The Care Quality Commission
  • Doctor
  • GP practice

Church Street Practice

Overall: Good read more about inspection ratings

Weybridge Primary Care Centre, 22 Church Street, Weybridge, Surrey, KT13 8DW (01932) 504450

Provided and run by:
Phoenix Family Practice

All Inspections

8 August 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at Church Street Practice on 8 August 2023. Overall, the practice is rated as good.

Safe - good

Effective - not inspected, rating of good carried forward from previous inspection

Caring - not inspected, rating of good carried forward from previous inspection

Responsive - not inspected, rating of good carried forward from previous inspection

Well-led - not inspected, rating of good carried forward from previous inspection

Following our previous inspection on 31 July 2019, the practice was rated good overall and for all key questions but requires improvement for providing safe services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Church Street Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection. This inspection was to follow up breaches of regulations 12: safe care and treatment and 18: staffing as identified in our previous inspection. We also reviewed staff immunisation as this was identified as an area for improvement in our previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Requesting evidence from the provider.
  • A short site visit.

Our findings

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 found that:

  • Staff training had been completed in line with practice policy, including safeguarding children and adults and infection prevention and control training.
  • Vaccines were appropriately stored, monitored and transported in line with UK Health Security Agency (UKHSA) guidance to ensure they remained safe and effective.
  • Blank prescriptions were kept securely, and their use monitored in line with national guidance.
  • Staff vaccination was maintained in line with current UKHSA guidance if relevant to role.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

31 July 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Church Street Practice on 31 July 2019. This was to follow up on a breach of regulations identified at our previous inspection on 3 July 2018, the practice was rated good overall and requires improvement for providing safe services. The details of these can be found by selecting the ‘all reports’ link for Church Street Practice on our website at www.cqc.org.uk.

During the inspection looked at the following key questions

  • Is it Safe

Our judgement of the quality of care at this service is based 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.

The practice remains rated as good overall and for all the population groups.

The key question remains rated as:

Are services safe? – Requires improvement

At this inspection we found some improvements:

  • The procedure for monitoring patients prescribed high risk medicines had been improved and was reviewed by a clinical pharmacist and GPs.
  • Health and safety risk assessments had been completed.
  • Non-clinical staff had received training in sepsis awareness.
  • Recruitment procedures were established and operated effectively to ensure only fit and proper persons are employed and specified information is available regarding each person employed, including locum staff.
  • The practice had reviewed patient feedback from all sources and improved their engagement with patients. Patient satisfaction was in line with local and England averages.

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

  • Staff training was not up to date, including infection control, hand hygiene, information governance, fire training and safeguarding.
  • The recording of fridge temperatures where vaccines were stored had been improved however action taken and recording of action when temperatures were out of range was not sufficient.
  • The practice system for storing and monitoring prescription stationary had been improved but did not maintain clear and unambiguous records of prescription forms that were distributed to prescribers and prescription forms were not stored securely once distributed to prescribers.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review and improve how staff immunisation status is monitored in line with current Public Health England guidance.

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

3 July 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating July 2016 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires improvement

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 Church Street Practice on 3 July 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • 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.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

The building that the practice was located in was destroyed in a large fire in July 2017. Through strong team work and by working with external stakeholders the practice provided a basic service to their patients for the first 48 hours following the fire. A full service was provided by the practice based in a local community hospital for six months before moving back to the original location in temporary modular buildings. The practice worked to ensure that a service was provided to patients throughout this period minimising impact to patients and staff. Feedback we received from patients praised the practice for the service provided following the fire.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

  • Review and improve the monitoring of patients prescribed high risk medicines.
  • Review and improve engagement with patients, including monitoring and acting on patient feedback.
  • Improve the awareness of red flag symptoms and signs of sepsis for non-clinical staff.

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.

24 June 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

Following an announced comprehensive inspection of The Church Street Practice in December 2015 the practice was given an overall rating of good.

At our inspection we identified concerns relating to equipment safety checks.

After the comprehensive inspection, the practice wrote and provided an action plan to tell us what they would do in respect of our inspection report findings and to meet legal requirements.

Our previous inspection in December 2015 found the following area where the practice must improve:

  • Ensure that safety testing of electrical equipment was up to date.

We also identified some areas in which the practice should improve:

  • Continue to ensure the regular review and monitoring of patients experiencing poor mental health.
  • Review the waiting area to ensure that there is a sufficient seating for patients to wait.
  • Ensure that patient confidentiality is maintained.

We undertook this focused inspection on 24 June 2016 to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements. The provider was now meeting all requirements and was rated as Good under the Safe domain. Overall the practice is rated as Good.

Our key findings across the areas we inspected for this focused inspection were as follows:

  • Risks to patients were assessed and well managed including equipment safety checks.
  • The practice ensured that patient confidentiality was maintained. At this inspection we saw that the practice has reviewed how patient confidentiality was maintained, shared this learning with all staff and provided refresher training.The practice had reviewed the waiting area in conjunction with other services who shared the area and had put measures in place to ensure there was sufficient seating for all patients.
  • The practice was reviewing and monitoring patients experiencing poor mental health. At this inspection we saw evidence that patients experiencing poor mental health were having regular reviews and monitoring and we saw unverified data which indicated the practice performance in this area was in line with other practices locally and nationally.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church Street Practice on 8 December 2015. Overall the practice is rated as good.

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, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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 GP 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.

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

Importantly the provider must

  • Ensure that safety testing of electrical equipment is up to date.

Importantly the provider should

  • Continue to ensure regular review and monitoring of patients experiencing poor mental health.
  • Review the waiting area to ensure that there is sufficient seating for patients to wait.
  • Ensure that patient confidentiality is maintained.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice