Statement for CQC Report

Between 4th-6th April 2022, the Care Quality Commission (CQC) inspected the Chelsfield Surgery.  Following the inspection, an overall rating of Requires Improvement was received.  The report is available on the CQC website at

CQC inspections are routinely carried out at all healthcare providers.

Chelsfield Surgery is committed to providing excellent quality care and have taken the findings of the inspection very seriously.  Whilst we are disappointed with the rating, we are pleased that the CQC identified many areas of good practice and innovation.  These include:

  • CQC reported that we identified the challenges and taken action to address them, including recruitment, upskilling staff, introducing new IT based system.
  • They also reported that the practice learned and made improvements when things went wrong had a system to learn and make improvements.
  • CQC acknowledged that the new practice manager had made a lot of positive changes including updating policies and procedures and implemented new ways of working. Practice now have regular meeting with fixed agenda items.
  • Practice was able to demonstrate a detailed business plan with clear strategies and objective in future.
  • CQC found clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • Appropriate standards of cleanliness and hygiene were met.
  • CQC recognised Practice regularly offered health checks to eligible patient group, full assessments were provided to patients living with severe frailty.
  • Practice offered services for all vaccination programmes as per recommended schedule.
  • We assessed and monitored patients with poor mental health.
  • All patients with Learning Disability were offered annual health check.
  • The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
  • Staff responsible dealing with critical need patients received specific training.
  • CQC recognised staff had the skills, knowledge and experience to carry out their roles, and we worked together with other organisations to deliver effective care and treatment. Staff were consistent and proactive in helping patients to live healthier lives.
  • CQC also reported that we were compassionate, inclusive and effective leadership at all levels. Leaders could demonstrate that they had the capacity and skills to deliver sustainable care.
  • The practice always able to demonstrate that it always obtained consent to care and treatment in line with legislation and guidance.
  • The practice had a clear vision and credible strategy to provide high quality sustainable care.

We responded quickly to the outcome of the inspections and are putting improvements in place.  These include:

  • We have recruited an experienced pharmacist technician who will provide support with medicine management. They will work closely with the prescribing lead to ensure all high risk drugs are prescribed with sufficient monitoring. They will also work with the clinicians to ensure medication reviews are done in timely manner.
  • We have now full protocol in place to ensure all MHRA/Safety alerts are managed safely in practice.
  • Practice is working very closely with CCG about implementing a full digital way for handling clinical correspondence.
  • Practice has fully adapted the safe recruitment policy.
  • We now have a new website which is mobile friendly to ensure accessibility for patients.
  • Regular meetings are scheduled to pass information effectively.
  • All our communications are now made digitally with clear audit trailing system.

We will continue to develop and evolve our services to meet the needs of our patients, families and carers building upon the strong foundations already in place.