Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Cheylesmore Surgery on 8 and 15 September 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The practice was found to be inadequate in safe, effective and well led and requires improvement in caring and responsive. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for The Cheylesmore Surgery on our website at www.cqc.org.uk.

An announced comprehensive inspection was carried out on 7 June 2017 following the period of special measures. Overall the practice is now rated as good.

Our key findings were as follows:

• Logs were kept of significant events and complaints and both were a standing item on the agenda at clinical and full practice meetings.
• Safeguarding processes had been tightened and multi-disciplinary meetings took place on a regular basis.
• The clinical team was trained to child protection or child safeguarding level three.
• Regular monitoring and reviews were carried out for patients on high risk medicines.
• Regular checks were carried out on emergency equipment to make sure that it was fit for use and regular checks were carried out.
• Recruitment processes had been introduced for locum GPs and new staff, which ensured that all relevant pre-employment checks were carried out and documented.
• Systems had been implemented to ensure that housebound patients were identified for appropriate review of their healthcare needs.
• A proforma had been introduced to improve communication with providers of other healthcare services, including the out of hours service.
• There were systems to ensure that all clinicians kept up to date with national guidance, guidelines and legislation including the Mental Capacity Act 2005.
• Staff had access to appropriate policies and guidance so that they could carry out their roles in a safe and effective manner.
• Staff were encouraged to study e-learning modules. A training log was kept to track training for all staff.
• Governance arrangements had been introduced which included systems for assessing and monitoring risks and the quality of service provision.
• Patient safety alerts were received electronically, logged and actions tracked.
• Prescription pads were monitored within the practice
• Staff were aware of the business continuity plan.
• The arrangements for storing medicines had been strengthened.
• Quality improvement activities, including regular audits, were undertaken.
• The practice produced an action plan in response to the in-house patient survey.
• The number of carers identified had doubled to 2% since the last inspection and appropriate support was offered.
• A portable hearing loop had been installed.
• The arrangements for making contact with bereaved families had been improved.
• Communication with other stakeholders, such as care home managers, had improved.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This practice is rated as Good overall. (Previous rating June 2017 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at The Cheylesmore Surgery on 18 July 2018 in order to check that satisfactory progress had been maintained since the practice was taken out of Special Measures as a result of the inspection in June 2017.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. The practice discussed incidents, learned from them and improved their processes in order to prevent a recurrence.
• 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 and best practice.
• There were clear responsibilities, roles and systems of accountability to support effective governance.
• Patients told us that staff involved and treated them with compassion, kindness, dignity and respect.
• Patient feedback on the level of care and treatment delivered by all staff was very positive. The majority of patients said that they found the appointment system easy to use and reported that they were able to access care when they needed it.
• Continuous learning and improvement was actively encouraged at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to monitor the availability of clinical appointments in response to the growing patient population.
• Continue to monitor and act on the results of patient satisfaction surveys in order to meet the needs of the patient population.

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

Please refer to the detailed report and the evidence tables for further information.