Chapel Street

We carried out an announced comprehensive Chapel Street (also known as Royton Medical Centre) on 7 September 2022. Overall, the practice is rated as requires improvement, with the following key question ratings:

Safe - requires improvement

Effective - good

Caring - good

Responsive - requires improvement

Well-led - inadequate

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities. This was the first inspection to this location following it registering with the Care Quality Commission (CQC) on 2 November 2021. The provider – Royton Medical Centre – has been registered since 2015 and had one location, also called Royton Medical Centre. In June 2021 the practice moved to a new building that registered under the name Chapel Street.

As this was the first inspection to the location all the key questions were inspected.

The full reports for this inspection can be found by selecting the ‘all reports’ link for Chapel Street on our website at www.cqc.org.uk

How we carried out the inspection/review

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

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 rated the practice requires improvement for providing safe services:

• The system for obtaining Disclosure and Barring Service (DBS) checks was not effective.
• The process for authorising nursing staff to administer medicines was not effective.
• Medicine reviews were completed without patient involvement and without all the required checks being carried out.
• The process for checking emergency medicines was not effective.
• The system for learning and making improvements when things went wrong was not effective.
• The systems to manage safety alerts were not fully effective.

We rated the practice good for providing effective services:

• Patients received effective care and treatment that met their needs.

We rated the practice good for providing caring services:

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice requires improvement for providing responsive services:

• Complaints were not used to improve the quality of care.
• Although we could see appointments were available at the time of the inspection, patient feedback around access was poor.

We rated the practice inadequate for providing well-led services:

• Leaders could not demonstrate they had the capacity to deliver high quality care.
• Most of the staff we asked were not aware they had a Freedom to Speak Up Guardian.
• We saw examples of policies being inaccurate and not being followed.
• We saw examples of systems and processes that were not effective, including the process for requesting Disclosure and Barring Service (DBS) checks, the process for checking emergency medicines and the process to manage significant events and complaints.
• The website was difficult to navigate and included incorrect information.

We found two breaches of regulation. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Work towards improving levels of cervical screening.
• Monitor patient satisfaction with a view to improving all below average areas of the GP Patient Survey.

If a service is rated as inadequate for one of the five key questions it will have usually have six months to improve. We will inspect this service again within six months, and if at that time service is rated as inadequate for a key question, it will be placed in special measures.

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 Hospitals and Interim Chief Inspector of Primary Medical Services