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Update on our Improvement Plan 01/15

CQC finds improvements at Church Lane Surgery

I am pleased to let you know that following another inspection at Church Lane Surgery last month, the Care Quality Commission (CQC) has now published a report on  improvements it found at the practice.

As you know Church Lane Surgery was rated ‘inadequate’ at an inspection in August last year and we have been implementing a comprehensive improvement action plan.

On 19 December the CQC conducted what it calls a ‘focused inspection’ to review if improvements had been made and you can read some of those findings below. The CQC does not rate practices at focused inspections.

We are proud that the inspectors have acknowledged the improvements that have already been made by our hard working colleagues.

However, we recognise there is still work to do to reach the standard we want for the practice and for you, our patients, and we are committed to implementing our long-term improvement plan.

We are determined to gain at least a ‘good’ rating for Church Lane Surgery or even, in time, ‘outstanding’.

Christian Ellwood, Practice Manager

 The CQC said – 

  • The practice has established clearer responsibilities, roles and systems of accountability to support good governance and management.
  • The systems for managing correspondence, referrals, pathology results and patient notes has improved and the CQC found these were routinely managed in a timely manner.
  • The practice has implemented a system for monitoring uncollected prescriptions to ensure they are monitored effectively and staff inspectors spoke with understood their roles and responsibilities.
  • There is a system in place to review staff competencies. Staff have received appropriate appraisals to ensure they are able to carry out their duties.
  • The practice has implemented a plan to ensure clinical audits are carried out regularly and used to drive improvements in the practice.

Other improvements from our action plan include –


Since August 2018, we have recruited an assistant service manager, two practice nurses, an advanced nurse practitioner and two administration staff. We have also recently offered three receptionists roles.

There is a national shortage of GPs and there’s a particular issue in the Essex area. However, we continue to work with eight different recruitment agencies to find new doctors. We also offer incentives such as a generous package and flexible working.


We are currently offering a wide range of appointments for GPs, advanced nurse practitioners, practice nurses and healthcare assistants.  We have recently restructured our appointments to offer more on the day availability.

The telephone system

A new improved call direction has been in place since early September offering quicker routes to speak to the appropriate staff members.

In February last year telephone calls were answered within an average of 10 minutes but this has now been reduced to an average of three minutes.  We appreciate this does fluctuate and we will continue to work hard to bring waiting times down.

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