We carried out an announced comprehensive inspection at Church Lane Surgery on 6 March 2019 as part of our inspection programme.

At the last inspection in April 2018, we rated the practice as requires improvement overall and specifically requires improvement for providing safe and well-led services because:

• There were inconsistent arrangements in how risks were assessed and managed. For example, during the inspection, we found risks relating to health and safety of the premises and patients including fire safety arrangements, management of legionella and management of blank prescription forms.
• There was a lack of good governance in some areas.

Previous reports on this practice can be found on our website at: www.cqc.org.uk/location/1-496491998. 

At this inspection, we found that the provider had demonstrated improvements in some areas, however, they were required to make further improvements in some areas and are rated as requires improvement for providing safe and well-led services.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall and good for all population groups.

We rated the practice as requires improvement for providing safe services because:

• Risks to patients were assessed and well managed in some areas, with the exception of those relating to safety alerts, infection control procedures and recruitment checks.
• The provider did not have a second thermometer which could log all the data and provide assurance that temperatures had been within the required range, nor was the existing thermometer calibrated at least monthly, as recommended in Public Health England guidance.
• Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes.

We rated the practice as requires improvement for providing well-led services because:

• There was a lack of good governance in some areas.
• The practice had not had an effective system to identify and monitor who was collecting the repeat prescriptions for controlled drugs from the reception.
• The practice had failed to take appropriate action in a timely manner to address the risk identified during the previous inspection in April 2018, regarding the rear fire exit door, which required to be fitted with a panic or push bar.
• The practice had not had a system to follow up women (after 12 weeks) who were prescribed contraceptive depot injections.
• There were no failsafe systems to follow up women who were referred as a result of abnormal results after the cervical screening.
• The practice was aware of and complied with the requirements of the Duty of Candour.
• There was a clear leadership structure and staff felt supported by the management.

We rated the practice as good for providing effective, caring and responsive services because:

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs.
• Patients could access care and treatment in a timely way. Patients were able to ring a duty GP directly (bypassing the reception) for a telephone consultation between 8.30am to 9am and 11.30am to 12pm Monday to Friday.
• The practice was encouraging patients to register for online services and 30% of patients were registered to use online Patient Access.
• Information about services and how to complain were available and easy to understand.

The areas where the provider must make improvements as they are in breach of regulations are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Review and improve the current arrangements to monitor effectively the use of blank prescription forms for use in printers and handwritten pads.
• Consider ways to improve the identification of carers to enable this group of patients to access the care and support they need.
• Continue to review and monitor the outcomes of patients with diabetes.
• Continue to review, monitor and encourage uptake of bowel cancer screening.
• Review ways to improve patients’ satisfaction with care and treatment, telephone access and refurbishment of the premises.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

This practice is rated as

requires improvement

overall.

(Previous inspection October 2014 - The practice was rated as good overall).

The key questions are rated as:

Are services safe? - Requires improvement

Are services effective? - Good

Are services caring? - Good

Are services responsive? - Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at Church Lane Surgery on 11 April 2018 as part of our inspection programme. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether Church Lane Surgery was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

• There were inconsistent arrangements in how risks were assessed and managed. For example, during the inspection, we found risks relating to health and safety of the premises and patients including fire safety arrangements, management of legionella and management of blank prescription forms.
• There was a lack of good governance in some areas.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• We found that completed clinical audits were driving positive outcomes for patients.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• Patients were able to ring a duty GP directly (bypassing the reception) for a telephone consultation between 8.30am to 9am and 11.30am to 12pm Monday to Friday.
• Information about services and how to complain were available and easy to understand. However, information about a translation service was not displayed in the reception areas and there were limited information posters and leaflets available in other languages.
• Staff we spoke with on the day of inspection informed us there was a clear leadership structure and they felt supported by the management.
• There was a strong focus on continuous learning and improvement at all levels of the organisation. However, clinical meetings were not documented.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Ensure all staff have received formal sepsis awareness training.
• Implement the system to promote the benefits of bowel cancer national screening in order to increase patient uptake.
• Review the process of identifying carers to enable them to access the support available via the practice and external agencies.
• Ensure information about a translation service is displayed in the reception area informing patients this service is available. Ensure information posters and leaflets are available in multi-languages.
• Improve access to patients with hearing difficulties.
• Ensure the most recent CQC rating is clearly displayed.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Church Lane Surgery on 23 October 2014. We rated the practice as ‘Good’ for the service being safe, effective, caring, responsive to people’s needs and well-led. We rated the practice as ‘Good’ for the care provided to older people and people with long term conditions and ‘Good’ for the care provided to, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

• The practice was visibly clean and infection control procedures were in place. Staff understood their responsibility to raise concerns and report incidents. Staff learnt from the outcomes of investigations into incidents and complaints. The practice had policies and procedures to monitor safety and respond to risk.
• Patients were offered effective care from GPs who met their medical needs. Staff were qualified and trained and had the skills to carry out their role effectively.
• Patients felt supported and said they were treated with dignity and respect by their GP.
• Patients needs were met through the way in which services were organised and delivered. The appointments system was easy to use and overall patients were satisfied with the availability of appointments.
• The leadership, management and governance of organisation and the practice supported learning and innovation. Staff and patients were involved in developing services and planning for the future.

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

• The provider should ensure all clinical staff are aware of the Mental Capacity Act 2005 and how this will impact on care and treatment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice