Archived: Chapelford Medical Centre

We carried out an announced inspection at Chapelford Medical Centre on 13 and 18 October 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Requires improvement

Well-led - Good

Following our previous assessment on 5 November 2020, the practice was inspected and not rated as a full comprehensive inspection did not take place.

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

Why we carried out this inspection

This inspection was a comprehensive inspection and included follow up of the previous assessment shoulds:

• Maintain visible and supportive leadership for all staff.
• Ensure systems and processes are clear to support staff to fulfil their roles and responsibilities effectively with accountability.
• Establish formal communications for opportunities to engage and communicate with staff effectively including sharing of incidents with all staff.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• 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 have rated this practice as Good overall

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

The practice is rated as requires improvement for being responsive because:

• Some patients reported difficulty accessing an appointment at the practice.
• Staff told us there was sometimes a delay experienced for those patients requesting a home visit.
• The practice website did not contain sufficient detail of how to make a complaint to the service or information about other sources of local support and resources available to patients.

Whilst we found no breaches of regulations, the provider should:

• Review the home visiting process to ensure timely visits are performed.
• Carry out weekly checks of emergency equipment and medicines as recommended by the UK Resuscitation Council.
• Continue to improve the uptake of cervical cancer screening in females.
• Update the practice website with information how to provide feedback to the service and local support services.
• Review the information available to those patients who can not use the digital systems to ensure they are aware of the services provided.

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