Chapel Street Medical Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence that people were protected from abuse and avoidable harm.

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

Systems were in place to protect individuals from abuse and avoidable harm, with safety clearly prioritised across the service. The provider responded seriously to concerns, and feedback from people using the service indicated they felt safe and well cared for. Safety incidents were investigated, and learning was used to identify shortfalls and prevent recurrence.

Safeguarding procedures were well established to protect those at risk, and services were designed around individuals to support safe transitions between care settings. People were supported to understand their care, enabling informed choices that reduced the risk of harm.

Leaders ensured there were sufficient numbers of appropriately skilled staff in place to deliver safe care. Pre-employment checks were completed, and staff received safeguarding training relevant to their roles, alongside regular appraisals and ongoing training to maintain high standards.

Health and safety procedures were in place, and the premises were appropriately maintained. Systems for monitoring patients’ health in relation to medicines, including those requiring regular review, were effective. Areas for improvement identified during the assessment were promptly addressed by the provider.

This service scored 66 (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 had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Managers encouraged staff to raise concerns when things went wrong. Meetings were held so that teams discussed and learnt from clinical issues, complaints or incidents. Staff described an open and transparent culture, with safety identified as a key organisational priority. There was a system to record and investigate complaints, and when things went wrong, staff apologised and gave people support. Clear processes were in place for reporting incidents, near misses, and safety related events. These issues were routinely discussed and contributed to governance oversight through integration with the wider Trust's reporting and review systems.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services. We found clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. There was a system in place to ensure all patient information including documents, laboratory test results and referrals were reviewed and actioned in a timely manner; however during our clinical searches we did find a delay in the actioning of pathology results which we discussed with the provider and action was taken to address the shortfall and strengthen the processes and oversight in place.

The provider was part of the Primary Care Network (PCN) and attended regular meetings with other agencies across the locality to share and discuss information relating to patient care and treatment, for example, people on the practice palliative care register.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns quickly and appropriately. For example, the provider regularly liaised with multi-disciplinary teams to coordinate the care for elderly residents living in care homes.

Safeguarding policies were in place and known to staff, who were appropriately trained in safeguarding procedures. The practice maintained a list of vulnerable people and acted on concerns working in partnership with other organisations.

Safeguarding was reviewed, and relevant information was shared amongst the team. Vulnerable patients were appropriately coded, and safeguarding registers were maintained. Specific coding protocols were followed for individuals identified as being at risk of domestic violence who accessed the NHS app.

Following the practice takeover by The Dudley Group NHS Foundation Trust, all the practice’s internal policies were aligned with the Trust policies to ensure consistency, accountability, and ongoing quality improvement.

The service worked with people to understand and manage risks by thinking holistically. They provided care to meet people’s needs that was safe, supportive and enabled people to do the things that mattered to them.

Emergency equipment was available and maintained. Staff could recognise a deteriorating patient and knew of action to take. Patients were advised on risks related to their condition and actions to take if their condition deteriorated.

The service detected and controlled potential risks in the care environment. They made sure equipment, facilities and technology supported the delivery of safe care.

Contracts were in place to ensure the premises were maintained. The practice provided us with evidence of health and safety risk assessments. Audits had been undertaken and risks identified had been addressed. The practice had undergone refurbishment, including upgrades to the reception area and clinical rooms, enhancing the overall environment for staff and patients. There was a fire safety policy in place and regular checks were undertaken. We saw that all staff had completed mandatory training in fire safety. Fire marshals were appointed, and the practice had carried out two fire drills in the last 12 months. There was a business continuity plan in place which was monitored and reviewed.

During the site visit, the practice informed us that a ramp was being installed to improve patient accessibility, with completion expected by September 2025.

The service ensured there was suitably qualified, skilled, and experienced staff who were supported through effective supervision, development, and ongoing training. Staff described leaders and managers as approachable, supportive and respectful, fostering a collaborative environment focused on delivering safe, person-centred care.

Nursing capacity at the practice was identified as limited, with the service operating without a full-time nurse for the past 12 months. Although cross cover arrangements had been implemented to maintain service delivery, the absence of a permanent nurse continued to present challenges. At the time of the inspection we were told that NHS Trust recruitment has additional controls in place which has impacted on the ability to recruit, as well as recent applications to job advertisements which were not from suitably qualified candidates. The provider was collaborating with the Primary Care Network (PCN) to recruit a Health Inequalities GP under the Additional Roles Reimbursement Scheme (ARRS), aiming to enhance support for the practice population. Staff reported that increasing workforce numbers would help alleviate pressure points and strengthen overall service resilience.

The practice employed a range of clinical and non-clinical roles. Training records confirmed that staff learning needs were appropriately managed. Following the transition to the Trust, it was noted that a small number of staff had experienced difficulties accessing the Trust’s training platform, resulting in some identified gaps. However, work was actively underway to resolve these issues and ensure all team members could fully engage with required learning.

Policies and processes were in place for auditing and supervising clinical staff, although oversight of the Enhanced Care Team was actively being strengthened. Nursing staff conducted weekly ward rounds, supported remotely by GP’s who provided clinical oversight. In addition, plans were progressing to reinforce clinical governance for Advanced Nurse Practitioners (ANPs), with a focus on enhancing audit processes to promote quality assurance and support ongoing professional development.

The Trust maintained recruitment policies aligned with safer recruitment standards. New staff participated in a structured induction programme and were required to complete mandatory training within designated timeframes. Staff were supported to deliver safe care through access to relevant training, development opportunities, and clinical supervision.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed. Risk assessments and audits were completed, and actions taken to mitigate risks. At the time of assessment, The Trust had completed an infection control audit and was in the process of aligning its findings and procedures with primary care standards to ensure consistency and compliance.

The service mostly made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. The service had implemented systems and processes to support safe monitoring and prescribing; however, we did identify some gaps that needed strengthening further.

Our search of the practice’s clinical system found that 8 patients living with asthma had received 2 or more courses of steroids in the last 12 months. We reviewed 3 patients and found that they were assessed appropriately. We identified 63 patients with diabetes who’s latest HbA1c (blood glucose levels) was above 75mmol/l. We reviewed 3 patients and found 2 out of 3 required further monitoring. We reviewed patients currently prescribed direct oral anticoagulants (DOACs), focusing on individuals aged over 75, those identified as frail, or those with a creatinine clearance above 30. Of the 205 patients prescribed a DOAC, 160 patients were frail or over age 75 and of this subgroup 87 (52%) were found to lack appropriate monitoring. A review of five patients found specific issues within this cohort, highlighting gaps in oversight and clinical follow-up. These findings were discussed with the provider, who acknowledged the challenges with monitoring some care home residents particularly in relation to patients receiving end of life care. The provider agreed to undertake further review and offered assurances that actions were being taken to address the concerns raised. Patients prescribed the Disease Modifying Antirheumatic Drug (DMARD) methotrexate, which is commonly used to treat autoimmune conditions, had the appropriate blood monitoring in place prior to a prescription being issued, however we sampled 5 patients and found that 4 out of the 5 did not have the specific day of methotrexate administration recorded.

Staff managed prescription stationery appropriately and securely and prescription printers were safeguarded by lockable mechanisms to prevent unauthorised use. All Patient Group Directions (PGDs) we looked at were in date and appropriately authorised. Staff stored medical gases, such as oxygen, safely. Staff checked the stock levels and expiry dates for vaccines and controlled drugs. Emergency medicines were in place; however, not all recommended items were available at the time of inspection, and there were some gaps identified in equipment checks. This was discussed with the provider, who confirmed that one of the missing medicines was on order. Emergency medicines were undergoing a review, with updated standard operating procedures being implemented. Evidence of this process was shared during the inspection.