The Care Quality Commission
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  • GP practice

Mitcham Family Practice

Overall: Requires improvement read more about inspection ratings

55 Mortimer Road, Mitcham, Surrey, CR4 3HS (020) 8648 2432

Provided and run by:
Mitcham Family Practice

Important: This service was previously registered at a different address - see old profile

All Inspections

14 June 2021

During a routine inspection

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

27 February 2020

During a routine inspection

We carried out this announced comprehensive inspection on 27 February 2020 following a previous comprehensive inspection on 5 June 2019, the practice had received a requirement notice due to a breach of regulation 17. At this inspection we found that action had been taken since our previous inspection. However, these steps had not completely addressed all the governance concerns previously noted. At this inspection, breaches of legal requirements were found, and a requirement notice was issued for breach of regulation 17 due to concerns with the governance of the practice.

We first inspected the practice on 4 November 2015, the practice was rated requires improvement overall and was issued requirement notices for breaches of regulations 12 and 17 due to not doing all that was reasonably practicable to mitigate risks to health and safety of service users as they did not have adequate systems in place for responding to emergencies, including mandatory training, equipment and required emergency medicines. We also found they did not have adequate systems and processes to improve the quality and safety of services. Governance systems to ensure that the outcomes of incidents, complaints and audits were acted on and monitored to drive improvements in the quality of the service were not effective.

An announced focused inspection was carried out on 21 June 2016 to follow up on the concerns raised at the November 2015 inspection. The practice was found to have made some improvements and was rated good overall and requires improvement for providing well-led services. The practice was not issued a requirement notice for a breach of regulation.

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 have rated this practice as requires improvement overall and for the effective, caring and well-led key questions. The safe and responsive key questions were rated as good. The population group: families, children and young people was rated inadequate; and working age was rated requires improvement. The population groups: older people, people with long-term conditions, people whose circumstances may make them vulnerable and people experiencing poor mental health were all rated good.

The reports of all the previous inspections can be found by selecting the ‘all reports’ link for Mitcham Family Practice on our website at .

We rated the practice as requires improvement for providing effective services because:

  • The practice was below the CCG and national average for three of the five cancer indicators. The action taken to improve performance was not yet having sufficient impact.
  • The practice had not met the minimum 90% uptake rate for the four child immunisation indicators.
  • The practice was not assured that all GPs had completed their mandatory training. For example, basic life support, the Mental Capacity Act 2005 and information governance. role.

We rated the practice requires improvement for providing caring services because:

  • Data from the GP Patient survey showed that the practice was not in-line with local and national averages in indicators relating to patients’ experience of the practice. The practice had not taken action to investigate or address their performance.

We rated the practice requires improvement for providing well-led services because:

  • The leadership culture did not always support the delivery of high-quality inclusive care.
  • Risk issues were not always identified and dealt with promptly.
  • Some staff did not feel their concerns relating to clinical staff would be addressed.

We rated the practice as good for providing safe services because:

  • Comprehensive risk assessments had been carried out for people who use services and risk management plans developed in line with national guidance.
  • Staff who carried out chaperoning had received training and were aware of their responsibilities.
  • The practice stocked all the required emergency medicines.

We rated the practice good for providing responsive services because:

  • Data from the national GP patient survey showed patients rated the practice in line with the CCG and nationally for all aspects of making an appointment at the practice.
  • Facilities and premises are appropriate for the services being delivered.

There were areas where the provider must make improvements:

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

The areas where the provider should make improvement are:

  • Put a plan in place to improve GP lateness and patient access to services.
  • Implement an effective staff immunisation programme in line with current guidance.

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

5 June 2019

During a routine inspection

We carried out an announced comprehensive inspection at Mitcham Family Practice on 21 June 2016 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was good overall and requires improvement for providing a well-led service.

This inspection was an unannounced comprehensive inspection, following concerns raised with CQC, which we undertook on 5 June 2019 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This report covers our findings in relation to those requirements.

The practice was rated as good for the safe key question, requires improvement for the effective, caring, and responsive key questions and inadequate for the well-led key question. This led to an overall rating of requires improvement. Breaches of legal requirements were found, and a requirement notices was issued in relation to patient safety and governance.

The reports of all the previous inspections can be found by selecting the ‘all reports’ link for Mitcham Family Practice on our website at .

We have rated this practice as requires improvement overall and requires improvement for all population groups due to significant issues affecting all these groups.

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 and the public.

We rated the practice as inadequate for providing well-led services because:

  • There was insufficient assurance that the practice had adequate governance arrangements in place to sustain required improvements this was demonstrated by the fact there had been repeated breaches of regulation since the provider was first inspected in 2015.
  • The practice had not established effective systems to monitor the quality of services provided and to mitigate risks to patients.

We rated the practice as requires improvement for providing effective services because:

  • Cervical screening rates were below the CCG and national average.
  • There was limited quality improvement activity other than that directed from the CCG.
  • Lack of consideration for the potential treatment needs of mental health patients.
  • Patients’ treatment was put at risk due to lack of adherence to best practice guidance for diagnosing conditions.

We rated the practice as requires improvement for providing a caring service because:

  • Data from the GP Patient survey showed that the practice was not in-line with local and national averages in indicators relating to patients’ experience of the practice.
  • The practice had identified less than 1% of their patients as being a carer.

We rated the practice as good for providing safe services because:

  • All necessary recruitment checks including references had not been undertaken for staff.
  • Staff who carried out chaperoning had received training and were aware of their responsibilities.
  • There was evidence of lessons learned and improvements made when things went wrong.

We rated the practice as good for providing a responsive service because:

  • Data from the national GP patient survey showed patients rated the practice in line with the CCG and nationally for all aspects of making an appointment at the practice.

  • Complaints were managed appropriately and in a timely manner.

The areas where the provider must make improvements are:

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

There are areas where the provider should make improvements:

  • Review processes in place for the identification of carers within the practice.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated

21 June 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 4 November 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(1)(2)(a)(b)(c)(f) Safe care and treatment and regulation 17(1)(2)(a) Good governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this announced focussed inspection on 21 June 2016 to check that they had followed their plan and to confirm that they now met 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 Mitcham Family Practice on our website at www.cqc.org.uk.

Overall the practice is rated as good. Specifically, following the focussed inspection we found the practice to be good for providing safe services but they remained as requires improvement for well-led services. As the practice was now found to be providing good services for safety, this affected the ratings for the population groups we inspect against. Therefore, it was also good 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) and people experiencing poor mental health (including people with dementia). The practice was previously rated as requires improvement for effective, caring, responsive and well-led services for people whose circumstances make them vulnerable. Although the practice is rated as good for safety, the rating for this population group remains as requires improvement.

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

  • Risks to patients were assessed and well-managed, including those related to responding to emergencies.
  • Systems had been established so that outcomes of complaints and audits were acted and monitored to drive improvements in quality of the service.

However there were areas of practice where the provider should make improvements:

  • Continue to develop the practice’s system to ensure adequate learning and development of the service from significant events.
  • Review the practice’s defibrillator risk assessment to ensure a full review of risks and control measures are included.
  • Continue to carry out clinical audits and develop a clinical audit plan for the practice.
  • Ensure issues with the partnership are resolved so they have the capacity to deliver all the improvements identified.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

4 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mitcham Family Practice on 4 November 2015. Overall the practice is rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, it was not always clear if the practice acted on and monitored significant events and incidents effectively.
  • Most risks to patients were assessed and well managed, with the exception of those relating to medical emergencies.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Data showed patient outcomes were average or above for the locality. Although some audits had been carried out, there was minimal evidence that audits were driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said they found it easy to make an appointment with a named GP and that 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.
  • Information about services was available but not everybody would be able to understand or access it.
  • Information about services and how to complain was available but the complaints process was not clear for patients.
  • The practice had a number of policies and procedures to govern activity and support staff.
  • The practice had proactively sought feedback from patients and had an active patient participation group.
  • Although staff felt supported by the partners and management, there was evidence of conflict within the partnership which affected communication and decision-making in the practice.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Ensure that the practice has systems in place to be able to appropriately respond to emergencies: specifically basic life support training for all staff, access to a defibrillator or adequate assessment and mitigation of risk and the availability of emergency medicines in line with recommended guidance.
  • Ensure that the practice has governance systems in place to ensure that outcomes of incidents, complaints and audits are acted on and monitored to drive improvements in the quality of the service.

In addition the provider should:

  • Carry out clinical audits including re-audits to ensure improvements have been achieved.
  • Ensure that clinical staff are aware of their responsibilities in relation to the Mental Capacity Act.
  • Ensure that multi-disciplinary meeting minutes are used effectively to monitor and improve patient outcomes.
  • Provide information for patients to direct them to support services available to cope emotionally with care and treatment, including support for carers and families who have suffered a bereavement.
  • Ensure the practice is able to identify patients acting as carers.
  • Ensure there is effective communication to ensure that the partnership has the capacity to deliver all improvements identified.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice