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Extended Access Clinic : Bermondsey Spa Medical Centre Good

Inspection Summary

Overall summary & rating


Updated 16 May 2019

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at on 27 March 2019 as part of our inspection programme.

At this inspection we found:

  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service 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 guidelines.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation

The areas where the provider should make improvements are:

  • Retain records related to staff induction for all staff.

  • Have oversight of risk management activities undertaken by third parties.
  • Advertise translation services.
  • Include contact details of the organisations patients can escalate

    complaints to in complaint response letters

  • Following guidance and best practice for the management of sharps waste
  • Include contact details for all staff in the service’s business continuity plan.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas



Updated 16 May 2019

We rated the service as good for providing safe services.

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider informed us that safety risks associated with the premises were managed by a third party. Although we saw evidence that third parties were actively managing risks associate with the premises the provider did not have adequate assurance that risks were being managed effectively. There were safety policies, including Control of Substances Hazardous to Health and Health & Safety policies, which were regularly reviewed and communicated to staff. Staff received safety information from the provider as part of their induction and refresher training.

  • The provider had systems to safeguard children and vulnerable adults from abuse. Policies were regularly reviewed and were accessible to all staff. They outlined clearly who to go to for further guidance. Policies were in place which discourage member practice from referring patients on the child protection register or adults with vulnerabilities to the service. This was to ensure that these patients continued to receive continuity of care at their own surgery.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. For example, there were systems in place for raising safeguarding concerns with the local safeguarding team and the patient’s own GP practice. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • Disclosure and Barring Service (DBS) checks were undertaken for all staff working at the service. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control in most respects. However, we found a sharps bin in a treatment room that was dated November 2018. We asked a member of staff how frequently sharps bins should be changed and they were not aware that this was required every three months.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed. There was an effective system in place for dealing with surges in demand.
  • There was an induction programme for all staff, including temporary staff, tailored to their role. However, we saw that completed schedules of induction had not been retained for all staff.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. In line with available guidance, patients were prioritised appropriately for care and treatment, in accordance with their clinical need. Systems were in place to manage people who experienced long waits.
  • Staff told patients when to seek further help. They advised patients what to do if their condition got worse.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service had consulted with their member practices and an agreement was made that if any referrals were required following consultations at the service, notification was sent back to the individual practices who would make the referral. Depending how the patient was booked into the service, the service was able to document directly into the patient’s practice clinical record. Tasks would then be sent to the service if any significant information needed to be shared or follow up was required. For other patients, notes from each consultation would be sent back to the practice including details needed for any referral. If the referral was urgent the clinician would provide the patient with their consultation notes and tell them to give this to the practice. They would also notify the receptionist on duty who would contact the patient’s practice to inform them that the referral was needed. The practice had completed a review of urgent referrals to ensure that those requested by the service had been made.

Appropriate and safe use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, emergency medicines and equipment, and vaccines, minimised risks. The service kept prescription stationery securely and monitored its use. Arrangements were also in place to ensure medicines were stored appropriately.
  • The service carried out the first cycle of a medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. The service had audited antimicrobial prescribing. There was evidence of actions taken to support good antimicrobial stewardship. The clinical lead for the service had also completed a two-cycle audit reviewing the service’s controlled drug prescribing.
  • Processes were in place for checking emergency medicines and staff kept accurate records of these medicines.

Track record on safety

The service did not have adequate oversight of risks associated with the premises which were managed by a third party. There were systems in place to act on safety alerts and review incidents with other organisations.

  • Management of most risks associated with the premises was undertaken by a combination of NHS property services and a member of staff from a GP practice that shared the premises with the service. We found that a fire risk assessment had been completed in 2018. The risk assessment contained action points but there was nothing recorded which confirmed that the action points had been addressed and the service did not know if these actions had been completed. The service sent information after our inspection which confirmed that risks had been addressed or that there were plans in place to address any outstanding risks.
  • There was a system for receiving and acting on safety alerts.
  • The service had a business continuity plan which was held off site. However, although the business continuity plan contained contact information for the organisations decision makers who also held a copy of the plan offsite, it did not have a complete list of contact information for staff working at the service.

  • Systems were in place to ensure joint reviews of incidents would be undertaken with referring organisations and others where appropriate.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events and incidents. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong including quarterly significant event review meetings. The service learned and shared lessons, identified themes and acted to improve safety in the service. For example, the provider had three incidents related to sufficiency of staffing. The provider had addressed the concern with the individual members of staff involved and had updated their lone working policy to ensure that there were always two receptionists scheduled to work each day.

  • The service learned from external safety events and patient safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.

  • The provider took part in end to end reviews with other organisations. Learning was used to make improvements to the service. For example, we reviewed a significant event related to the expired emergency medicines. In response to the incident the provider updated their emergency medicine protocol so that stock would be checked weekly.



Updated 16 May 2019

We rated the service as good for providing effective services.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Clinical staff had access to guidelines from the National Institute for Health and Care Excellence (NICE) and used this information to help ensure that people’s needs were met. The provider monitored that these guidelines were followed through audits of clinical consultations.
  • All patients who requested an urgent appointment through their GP practice would be triaged by a GP before being booked into the service. Patients who requested a routine appointment with a nurse would be directed to the service by reception staff. Both reception staff and clinical staff booking into the service could refer to a policy which provided an outline of what ailments could be sent to the service and those which would not be appropriate to refer. For example; patients with complex conditions, the elderly and those with co-morbidities, possible safeguarding concerns or known substance misuse issues. The service would undertake regular reviews of the appropriateness of appointments booked by member practices and provided feedback. NHS 111, urgent care services and accident and emergency units could book appointments with the service. We were told that staff at the service had also held training with secondary care services on how to use the service to improve uptake.
  • We saw no evidence of discrimination when making care and treatment decisions.

Monitoring care and treatment

The service had a comprehensive programme of quality improvement activity and routinely received the effectiveness and appropriateness of the care provided. For example, the service provided monthly reports to the CCG on several key indicators of performance (KPI) including appointment utilisation. Monitoring reports indicated that appointment utilisation between December 2018 and February 2019 was 80% and 85% of the target agreed with the CCG.

Although there were no set KPI targets we were told by the CCG that they would periodically review the service’s performance and that they were currently satisfied with the level of appointment utilisation.

The service undertook quarterly audits of referrals for appointments by member GP practices. The service would review referrals from the three practices who had the highest rate of referrals into the service. The audit would review 30 referrals from each of these practices and assess whether the referral met the criteria to be seen at the service (including assessment of any risk factors which may mean the patient was not suitable to be seen at the service). The service fed back the results of the audit to member practices to enable them to learn and improve their referral systems. In addition, the clinical lead would contact the member practices on an ad hoc basis if GPs working with the service identified that a patient’s referral was not appropriate. The service also reviewed the appropriateness of referrals made by 111. Of the 437 appointments made by 111 only three were identified as having been inappropriate referrals.

An annual audit of consultations was also completed by the clinical lead at the service following criteria adopted by the local out of hours provider which included a review of prescribing, documenting and acting on safeguarding concerns and record keeping. All 21-clinical staff working at the service in the three months prior to March 2019 had five consultations reviewed. The results of each clinician’s audit were sent to them. Clinicians whose performance significantly deviated from that of other clinical staff would have their consultations reviewed more frequently as well as new members of staff. Areas identified for improvement would be fed back to individual clinicians.

The service had reviewed the prescribing of broad spectrum antibiotic prescribing between November 2018 and February 2019. Of the 54 prescriptions for broad spectrum antibiotics seven were deemed to be inappropriate and six of the inappropriate prescriptions were by one clinician. The audit was shared with all clinicians within the service for learning purposes and the clinician with the highest level of inappropriate prescribing reflected on their prescribing. The audit was to be repeated for this staff member after three months and for the whole service after 12 months.

The service had completed a two-cycle audit of controlled drug prescribing. In the first cycle which reviewed prescribing from April 2017 to March 2018 the service found that out of 195 prescriptions issues for controlled drugs, benzodiazepines or z drugs two of these were not appropriate. Learning from the audit was shared with clinicians working at the service. The second cycle reviewing prescribing between April and September 2018 showed that all 48 prescriptions reviewed within this time were appropriate.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff. However, the provider had not retained copies of induction schedules for all staff.
  • The provider ensured that all staff worked within their scope of practice and had access to clinical support when required.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The provider provided staff with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The provider could demonstrate how it ensured the competence of staff employed by audit of their clinical decision making.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together, and worked well with other organisations to deliver effective care and treatment.

  • The service had access to patients’ GP NHS records and depending how the patient was booked into the service could document directly into the patient’s record. For those patients who attended the service where the service was unable to document directly into the patient’s record; the service would record notes from consultations in a separate entry on their own clinical system. The notes would then be sent to the patient’s GP practice. The service would not undertake any referrals for patients. Instead the referral information was completed by the service and sent back to the patient’s GP practice. The service had developed a failsafe system for two week wait referrals whereby the consulting GP would notify a receptionist that the referral had been made. The receptionist would then contact the practice that day to ensure that the referral was made.
  • The service provided patients with forms for basic investigations including blood and urine tests and x-rays.

Helping patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • The service identified patients who may need extra support and would highlight this to the patient’s own GP to take forward.
  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors, where identified, were highlighted to patients and their own GP so additional support could be given.
  • Where patients’ needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The provider monitored the process for seeking consent appropriately.



Updated 16 May 2019

We rated the service as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • Thirty-five patient Care Quality Commission comment cards we received were positive about the service experienced. Only one comment card provided negative feedback about the condition of the premises. The positive comments referred to ease of access and the helpfulness of staff at the service.
  • Friends and family data from March 2018 to February 2019 indicated that most of patients were happy with the service provided. For example:
  • When asked “How likely are you to recommend the Extended primary care service to your friends or family if they needed similar care or treatment?” at least 90% of respondents each month said they would be likely or extremely likely to recommend the service. The highest month for satisfaction was February 2019 with 98% of patients saying that they were likely or extremely likely to recommend. The provider told us that 100% of patients were offered patient feedback forms and that 15% were completed. The service had recently created their own patient survey which asked patients if they felt they were treated with dignity and respect and involved in decisions about their care and treatment. The service had yet to collate feedback from this survey.

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about their care and were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information they are given):

  • Interpretation services were available for patients who did not have English as a first language although there were no notices informing patients that this service was available. However, we were told that staff at the member practices would not routinely send patients who needed support with translation to the service.
  • Patients told us through comment cards, that they felt listened to and supported by staff but some reported feeling rushed during consultations.
  • Staff helped patients find further information and access community and advocacy services. They helped them ask questions about their care and treatment.

Privacy and dignity

The service respected and promoted patients’ privacy and dignity.

  • Staff respected confidentiality at all times.
  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.



Updated 16 May 2019

We rated the service as good for providing responsive services.

Responding to and meeting people’s needs

The provider organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of its population and tailored services in response to those needs. For example, the provider had approached the CCG and offered to provider long- acting reversible contraception (LARC) after the previous provider of this service had closed. The provider engaged with their member practices and commissioners to secure improvements to services where these were identified. For example, the service had started offering routine nursing appointments in addition to the urgent GP appointments they were originally commissioned to provide. The service had plans to further expand nursing provision as requested by their member practice. The commissioners reported that the service had helped to support the burden on the local healthcare economy caused by nearby practices closing after CQC inspections.
  • The service was able to offer 15-minute appointment slots if needed.
  • The facilities and premises were appropriate for the services delivered.
  • The service made reasonable adjustments when people found it hard to access the service. For example, the practice had a hearing loop for patients who had hearing difficulties and translation services for those who required them.
  • The service was responsive to the needs of people in vulnerable circumstances if they were referred to the service. However, the service was not designed or commissioned to meet the needs of patients with complex care needs or those considered vulnerable. The systems and protocols for triage meant that patients with these needs would typically not be referred to the service by their own practice. The service would provide feedback to their member practices if they referred patients inappropriately.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients were able to access care and treatment at a time to suit them. The service operated from 8 am to 8 pm 7 days per week.
  • Patients could access the service either as after being referred by their own GP practice or via NHS 111, and local UCC and accident and emergency units

  • Waiting times, delays and cancellations by the service were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • The service sent clinical tasks or forwarded consultation notes to the patient’s own GP in good time to enable the practice to make prompt onward referrals to other services where required. The service had failsafe systems in place to ensure that referrals were highlighted to the patient’s practice quickly.
  • Ease of access was referred to in most of the CQC comment cards provided. No comment cards referred to difficulties around access.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available and it was easy to do. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. Five complaints were received in the last year. We reviewed four complaints and found that they were satisfactorily handled in a timely way. However, the responses did not include details of organisations that patients could escalate their complaint to if they were unsatisfied with the practice’s response.
  • Issues were investigated across relevant providers, and staff could feedback to other parts of the patient pathway where relevant. For example, the service had received a complaint through one of their member practices. Some of the issues raised related to the care and treatment provided by the service. The service provided a response to the patient and shared with this the member practice.
  • The service learned lessons from individual concerns and complaints and from analysis of trends. It acted as a result to improve the quality of care. For example, the service had four complaints related to the individual clinical consultations. The service involved the clinician involved in reviewing the relevant consultation and discussed areas for improvement.



Updated 16 May 2019

We rated the service as good for leadership.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders had the experience, capacity and skills to deliver the service strategy and address risks to it.
  • They were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • Management was accessible throughout the operational period.
  • The provider had effective processes to develop leadership capacity and skills, including upskilling staff and planning for the future leadership of the service. The provider aimed to take a leadership role on behalf of its member practices within the local health economy.

Vision and strategy

The service had a clear vision and set of principles which aimed to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of principles which focused on improving local population health through inter practice co-operation. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff, member practices and external partners. The strategy focused on patient need.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social priorities across the region. The provider planned the service to meet the needs of the local population.
  • The provider monitored progress against delivery of the strategy.


The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers told us that they would act on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Leaders had established proper policies, procedures and activities to ensure safety in most respects. However, systems to ensure some risks associated with fire had been mitigated were lacking.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance. However, systems to ensure some risks associated with fire had been mitigated were lacking.

We saw evidence that risk was actively managed within the service. We were told that responsibility for risks related to the premises were managed by a building manager who was employed by a separate GP service operating in the same building. Although we saw evidence that risks were being actively managed by third parties; the provider had no system in place to assure themselves that some risks associated with fire were being reviewed and mitigated.

The provider had processes to manage current and future performance of the service. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of MHRA alerts, incidents, and complaints. Leaders also had a good understanding of service performance against local key performance indicators. Performance was regularly discussed at senior management level. Performance was shared with staff and the local CCG as part of contract monitoring arrangements.

Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality.

The providers had plans in place and had trained staff for major incidents although the business continuity plan for the service did not contain contact information for all staff who worked at the service.

The provider implemented service developments and where efficiency changes were made this was with input from clinicians to understand their impact on the quality of care.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service used information technology systems to monitor and improve the quality of care.
  • The service submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • Patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. For example, the service was now providing NHS health checks after being requested to do this by their member practices. This would support member practices in achieving local population health management targets. The service had recently introduced their own patient survey which questioned patients on the cleanliness of the service, whether patients felt they were treated with dignity and respect and involved in decisions about their care and treatment.
  • Staff felt able to give feedback and believed that leadership within the organisation would act on feedback where they could and offer appropriate support where necessary.
  • The service had held engagement events at the locality patient participation group forum. Feedback from the group resulted in the service devising a campaign to promote the service and increase utilisation.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement at all levels within the service. For example, the service trained medical students from a local secondary care service.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There was a strong culture of innovation evidenced by the number of pilot schemes the provider was involved in. For example, the provider was involved in a pilot scheme which enabled GPs and reception staff to book patients with musculoskeletal conditions with a physiotherapist thereby saving GP appointments. The service told us that they were also about to commence a screening pilot to identify latent tuberculosis. There were systems to support improvement and innovation work.