Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Chapel Street Surgery on 19 January 2016. Overall the practice is rated as good.

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

• We found that the service provision at Chapel Street Surgery was safe, effective, caring, responsive and well led. Staff we spoke with were confident to report serious incidents, whistle blow or challenge poor practice.There were arrangements in place to implement good practice and learn from any untoward incidents. There was an open culture that focused on patient safety.

• Risks to patients were assessed and well managed. Information about safety was monitored, appropriately reviewed and addressed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. There were regular multi-disciplinary team discussions to ensure patients’ care and treatment was coordinated and the expected outcomes were achieved.
• We found that staff were supported to participate in training and development which would enable them to deliver effective quality care.
• Patients said they were treated with compassion, dignity and respect, and they were involved in their care and decisions about their treatment. They were complimentary about the dedication of the doctors at the surgery. Information about services and how to complain was available and easy to understand.
• Patients said they could make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. Access on the phone and waiting times were considered too long by patients at times. We saw that actions were being taken to improve these timeframes.
• The premises were not purpose built but ongoing refurbishments maintained an acceptable standard, although access for disabled people was restricted in parts of the surgery. Plans to extend and improve the premises were in place.
• There was a clear leadership structure. All staff were appropriately qualified and competent to carry out their roles safely and effectively in line with best practice.
• The practice had a system in place for staff appraisals, and staff told us they felt valued and supported by the provider.
• The provider was aware of and complied with the requirements of the Duty of Candour. The practice sought feedback from staff and patients, which it acted on.

However, there was an area where the provider should make improvements.

The provider should strengthen systems for recording outcomes and practice changes identified from monitoring the services provided to ensure a clear audit trail that includes discussions with staff, the implementation of action plans and the cascading of learning.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We inspected Chapel Street Surgery on 13 January 2014.

We found information, health promotion and other notices in the waiting room such as, safeguarding and support services for people. We received positive comments from people about the care provided by the surgery. For example one person told us: “This is an excellent surgery.”

We saw that staff spoke politely to people and consultations were carried out in private treatment rooms.

We saw the surgery had appropriate medicines management arrangements in place.

Staff were supported by annual appraisals and received appropriate training and development.

We saw that both paper and electronic records were maintained and kept securely.