Background to this inspection
Updated
23 August 2021
The Mitcham Family Practice is located at
55 Mortimer Road
Mitcham
Surrey
CR4 3HS
Tel: 02086482432
https://www.mitchamfamilypractice.nhs.uk
The practice reception and telephone lines are open from 8am to 7pm Monday to Thursday, 8am to 6:30pm on Friday and 10am to 12pm on Saturday. Appointments are available between 9am and 11am every morning and 4.30pm and 6pm every afternoon. Extended hours surgeries are offered from 10am to 12.30pm on Saturday. The practice has opted out of providing out-of-hours (OOH) services to their own patients between 6.30pm and 8am and directs patients to the out-of-hours provider for South West London Clinical Commissioning Group.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury.
The practice is situated within the South West London CCG. The practice operates under a Personal Medical Services (PMS) contract. The practice is part of a wider network of GP practices within the Merton local area.
Information published by Public Health England shows that deprivation within the practice population group is in the fifth least deprived decile in England (five of 10). The lower the decile, the more deprived the practice population is relative to others. The practice population has a lower than CCG average representation of income deprived children and older people. The practice population of children, older people and those of working age are in line with local and national averages. The practice area is comprised of predominantly white British at 45%, 26% Asian or Asian British and 21% Black African, Caribbean and Black British patients
Mitcham Family Practice provides primary medical services in Merton to approximately 3600 patients and is one of 24 practices in Merton local area.
The practice operates from purpose-built premises in Mitcham. All patient facilities are on the ground floor and are wheelchair accessible. The practice has four doctor consultation rooms, one nurse consultation room and one treatment room which is used by a part-time counsellor.
The practice team at the surgery is made up of two male GP partners (one full-time/one part-time), one part-time locum female GP completing two sessions per week on a Saturday and a part time female practice nurse. The practice team also consists of a practice manager, and four part time administrative and reception staff.
Updated
23 August 2021
We carried out an announced comprehensive inspection at The Mitcham Family Surgery on 14 June 2021 as part of our inspection programme. In response to Covid- 19 we undertook a site visit on 14 June 2021 and carried out remote staff interviews after the site visit.
At our last inspection in February 2020 we rated the practice as Requires Improvement overall. We served the practice with a requirement notice during that inspection.
During this inspection, we found that while they were some improvements, patient outcomes were still low. However, early indication is that uptake rates for childhood immunisations are increasing. We also found that the leadership of the practice were still in conflict and this was impacting the day to day running of the practice resulting in some outstanding and delayed tasks.
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.
Our findings
We have rated this practice as Requires Improvement overall and requires improvement for all population groups.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs. However, patient outcomes remained low for people with long term conditions, childhood immunisations and cancer screening.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care. However patient feedback through the National GP Patient Survey was not always positive.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- We found concerns with the leadership of the practice. There was a conflict within the leadership that resulted in low morale in staff and delays in implementing day to day matters within the practice.
- There was a delay in responding to some patient complaints.
We found breaches of regulations. The provider must:
- Improve and increase the uptake for childhood immunisations and cervical cancer screening.
- Develop a formal process to ensure paramedics working at the practice as part of the primary care pilot are provided with adequate supervision.
- Ensure they follow their complaints process adequately to ensure all complaints are resolved within a reasonable time frame.
- Ensure the leadership of the practice resolves their differences to enable a cohesive leadership team that works constructively to ensure all staff are able to undertake their roles adequately and provide effective, caring and responsive services to patients.
The provider should:
- Improve the process of recording medication reviews.
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