The Care Quality Commission
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  • GP practice

Archived: Dr Vijaya Joshi Also known as Chapel Medical Centre

Overall: Good read more about inspection ratings

Chapel Medical Centre, 220 Liverpool Road, Higher Irlam, Manchester, Greater Manchester, M44 6FE (0161) 775 7373

Provided and run by:
Dr Vijaya Joshi

All Inspections

9 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Vijaya Joshi on 15 March 2016. The overall rating for the practice was good, however the practice required improvement in the key question safe. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Dr Vijaya Joshi on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 9 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 15 March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as good.

Our key findings were as follows:

  • We reviewed a range of documents and spoke with staff which demonstrated they were now meeting the requirements of Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014: Safe care and treatment and Regulation 19 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014: Fit and proper persons employed
  • Significant events were now recorded appropriately and systems were in place to disseminate learning from the discussion and analysis of these, with a clear audit trail in place.
  • The registered provider had ensured that recruitment arrangements included all necessary employment checks for all staff that included taking up references and completing enhanced disclosure and barring service checks, in particular for staff who were already undertaking chaperoning duties.

On this inspection we also found that the practice had:

  • Reviewed the Patient Group Directions and the Patient Specific Directions to ensure they are all signed.
  • Ensured that non-clinical team meetings were held on a regular basis.
  • Implemented a note summarising procedure and note summarising training for staff performing the task.
  • Reviewed confidentiality at the reception desk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chapel Medical Practice on 15 March 2016. Overall the practice is rated as good.

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

  • There was an inconsistent system in place for reporting and recording significant events, however we found examples of events that were not reported through a clinical governance system.
  • Risks to patients were assessed and well managed.
  • 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.
  • 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.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • 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 and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvement are:

  • Ensure staff performing chaperone duties have a valid disclosure and baring service check or risk assessment.
  • Ensure all staff are aware of what constitutes a significant event and that they are reported through a clinical governance system.

The areas where the provider should make improvement are:

  • Review the Patient Group Directions and the Patient Specific Directions to ensure they are all signed.
  • Ensure that non-clinical team meetings are held on a regular basis.
  • Review the process for amending medical records and ensure a clear audit trail is maintained.
  • Implement a note summarising procedure and note summarising training for staff performing the task.
  • Review confidentiality at the reception desk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice