient outcomes and safety.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. There were policies and procedures in place such as mental capacity and best interest meeting. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. The provider carried out mortality audits each month to identify areas for improvement.

We saw evidence that consent was obtained for patients so that they understand their rights around consent to the care and treatment they are offered.

The national GP patient survey demonstrated that 96% of patients were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. This was higher than the local average of 90% and the national average of 91%.