• Doctor
  • GP practice

Hetherington at the Pavilion

Overall: Good read more about inspection ratings

9 Brighton Terrace, London, SW9 8DJ (020) 7326 2990

Provided and run by:
Hetherington Group Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Hetherington at the Pavilion on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Hetherington at the Pavilion, you can give feedback on this service.

24 November 2023

During an inspection looking at part of the service

We carried out an announced focused assessment at Hetherington at the Pavilion on 17 November 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 – good

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

Following our previous inspection on 21 November 2022 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 Hetherington at the Pavilion on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this assessment as part of our work to understand how practices are working to try to meet demand for access and to better understand the experiences of people who use services and providers.

We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know colleagues are doing this while demand for general practice remains exceptionally high, with more appointments being provided than ever. In this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. These assessments of the responsive key question include looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement.

How we carried out the review

This assessment was carried out remotely. It did not include a site visit.

The process included:

• Conducting an interview with the provider and members of staff using video conferencing.

• Reviewing patient feedback from a range of sources

• Requesting evidence from the provider.

• Reviewing data we hold about the service

• Seeking information/feedback from relevant stakeholders

Our findings

We based our judgement of the responsive key question on a combination of:

• what we found when we met with the provider

• information from our ongoing monitoring of data about services and

• information from the provider, patients, the public and other organisations.

We found that:

• During the assessment process, the provider highlighted the actions they have taken to make improvements to the responsiveness of the service for their patient population. They also identified the areas to be put in place to continue this improvement.

• Patient feedback was that they could access care and treatment in a timely way. Patients were satisfied with the arrangement for getting through to the practice by phone, their experience of obtaining an appointment and with appointment times offered.

• Patient feedback regarding satisfaction with the appointment offered was marginally lower than the England average, however, the practice were aware of this and monitoring on an ongoing basis to ensure improvements.

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

10 November 2022

During a routine inspection

We carried out an announced inspection at Hetherington at the Pavilion between 7 and10 November 2022. Overall, the practice is rated as Good.

Safe- Good.

Effective - Good.

Caring - Good

Responsive – Good.

Well-led - Good.

Following our previous inspection on 5 December 2017, the practice was rated Good overall and for all key questions.

The full report for previous inspections can be found by selecting the ‘all reports’ link for Hetherington at the Pavilion on our website at www.cqc.org.uk

This inspection was a comprehensive inspection part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach which involved a site visit: We looked at the Safe, Effective, Caring, Responsive and Well-led 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

  • Conducting staff interviews using video conferencing.
  • 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 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.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • 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.
  • 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:

  • Engage with those not attending for immunisations and screening to understand the barriers to uptake, and take action to remove those barriers.
  • Implement a system to formally document internal performance monitoring or peer reviews.
  • Develop medication reviews by even more effectively looking at monitoring.
  • Undertake a patient survey.
  • Review/risk assess the need for defibrillator pads for children.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

5 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection November 2014 – Good)

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

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out a comprehensive inspection of Hetherington at the Pavilion on 5 December 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice 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 patients with compassion, kindness, dignity and respect.
  • The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences and responded to feedback.
  • 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:

  • Review processes and procedures for prescription stationary storage and security to include monitoring the issue and use of blank prescriptions.
  • Review and improve the practice’s uptake for the cervical screening programme.
  • Continue monitoring the implementation of the GP led patient access system to ensure the system meets the needs of patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice