Chapel Street Medical Centre

On this page

• Overview
• Person-centred Care
• Care provision, Integration and continuity
• Providing Information
• Listening to and involving people
• Equity in access
• Equity in experiences and outcomes
• Planning for the future

We looked for evidence that the service met people’s needs, and that staff treated people equally and without discrimination.

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

People using the service provided positive feedback regarding their ability to access care and treatment. Services were available when needed, with no significant physical or digital barriers, including access outside of normal hours and in emergencies.

Leaders demonstrated a clear understanding of the challenges faced by certain patient groups and actively worked to design services that were timely, inclusive, and responsive particularly for those most at risk of exclusion. Resources and opportunities were prioritised to reduce inequalities and promote equity of access across the patient population.

The provider engaged positively with partner agencies, with a particular focus on supporting older individuals in care homes and patients facing barriers to healthcare. People were actively involved in planning their care and were supported to understand their options, including the right to decline or withdraw from treatment. This approach promoted autonomy, dignity, and informed decision-making.

Clear information was provided to patients on how to raise concerns or make a complaint. The provider demonstrated a strong understanding of its population and took proactive steps to identify and implement service improvements.

Leadership teams were committed to continuous improvement, actively seeking ways to overcome barriers to patient experience and outcomes. The provider also worked collaboratively within the Primary Care Network (PCN), contributing to the development of local services and supporting wider system integration.

This service scored 75 (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 made sure people were at the centre of their care and treatment choices and they decided, in partnership with people, how to respond to any relevant changes in people’s needs.

Care plans reflected physical, mental, emotional, and social needs of patients including those related to protected characteristics under the Equality Act. Our review of clinical records showed patients were supported to understand their condition and were involved in planning for their care needs. They were also involved in decisions about their care.

Peoples overall experience of the GP service was positive as demonstrated in the National GP Patient survey, where the practice had achieved 88%, which was higher than the local average of 71% and the national average of 75%.

Patient satisfaction scores in the GP National Patient Survey were higher than local and national averages, particularly in areas relating to patient centred care. For example, 88% of respondents found the reception and administrative team helpful, in comparison to the local average of 79% and the national average of 83%.

A review of clinical records confirmed that patients were supported in understanding their conditions and were actively involved in planning and making decisions about their care.

The service understood the diverse health and care needs of people and their local communities. Care was joined-up, flexible and supported choice and continuity. We saw the practice worked in partnership with other services and the community to meet the needs of its patient population.

The practice had tailored its services to meet the diverse needs of its community. For example, working with services to help improve the uptake of cervical screening and immunisations amongst Minority Ethnic groups. An administrator was appointed to focus on improving quality outcomes for patients with an emphasis on improving targets for the various immunisation and screening programmes. Practice staff were able to offer patients access to other services such as pharmacists, social prescriber, paramedic, first contact mental health practitioner, care coordinator, a health and wellbeing coach and a phlebotomy service.

The provider had established systems for engaging with care homes, ensuring consistent and coordinated care delivery. Clinicians were specifically employed within the Enhanced Care Home team and assigned to designated care homes, where they conducted weekly ward rounds. This approach supported continuity of care and close collaboration with care home staff, enhancing clinical oversight and responsiveness to residents’ needs.

The service supplied appropriate, accurate and up-to-date information in formats that were tailored to individual needs.

Information to promote the take up of health screening was available in a range of languages. The practice had access to interpreter services. Information provided by the service met the Accessible Information Standards. Patients were informed as to how to access their care records.

The practice website included useful information on health awareness and promotion. Information and resources were available for patients to support them to understand how to access services. For example, the service had arrangements in place to support individuals requiring translation services or those who may be digitally excluded. To further enhance accessibility, flashcards were made available at reception to assist Romanian speaking patients who may not be fluent in English.

The GP Patient Survey results found that 91% of respondents stated the health care professional they saw had all the necessary information about them.

The service made it easy for people to share feedback and ideas, or raise complaints about their care, treatment and support. They involved people in decisions about their care and told them what had changed as a result.

We saw complaints were managed in line with the Trust’s policy. There were processes within the Trust and meetings at a practice level where complaints were discussed to share learning to make improvements. Information about how to complain was readily available and patients could make a complaint in person or via the practice website.

Feedback from the GP national patient survey demonstrated that 94% of patients say the healthcare professional they saw or spoke to was good at listening to them during their last general practice appointment. This was above with the local average of 84% and the national average of 87%.

The service made sure that people could access the care, support and treatment they needed when they needed it.

The practice demonstrated responsiveness to the needs of its patient population by actively developing services tailored to local requirements. The provider reported that 85% of patient attendances were face to face presentations, and this demand was effectively managed to ensure continuity of care.

On the day of inspection, same day appointments with a GP were readily available, reflecting the practice’s commitment to flexible and timely access to care.

Appointments were accessible for individuals with a learning disability, and multiple routes of access were provided including online, in-person, and telephone options to accommodate varying preferences and needs.

Treatment rooms were located on the ground floor to support physical access, and further improvements were underway, including the planned installation of a ramp to enhance accessibility for all patients.

The practice told us they obtained feedback from various sources such as complaints and via informal feedback from patients. The GP national patient survey showed 70% of respondents found it easy to get through by phone. This was significantly higher than the local average of 48% and the national average of 53%.

Staff and leaders actively listened to information about people who are most likely to experience inequality in experience or outcomes and tailored their care, support and treatment in response to this.

The practice had promoted and responded to feedback by people who used the service within the last 12 months. People were able to share their views via the practice website or by contacting The Trust directly. Friends and Family Test data from May 2025 indicated that 80% of patients rated their overall experience of the service as ‘very good’. Staff used appropriate systems to capture and review feedback, including from individuals who did not speak English or had internet access. Patients reported being treated equally and without discrimination, and staff were described as respectful and supportive.

The provider complied with legal equality and human rights requirements, including avoiding discrimination, considering the needs of people with protected characteristics, and making reasonable adjustments to support equitable experiences and outcomes. The practice met the Accessible Information Standard (AIS); however, it was noted that a hearing loop was not available at the time of the assessment.

Due to language barriers the practice demonstrated flexibility in accommodating walk in patients who required face to face appointments. Staff were able to speak a range of languages and had access to interpreters to support communication with patients if required.

The provider had processes to ensure people could register at the practice, including those in vulnerable circumstances such as homeless people. Staff used appropriate systems to capture and review feedback from people using the service, including those who did not speak English or have access to the internet.

People with learning disabilities and poor mental health experienced additional care through annual reviews. People with dementia were referred to appropriate services where required.

Feedback provided by people using the service, both to the provider as well as to CQC, was positive. Staff treated people equally and without discrimination. Leaders proactively sought to identify and address barriers to care, working in partnership with local organisations, including those in the voluntary sector, to reduce health inequalities and improve patient experience.

People were supported to plan for important life changes, so they could have enough time to make informed decisions about their future, including at the end of their life.

Leaders understood the requirements of legislation when considering consent and decision making and had access to policies to support them. The provider supported a significant number of care homes and facilitated multidisciplinary meetings to review and coordinate patient care and treatment. These meetings included discussion of patients on the palliative care register to ensure continuity and responsiveness in end-of-life care.

Regular death audits were conducted to monitor quality and adherence to key processes, including documentation of preferred place of death, Recommended Summary Plan for Emergency Care and Treatment (ReSPECT) forms, DNACPR decisions, and verification procedures to support safe, personalised care planning and accountability across clinical teams.

There were registers held for those patients who were vulnerable who were on the palliative care register or at the end of their life. We found that clinicians understood the requirements of legislation and guidance when considering consent and decision making and saw that consent was documented.

Our records review showed people were supported to consider their wishes for their end-of-life care, including cardiopulmonary resuscitation. This information was shared with other services when necessary.