Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Street Partnership on 19 September 2017. The overall rating for the practice was good with requires improvement for providing responsive services. The full comprehensive report on the 19 September 2017 inspection can be found by selecting the ‘all reports’ link for Church Street Partnership on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 9 October 2018 to confirm that the practice had made the recommended improvements that we identified in our previous inspection on 19 September 2017. This report covers our findings in relation to those improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings were as follows:

• The practice had comprehensive systems in place to collect and review patient feedback and audit their telephone and appointment booking systems. An improvement plan had been implemented in order to increase access for patients and enhance their experience of using the practice.
• Leaders had committed to improving performance and patient access and had invested in employing additional staff and upskilling existing staff members.
• Patients told us that they were able to obtain an appointment that was convenient to them and patient feedback demonstrated that the changes introduced by the practice had resulted in some improvements.

The area where the provider should make improvements is:

• Continue to review and ensure improvement to the National GP Patient Survey results, including access to the practice by telephone.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Street Partnership on 21 May 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe and well led services. It was good for providing a caring, effective and responsive service.

We also found the practice to be good at providing services for older people, those with long term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable, and people experiencing poor mental health, including people with dementia. As the provider was rated as requires improvement for safety and for well-led, the concerns which led to these ratings apply overall to everyone using the practice, including the population groups.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded and assessed but was not always monitored, reviewed and addressed appropriately.
• Data showed patient outcomes were average for the locality. Audits had been carried out and we saw evidence that audits were driving improvement in performance to improve patient outcomes.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Urgent appointments were usually available on the day they were requested. However, patients said that they sometimes had difficulty getting through on the telephone.
• The practice had a number of policies and procedures to govern activity but there were some omissions and policies were not always followed and monitoring processes were not always robust.
• The practice had proactively sought feedback from patients but did not actively seek feedback from non-clinical staff or provide an opportunity for them to meet as a team or give feedback on performance through appraisal.

The areas where the provider MUST make improvements are:

• Establish systems and processes to assess risks and implement actions to ensure the health and safety of people who used the service including those related to infection control, checking of emergency medicines, emergency equipment, legionella risk assessments, fire procedures and safeguarding children and adults.

• Introduce systems to provide reception and administration staff with appropriate on-going and periodic supervision, appraisal and staff meeting opportunities in their role to make sure their competencies are maintained.

• Ensure that risk assessment or a Disclosure and Barring checks (DBS) are carried out for non-clinical staff that needed this check such as those carrying out chaperone duties.

Action the provider SHOULD take to improve:

• Ensure robust systems are in place to monitor the checking of fridge temperatures, emergency medicines and equipment

• Introduce means of gaining regular effective two way communication and involvement between management and reception and administrative staff and sharing of lessons learned from complaints and significant events.

• Carry out fire drills to ensure staff know what to do in the event of a fire.

• Ensure staff are trained in equality and diversity.

• Continue to monitor and improve telephone access.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at Church Street Partnership on 30 August 2016. Overall the rating for the practice in 2016 was requires improvement; specifically it was rated requires improvement for safe, effective, responsive and well-led. During our inspection in August 2016 we identified regulatory breaches in relation to;

• Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014

- good governance.

The full comprehensive report from the August 2016 inspection can be found by selecting the ‘all reports’ link for Church Street Partnership on our website at www.cqc.org.uk.

We carried out a further announced comprehensive inspection on 19 September 2017; overall the practice is now rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patient comments highlighted that they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvements are:

• Continue to review and ensure improvement to the national GP patient survey results, including appointment waiting times, access to the practice by telephone and pre-bookable appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice