The Care Quality Commission
  • Doctor
  • Independent doctor

SurreyGP

Overall: Good read more about inspection ratings

32-34 London Road, Guildford, Surrey, GU1 2AB (01483) 230481

Provided and run by:
SurreyGP Limited

All Inspections

6 July 2023

During a monthly review of our data

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

16 to 17 September 2021

During a routine inspection

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services well-led? – Good

We carried out a comprehensive inspection of SurreyGP on 8 November 2019. We identified breaches of regulation 12 (Safe care and treatment) and regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 and issued requirement notices. The service was rated as requires improvement for providing safe and well-led services and good for providing effective, caring and responsive services. The service was rated as requires improvement overall.

We carried out this announced comprehensive inspection of SurreyGP between 16 and 17 September 2021 under Section 60 of the Health and Social Care Act 2008. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008. At this inspection we checked that the service was providing safe, effective and well-led services.

Throughout the COVID-19 pandemic the Care Quality Commission (CQC) has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Speaking with staff in person and using video conferencing.
  • Requesting documentary evidence from the provider.
  • A site visit.

We carried out an announced site visit to the service on 17 September 2021. Prior to our visit we requested documentary evidence electronically from the provider. We spoke to staff by telephone and using video conferencing, prior to our site visit.

SurreyGP is an independent provider of a range of GP services, including consultations, child and adult immunisations, cervical screening, travel health advice and vaccinations, ear syringing, well man and well women screening and advice, sexual health advice and testing and home visits. The service is a registered Yellow Fever vaccination centre.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Services are provided to patients under arrangements made by their employer or insurance provider with whom the servicer user holds an insurance policy (other than a standard health insurance policy). These types of arrangements are exempt by law from CQC regulation. Therefore, we were only able to inspect the services which are not arranged for patients by their employer or insurance provider.

The service is registered with CQC to provide the following regulated activities: Diagnostic and screening procedures; Treatment of disease, disorder or injury; Maternity and midwifery services.

Services are provided by one lead GP who is female and a locum GP who is male. The GPs provide all travel advice and vaccination services.

The Director of Operations is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our key findings were

  • Staff had received training in key areas. There was a clear plan of training for staff and monitoring of training undertaken by clinical staff employed on a sessional basis.
  • There were processes in place for performance review and monitoring of clinical staff. Staff employed by the service had undergone appraisals.
  • There were effective systems and processes to assess monitor and control the spread of infection.
  • There were safeguarding systems and processes to keep people safe. Staff had received training in the safeguarding of adults and children.
  • Arrangements for chaperoning were effectively managed. Staff had received chaperone training and had been subject to Disclosure and Barring Service (DBS) checks.
  • There were appropriate arrangements to manage medical emergencies and suitable emergency medicines and equipment in place.
  • Clinical record keeping was clear, comprehensive and complete.
  • There was evidence of clinical audit and review of patient treatment outcomes.
  • There were clear and improved governance and monitoring processes to provide assurance to leaders that systems were operating as intended.
  • Staff found leaders approachable and supportive and felt they provided an individual service to patients.
  • There was frequent and open communication amongst the staff team which was well documented.
  • Service users were routinely asked to provide feedback on the service they had received. Complaints were managed appropriately.

The areas where the provider should make improvements are:

  • Review arrangements for the retention of all records which relate to staff immunisation status.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

8 November 2019

During a routine inspection

We carried out an announced comprehensive inspection at SurreyGP on 8 November 2019 as part of our inspection programme, under Section 60 of the Health and Social Care Act 2008. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008. This was the provider’s first rated inspection. The practice was previously inspected in December 2017 when the practice was not rated but was found to be meeting all regulations.

SurreyGP is an independent provider of a range of GP services, including consultations, child and adult immunisations, cervical screening, travel health advice and vaccinations, ear syringing, well man and well women screening and advice, sexual health advice and testing, and home visits. The practice is a registered Yellow Fever vaccination centre.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. SurreyGP provides a range of non-surgical cosmetic interventions, for example Botox injections and facial fillers, which are not within CQC scope of registration. Therefore, we did not inspect or report on these services. Services are also provided to patients under arrangements made by their employer or insurance provider with whom the servicer user holds an insurance policy (other than a standard health insurance policy). These types of arrangements are exempt by law from CQC regulation. Therefore, we were only able to inspect the services which are not arranged for patients by their employer or insurance provider.

The practice is registered with the Care Quality Commission to provide the following regulated activities: Diagnostic and screening procedures; Treatment of disease, disorder or injury; Maternity and midwifery services.

Services are provided by the Medical Director who is the founder of the service and one part-time GP. Both GPs are female. The GPs also provide all travel advice and vaccination services.

The Medical Director is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

We received written and verbal feedback about the practice from 47 patients on the day of inspection. Feedback from patients was positive about the service and care provided. Patients described the service as being caring, respectful, professional, thorough, reassuring and attentive. Several patients commented upon the exceptional standards of clinical care afforded to them.

Our key findings were :

  • The clinic had good facilities and was equipped to treat clients and meet their needs.
  • Services were offered on a private, fee paying basis only.
  • Assessment of patients’ treatment plans were thorough and followed national guidance.
  • Clients received full and detailed explanations of any treatment options.
  • Medical staff had the relevant skills, knowledge and experience to deliver the care and treatment offered by the service. However, some staff had not completed safeguarding and safety training appropriate to their role.
  • The service had systems in place to promote the reporting of incidents. However, actions taken and the review of learning in response to some incidents had not led to safety improvements.
  • We saw examples of recent safeguarding referrals by GPs which demonstrated a thorough and effective approach to ensuring the ongoing safety of vulnerable patients.
  • There were infection prevention and control policies and procedures in place to reduce the risk and spread of infection. However, some infection prevention arrangements required review.
  • The service encouraged and valued feedback from clients and staff. Feedback from clients was positive.
  • The culture of the service encouraged candour, openness and honesty.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Ensure patients raising concerns are correctly identified as complainants where indicated and informed of any further action or support that may be available to them.
  • Ensure records relating to the management of health and safety of the premises are reviewed in a timely manner by leaders within the practice to support governance arrangements and oversight.
  • Review the arrangements for handwashing within one clinical room and the level of training for staff undertaking infection prevention audits.
  • Review processes and risk assessments to consider whether patients should provide personal identification on registration with the practice.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

7 December 2017

During a routine inspection

We carried out an announced comprehensive inspection of SurreyGP on 7 December 2017 to ask the service the following key questions; are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

SurreyGP provides private GP services and vaccination services including travel services. Additionally it carries out private medical examinations for employment and occupational purposes and provides some facial aesthetic services.

This service is registered with CQC under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of service and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At SurreyGP the aesthetic cosmetic treatments are exempt by law from CQC regulation. Therefore we were only able to inspect GP services but not the facial aesthetic services.

The Medical Director is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Fifty three people provided feedback about the service both face to face and via comment cards all of which was positive about the standard of care they received. The service was described as excellent, professional, helpful and caring.

Our key findings were:

  • The service had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based research or guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The practice were proactive in seeking patient feedback and identifying and solving concerns.
  • The culture of the service encouraged candour, openness and honesty.

There were areas where the provider could make improvements and should:

  • Consider reviewing whether all patients should provide personal identification on registration with the practice.
  • Review whether to install a hearing loop and consider providing access to an interpreter service.
  • Review whether to provide a written business continuity plan and lone worker policy.

16 October 2014

During a routine inspection

A single inspector carried out the inspection. The focus of the visit was to answer five key questions: is the service safe, effective, caring, responsive and well-led.

Below is a summary of what we found. The summary describes what patients and staff told us, what we observed and the records we looked at.

If you want to see the evidence that supports our summary please read the full report.

This is a summary of what we found:

Is the service safe?

Patients had confidence in the service and the knowledge and skills of the clinical staff.

There were regular reviews to discuss clinical issues, and in particular following adverse incidents to learn from, and improve safety.

Staff demonstrated a good understanding of their responsibilities in relation to safeguarding.

There were arrangements in place for the safe storage of medicines and also arrangements for checking equipment.

We found the service to be safe.

Is the service effective?

Records demonstrated that people's consent was obtained and other professionals were kept informed of patient's needs and progress.

Patients told us they appreciated that staff had time for them and they did not feel rushed and we saw they were seen on time during the visit.

Some patients told us they were returning to the clinic due to previous positive experiences and others were attending because the specific treatment was only available privately.

We found the service to be effective

Is the service caring?

One patient described the staff as "brilliant" and other feedback described how people felt they could "trust" the staff.

We observed staff talking to people in a friendly, professional and courteous way and one patient said the staff made them "feel like a real person".

Staff spoke with confidence about how they were required to provide people with a high quality service and how the needs of the patient are paramount.

We found the service to be caring.

Is the service responsive?

We were told that patients could be offered appointments very quickly, and the same day if necessary. We were told the clinic was open at weekends to enable people who were at work or school to attend. Patients confirmed they had been offered appointments in a timely way.

We found the service to be caring.

Is the service well-led?

Staff told us their managers were approachable and supportive. They felt able to raise any ideas or concerns with them.

We saw there were detailed reviews following incidents and actions were made and implemented to reduce the risk and improve safety.

Patient's complaints were addressed and detailed feedback provided to the complainant.

We found the service to be well-led.