The Care Quality Commission
  • Doctor
  • GP practice

The Cheylesmore Surgery

Overall: Good read more about inspection ratings

51 Quinton Park, Coventry, West Midlands, CV3 5PZ (024) 7650 2255

Provided and run by:
The Cheylesmore Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Cheylesmore Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Cheylesmore Surgery, you can give feedback on this service.

4 February 2020

During an annual regulatory review

We reviewed the information available to us about The Cheylesmore Surgery on 4 February 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

18 Jul to 18 Jul 2018

During a routine inspection

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.

7 June 2017

During a routine inspection

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

8 September 2016, 15 September 2016

During a routine inspection

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. Overall the practice is rated as inadequate.

  • Patients were at risk of harm because some of the systems and processes were not in place to keep them safe. For example, recording information regarding monitoring of patients taking high risk medicines, review of all patient safety alerts such as Medicines and Healthcare products Regulatory Agency (MHRA) and recruitment checks on locum doctors undertaking minor surgery.

  • Incident reporting was low and as a result there was limited evidence of practice staff learning and communication with all staff. Meetings held with practice staff were ad hoc and not documented.

  • Patient outcomes were hard to identify as little reference was made to completed audits or quality improvement.

  • Patient feedback on CQC comment cards was positive about interactions with staff and patients said they were treated with compassion and dignity. Whilst the practice had a Patient Participation Group (PPG) they had not obtained a representative sample of patient viewpoints regarding services delivered and any areas which may be identified for improvement.

  • Feedback obtained from the National GP Patient Survey showed that patients could access the appointment system and obtain an appointment with their preferred GP.

  • Whilst the practice had a leadership structure in place, governance arrangements required strengthening.

The areas where the provider must make improvements are:

  • Ensure all significant events, incidents and near misses are identified and reported. Ensure any lessons learned are shared amongst all staff.

  • Review its safeguarding arrangements to ensure that all children of concern have records maintained.

  • Implement an effective system to ensure patients prescribed with high risk medicines are monitored appropriately.

  • Undertake a risk assessment or make suitable arrangements regarding access to a defibrillator on site.

  • Ensure recruitment arrangements include all necessary employment checks for locum staff working within the practice.

  • A structured approach must be implemented for those housebound patients with long term conditions to ensure regular reviews take place.

  • Implement effective systems or processes for the sharing of information with out of hours services particularly in relation to vulnerable and special patients who may need access to out of hours care.

  • Put systems in place to ensure all clinicians are kept up to date with national guidance, guidelines and legislation including the Mental Capacity Act 2005.

  • Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

  • Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision.

The areas where the provider should make improvement are:

  • Ensure that the use of prescription pads are monitored within the practice.

  • Ensure that all staff are aware of business continuity arrangements in place.

  • Review the arrangements for storing medicines; to consider monthly calibration of the vaccine refrigerator or utilising a secondary thermometer to cross check the accuracy of the main thermometer.

  • Carry out clinical quality monitoring activities to identify areas where improvements could be made. Improvements in practice should be evident from completed audits undertaken.

  • Ensure measures are implemented for the review of patient feedback such as the National GP Patient Survey results. Arrangements should include any responsive action taken by the practice as a result of feedback obtained.

  • The provider should review the arrangements in place for identifying carers as a low number had been identified (1.2% of the practice list).

  • The provider should review its arrangements for communicating with those patients who have hearing difficulties, as a hearing loop was not installed within the premises.

  • Review its arrangements for making contact with bereaved families to offer appropriate support and provide signposting to organisations that may be able to assist.

  • Review its arrangements in place with other stakeholders such as the care homes where some practice patients were living with an aim to improve communications and address perceptions of un-responsiveness.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice