We carried out a review of the data available to us about Wimbledon Village 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 Wimbledon Village Surgery, you can give feedback on this service.
We carried out an unannounced inspection of Wimbledon Village Surgery on 9 December 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 12 (Safe care and treatment) and regulation 18 (Staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We undertook this focussed inspection on 18 October 2016 to check they had followed their plan and to confirm that they now meet the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Wimbledon Village Surgery on our website at www.cqc.org.uk.
After the focussed inspection of 9 December 2015, the practice was rated as requires improvement. They were rated as requires improvement for providing safe and well led services. Following the focussed inspection of 18 October 2016 we found the practice to be good overall, and good for providing safe and effective services.
Our key findings across all the areas we inspected were as follows:
Chief Inspector of General Practice
We carried out an announced comprehensive inspection of the practice on 4 March 2015. Breaches of legal requirements were found. Specifically, breaches of regulation 12(2)(a)(c), relating to the provision of safe care and treatment and regulation 18(2)(a), relating to staffing, of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
After the comprehensive inspection, the practice wrote to us to inform us that in their consideration, no further action was necessary following the comprehensive inspection. CQC subsequently informed the provider that as breaches of regulations had been identified, we would expect services to respond to areas of concern and to make required improvements. We advised the provider that the service would be re-inspected to review compliance with the regulations breached.
We undertook this unannounced focussed inspection on 9 December 2015 to confirm that the practice now met the legal requirements. This report covers our findings in relation to those requirements and also where improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Wimbledon Village Surgery on our website at www.cqc.org.uk.
Overall the practice is rated as requires improvement. Specifically, following the focussed inspection we found the practice to be requires improvement for both providing safe services and well-led services. As the practice remains rated as requires improvement overall, the ratings for the population groups have not changed. Therefore, it remains requires improvement for providing services for older people; people with long-term conditions; families, children and young people; working age people (including those recently retired and students); people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia).
Our key findings across all the areas we inspected were as follows:
Ensure that the practice has assessed the risks in relation to fire safety.
Ensure that leads in infection control and fire safety have received appropriate training for their roles.
Ensure that there are formalised systems in place to improve communication with the practice nursing team, including involvement in practice and clinical meetings.
Establish an active Patient Participation Group (PPG) or alternative systems for engaging formally with service users.
Act on improvements identified in the infection control audit dated December 2014.
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at 8.30am on 4 March 2015. The practice had previously been inspected during our pilot phase in May 2014. We must conduct inspections at those practices that were inspected during our pilot phase in order to provide a rating for the service under the Care Act 2014.
We rated the practice as ‘good’ for the service providing effective, caring and responsive services, ‘requires improvement’ for providing safe services, and ‘inadequate’ for the service being ‘well-led’. We rated the practice as ‘requires improvement’ for the care provided to older people and people with long term conditions and ‘requires improvement’ for the care provided to, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia).
Overall the practice is rated as requires improvement.
Our key findings across all the areas we inspected were as follows:
We saw some areas of outstanding practice:
There were areas of practice where the provider needs to make improvements.
Importantly, the provider must:
In addition the provider should:
Chief Inspector of General Practice
Wimbledon Village Surgery is on the High Street in Wimbledon Village. The practice has a patient list size of approximately 10,000 people. It is open Monday to Friday from 8.30am to 6.30pm and offers appointments until 8pm two evenings (Mondays and Thursdays). Patients can have telephone consultations and a home visit if needed. All GPs have personal patient lists to ensure continuity of care for patients and to better meet their needs. Health visitors are attached to the service and provide clinics on-site.
The practice is in purpose-built premises and is set out over two floors. There are seven consulting rooms, two treatment rooms, a meeting room and a staff room as well as a reception area. The practice is an NHS general practice and is registered to carry out the regulated activities of diagnostic and screening procedures, family planning services, maternity and midwifery services, treatment of disease, disorder and injury and surgical procedures.
Overall we found the practice was providing a responsive, well-led, effective and caring service. However, there were some areas that required improvements to ensure it was safe at all times. The practice employed two nurses and could not demonstrate their child protection competencies by means of producing certificates confirming completion of level 2 child protection training. Recruitment processes did not ensure that all staff were of suitable character, as not all personnel files included photographic identification, references were not checked for one member of staff and they had not assessed the risk appropriately for non-clinical staff not having a Disclosure and Barring Services (DBS) check carried out. The practice told us they had assessed the risk of non-clinical staff not having DBS check as being a low risk. However, they provided no clear rationale for this assessment and we saw no documentation to confirm that this had been assessed formally.
All the patients we spoke with during the inspection were complimentary about the service. Patients felt the service was good and responsive to their needs. They described staff as caring and hardworking and valued the service.
We saw positive outcomes for patients experiencing mental health problems. Prescribing for medication was low and medication was monitored effectively to control mental health conditions. There were regular reviews for patients with long term conditions such as diabetes, chronic obstructive pulmonary disease (COPD), asthma and high blood pressure and the practice had good links with other organisations involved in managing long term conditions. The practice worked closely with a local hospice providing end of life care and local care homes, and it held regular meetings with district nurses and psychiatric services. Effective processes were in place to ensure babies and children received appropriate immunisations and staff followed up where there were gaps in immunisation records. Older people valued the service and told us that staff were caring and responded to their needs appropriately.
Although governance arrangements were in place, they were not always formally documented. The practice supported its staff and in the files we looked at, we saw evidence of clinical staff completing sufficient hours for their continuing professional development.