The Care Quality Commission
  • Doctor
  • GP practice

Upper Norwood Group Practice

Overall: Good read more about inspection ratings

Chaucer House, 130 Church Road, Upper Norwood, London, SE19 2NT (020) 8771 6050

Provided and run by:
Upper Norwood Group Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Upper Norwood Group Practice 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 Upper Norwood Group Practice, you can give feedback on this service.

6 September 2019

During an annual regulatory review

We reviewed the information available to us about Upper Norwood Group Practice on 6 September 2019. 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.

8 March 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Upper Norwood Group Practice on 28 July 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the July 2016 inspection can be found by selecting the ‘all reports’ link for Upper Norwood Group Practice on our website at www.cqc.org.uk.

At our previous inspection on 28 July 2016, we rated the practice as requires improvement for providing safe services as the risks to patients were not always assessed and well managed including those related to health and safety, fire safety, chaperoning and recruitment checks for locum and permanent staff. Some of the staff had not undertaken training appropriate to their role including basic life support, safeguarding children and fire safety. Blank prescriptions were not securely stored and portable appliance testing was not undertaken as required.

At our previous inspection on 28 July 2016, we rated the practice as requires improvement for providing effective services as non-clinical staff were not receiving regular appraisals and some of the clinicians did not use problem oriented notes to record patient consultations.

At our previous inspection on 28 July 2016, we rated the practice as requires improvement for providing well-led services as the practice did not have an active Patient Participation Group and the practice policies and procedures were not regularly reviewed and updated.

This inspection was an announced focused inspection carried out on 8 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 that we identified in our previous inspection on 28 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • Risks to patients were assessed and well managed especially those related to health and safety, fire safety and chaperoning. Portable appliance testing was carried out as required.
  • Blank prescriptions were securely stored and the use of prescriptions was monitored.
  • The practice had an effective system in place to ensure role specific training was undertaken for all practice staff including basic life support, safeguarding children and fire safety.
  • Complaints processes in place were adequate.
  • The practice policies and procedures had been reviewed and updated.
  • The practice documented the discussions from meetings.
  • The practice proactively sought feedback from staff and patients and the PPG was recently re-established.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

28 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Upper Norwood Group Practice on 28 July 2016. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were not always assessed and well managed including those related to health and safety, fire safety, chaperoning and staff recruitment.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment; however there was no effective system in place to ensure mandatory training including safeguarding, fire safety and basic life support are undertaken.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a leadership structure and most staff felt supported by management. The practice had not proactively sought feedback from staff and patients and the Patient Participation Group (PPG) was not active.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

There were areas of practice where the provider must make improvements:

  • Ensure that a comprehensive fire risk assessment and health and safety risk assessment of the premises is undertaken and that electrical installation checks are undertaken every five years as required and that all the recommendations from the legionella risk assessment are actioned and that the chaperone processes are in line with guidelines and undertake a risk assessment to ascertain if Disclosure and Barring Service (DBS) checks are required for all staff who undertake this role.
  • Ensure that adequate recruitment checks are undertaken prior to employing locums and permanent staff, clinical staff have DBS checks before they undertake their role, all clinical and non-clinical staff receive child protection training relevant to their role and that all staff receive annual basic life support training.
  • Ensure that regular appraisals are carried out for all members of staff.
  • Ensure that a system to seek and act on feedback from service users is developed, including establishing a Patient Participation Group (PPG).

There were areas of practice where the provider should make improvements:

  • Review the practice procedures to ensure all staff have fire safety training and that staff training records are kept up-to date; ensure all portable electrical appliances are tested annually.
  • Ensure that blank prescriptions are securely stored and there is a system for monitoring their use.
  • Review the complaints process to ensure it includes all the required actions being taken.
  • Review the practice procedures to ensure that the practice policies and procedures are reviewed and regularly updated.
  • Review practice procedures to ensure all clinicians use problem oriented notes to record patient consultations.
  • Consider documenting discussion from meetings.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

16 January 2014

During a routine inspection

During the inspection we spoke with the registered manager who was a General Practitioner (GP) at the practice. We also spoke with the practice manager, an administrator, a practice nurse and three people using the service.

People using the service said that they were very happy with the practice. They told us that they were treated with respect and kindness. They felt involved in discussions about their health care and the GP's always had time to listen to them. One person told us 'The GP's give me time to talk and listen to what I have to say'. Another person said 'It's very easy to make an appointment. If I need something urgently the reception staff get the GP to call me back. I get the very best care'. Another person said 'Sometimes it's a bit difficult to get to see my own GP but I always get to see someone. The reception staff and practice nurses are friendly and helpful'.

We saw that the practice had safeguarding policies that related to adults and children. We saw the practice was clean and well maintained throughout. We saw that the practice had effective systems in place to regularly assess and monitor the quality of service that people received.