• Doctor
  • GP practice

Eltham Palace Surgery

Overall: Inadequate read more about inspection ratings

30 Passey Place, Eltham, London, SE9 5DQ (020) 8294 8150

Provided and run by:
Eltham Palace PMS

Latest inspection summary

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Background to this inspection

Updated 10 August 2023

Eltham Palace Surgery is located in Eltham at:

Eltham Community Hospital

30 Passey Place



Greater London


Eltham Palace Surgery serves approximately 8000 patients. It is based within South East London Integrated Care Board. The practice is registered with the CQC for the following regulated activities: treatment of disease, disorder or injury; surgical procedures; diagnostic and screening procedures, family planning, and maternity and midwifery services.

The practice is part of a wider network of GP practices within Eltham Primary Care Network.

There is a team of 2 GP Partners supported by a team of approximately 5 locum GPs. The practice has a team of 3 nurses. The GPs are supported at the practice by a team of 6 reception/administration staff. There is also a practice manager and assistant practice manager.

The practice is open between 8 am to 6.30/8pm Monday to Friday. The practice offers a range of appointment types including, book on the day, telephone consultations and advance appointments.

Out of hours services are provided by NHS 111.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th lowest decile (4 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 6.4% Asian, 80.3% White, 8% Black, 3.6% Mixed, and 1% Other.

Overall inspection


Updated 10 August 2023

We carried out an announced comprehensive inspection at Eltham Palace Surgery on 3 and 4 May 2023. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective - Inadequate

Caring - Requires improvement

Responsive - Inadequate

Well-led - Inadequate

Following our previous inspection on 12 July 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 Eltham Palace Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up concerns in response to risk reported to us.

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:

  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • 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 and
  • information from the provider, patients, the public and other organisations.

We found that:

  • Patient records did not demonstrate those on high-risk medicines or with long-term conditions had sufficient monitoring to ensure their safety.
  • There was evidence that safety alerts were not being monitored or audited to ensure patient safety.
  • Patients were not able to access care and treatment in a timely way.
  • Patients were not satisfied with GP appointment systems.
  • There were insufficient staff.
  • There was a divide between the two GP partners which had created a toxic work environment for staff.
  • Not all patients’ medical records were kept up to date and accurate.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.
  • The overall governance arrangements were inadequate.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice culture did not effectively support high quality sustainable care.
  • Many staff had not completed recommended training such as safeguarding, infection control or equality and diversity.
  • Some staff did not have disclosure and barring checks completed.
  • There was little to no evidence of auditing or quality assurance.
  • Although the complaints process was on the website, it was not easily accessible.
  • We found hundreds of physical medical records which needed to be summarised and added to clinical records.
  • The practice did have an active patient participation group.

We found three breaches of regulations. The provider must:

  • 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.
  • Provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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