The Care Quality Commission
  • Doctor
  • GP practice

Bishopsford Road Medical Centre

Overall: Good read more about inspection ratings

191 Bishopsford Road, Morden, Surrey, SM4 6BH (020) 8648 3187

Provided and run by:
Bishopsford Road Medical Centre

Important: The provider of this service changed - see old profile

All Inspections

10 August 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at Bishopsford Road Medical Centre on 10 August 2023. Overall, the practice is rated as good.

Safe - not inspected, rating of good carried forward from previous inspection

Effective - not inspected, rating of good carried forward from previous inspection

Caring - not inspected, rating of good carried forward from previous inspection

Responsive - not inspected, rating of good carried forward from previous inspection

Well-led - good

Following our previous inspection in June 2022 the practice was rated good overall and for all key questions apart from well-led, which was rated as requires improvement.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bishopsford Road Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection.

Following the last inspection we rated well-led as requires improvement because:

  • Some aspects of below average patient satisfaction had not been effectively assessed. Where the practice had taken action to improve the patient experience, there was no active monitoring to ensure that this had been successful and had not had any unintended consequences.
  • There were systems and processes to identify, manage and mitigate risks, but these were not all consistently effective.
  • There was not, at the time of the inspection, any documented overview of incomplete actions arising from risk assessments/other safety mechanisms, to allow governance oversight of risk management.

As well as requiring the practice to establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care, we said that they should:

  • take further steps to assess and improve patient perception of healthcare professionals.
  • continue to monitor and take action on areas of below average/below target performance in hypnotics prescribing, childhood immunisation and cervical screening.

Following this inspection we rated the practice as good for providing well-led services because of improvements that the practice had made.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Reviewing available data
  • A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The practice had taken action on all of the areas identified for improvement. Actions to address risk were complete and changes were working well. In some more challenging areas, the practice had made improvements and were continuing to implement changes to try to improve further.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • continue to monitor and take action on areas of below average/below target performance in patient satisfaction, hypnotics prescribing, childhood immunisation and cervical screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

Records review 6 June 2022, Visit 9 June 2022

During a routine inspection

We carried out an announced inspection visit to at Bishopsford Road Medical Centre on 9 June 2022. A records review was carried out on 6 June 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Requires improvement

Following our previous inspection on 9 November 2017, the practice was rated Good overall and for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Bishopsford Road Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This was a comprehensive inspection, which reviewed all of the key questions.

How we carried out the inspection

Throughout the pandemic 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:

  • Using a questionnaire to obtain staff feedback as well as conducting staff interviews.
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short site visit.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • What we found when we inspected.
  • Information from our ongoing monitoring of data about services.
  • Information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall.

We have rated Well-led as Requires improvement, as governance of arrangements for managing risks were not consistently effective and some aspects of below average patient satisfaction had not been effectively assessed or monitored.

We found that:

  • The practice provided clinical care in a way that kept patients safe and protected them from avoidable harm.
  • Most safety risks were well-managed, but governance processes had not identified that some risks had not been effectively identified, assessed, and mitigated.
  • Patients received effective care and treatment that met their needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. The practice had recently increased the amount of face-to-face appointments with doctors, in response to feedback. Phone access was not actively monitored, although there was some indication that patients found this difficult.
  • The partners began leading the practice in April 2021. Most of the staff in post at the time of the inspection were appointed after October 2021. This means that national survey results were not useful evidence.
  • There was limited information about that was available at the time of the inspection was mixed. The partners were aware of the concerns that had been raised and had taken some actions to improve. The most recent feedback was positive about the way staff treated people.

We found one breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Please refer to the requirement notice section at the end of this report for more details.

In addition, the provider should:

  • Take further steps to assess and improve patient perception of healthcare professionals.
  • Continue to monitor and take action on areas of below average/below target performance in hypnotics prescribing, childhood immunisation and cervical screening.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

9 November 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 Bishopsford Road Medical Centre on 4 April 2017. The overall rating for the practice was good, but with a rating of requires improvement for safety. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Bishopsford Road Medical Centre on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 9 November 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 4 April 2017. 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. The practice had improved arrangements for assessing and managing the risk of legionella and fire safety.

In response to recommendations we made in the report, the practice had also:

  • Implemented a system of procedures for an administrator to follow to improve the uptake of childhood immunisations, by for example, sending invitations, adding alerts to the records of children who have missed immunisations. There was no recent published data on childhood immunisations to confirm if the actions taken had improved performance to in line with average.
  • Improved the arrangements to identification of patients with caring responsibilities to be able to provide appropriate support and signposting. Fifty-eight patients (just over 1% of the practice list) were now on the practice carer’s register (compared to 11 patients at the time of the last inspection).
  • Added information about the availability of a translation service to the waiting room.
  • Implemented a systematic approach to encourage patients to attend for breast screening and to following up patients who did not attend. There was no recent published data on breast screening to confirm if the actions taken had improved performance to in line with average.
  • Improved the system to monitor training to ensure that staff had the training necessary to do their job.
  • Reviewed a number of policies to ensure that they remained accurate, for example, with correct staff details.
  • Ensured that all patients received a copy of the complaints leaflet if they indicated to reception that they wished to complain, and with the initial acknowledgement letter. This leaflet included details of other agencies patients could contact if they were unhappy with the practice’s response. These details were also on the practice website.

The provider should:

  • Continue to monitor and take action to improve the uptake of childhood immunisations and breast screening.
  • Include with all final responses to complaints, information about agencies patients can contact if dissatisfied with the practice response.
  • Monitor actions taken to manage risks to patients to ensure they are implemented consistently.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

4 April 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bishopsford Road Medical Centre on 4 April 2017. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The systems in place to minimise risks to patients were not sufficiently robust, particularly in respect of fire safety and risks associated with legionella. The practice did not have a full stock of emergency medicines or a risk assessment which considered the necessity of the medicines which were absent.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the clinical skills and knowledge to deliver effective clinical care and treatment. However staff had not received information governance training and one member of staff had not received basic life support training.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns. Some of the practice’s complaint responses did not include information on who to escalate concerns to if they were unhappy with the practice’s response.
  • Most of the patients we spoke with said they found it easy to make an appointment with a named GP and 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.
  • Though the practice had a detailed policy framework which was being used effectively by staff, there were a number of policies including infection control, fire safety and the practice’s business continuity plan which referred to members of staff who no longer worked at the practice.
  • Again, although incorrect staffing was noted in some policies, evidence showed that there was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

Actions the practice must take:

  • Ensure that all risks to patients are assessed and mitigated.

Actions the practice should take:

  • Continue work to improve the uptake of childhood vaccinations.

  • Improve the identification of patients with caring responsibilities to be able to provide appropriate support and signposting.

  • Take steps to ensure that information regarding translation services are easily accessible to patients.

  • Ensure that policies are up to date and accurate.

  • Take action to promote and encourage uptake of breast cancer screening.

  • Put mechanisms in place to ensure that staff have the training necessary to do their job and that this training is updated in accordance with current guidance.

  • Provide appropriate escalation and support contact details in all complaint responses.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice