The Care Quality Commission
  • Doctor
  • GP practice

Beeches Surgery Also known as Drs Froley & Ghoorbin

Overall: Requires improvement read more about inspection ratings

9 Hill Road, Carshalton, Surrey, SM5 3RB (020) 8647 6608

Provided and run by:
Beeches Surgery

All Inspections

Site visit 3 August 2022, Offsite clinical review 12 August, Offsite interviews 29 July – 12 August

During a routine inspection

We carried out an announced comprehensive inspection at Beeches Surgery in August 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - good

Caring - good

Responsive - good

Well-led - inadequate

The practice has been inspected on five previous occasions:

  • January 2015 - rated inadequate overall and placed in special measures. Concerns included not having appropriate arrangements in place for processing prescriptions, inadequate systems for the reduction of healthcare associated infection control processes, inadequate systems to safeguard patients from abuse and poor leadership structures.
  • November 2015 - rated as requires improvement overall. We found improvements but also found two breaches of regulations concerning recruitment checks and managing risks.
  • May 2017 we found no breaches and the practice was rated as good.
  • June 2019 - rated as requires improvement overall. We found issues in relation to safety systems and processes, medicines management, management of significant events, outcomes for patients with long-term conditions, monitoring and seeking consent, complaints management and access to appointments.
  • 30 September 2021- rated as as requires improvement overall. We found the provider had made some improvements in providing safe and well led services, but we found new issues in recruitment, medicines management and systems to manage safety, including systems to identify, manage and mitigate risks.

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

Why we carried out this inspection

We carried out this inspection to breaches of regulation from a previous inspection. We inspected all of the key questions.

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:

  • Conducting staff interviews using video conferencing.
  • Receiving feedback from staff using questionnaires
  • 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:

  • Systems and processes put in place to manage risks were not being monitored to ensure they were working effectively. Some risks were not being well managed. Risks that were not being well managed in areas we had previously requested the provider to improve.
  • These issues had not been identified and rectified by the provider’s own systems and processes.
  • 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.
  • There was mixed feedback about whether people were able to access care and treatment in a timely way.

We found breaches of two regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way for patients.
  • Establish effective systems and processes to ensure good governance in accordance with fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Carry out a fuller assessment of whether changes made to levels of staff resource and support for non-clinical staff address the concerns raised.

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

30 September 2021

During a routine inspection

We carried out an announced comprehensive inspection at Beeches Surgery on 30 September 2021 and a remote clinical review on 28 September 2021 to follow up on breaches of regulations. Overall, the practice was rated as requires improvement.

The practice was previously inspected on 19 June 2019. Following the last inspection, the practice was rated as requires improvement overall for issues in relation to safety systems and records, medicines management, significant events, outcomes for management of patients with long-term conditions, monitoring of consent and management of complaints.

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

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

We rated the practice as Requires Improvement for providing safe services.

At this inspection we found the provider had made some improvements in providing safe services. In particular, the provider had made improvements to their systems and process in relation to significant events. However, we found new issues in relation to recruitment systems, safety systems and processes and medicines management.

We rated the practice as Good for providing effective services.

At this inspection we found the provider had made some improvements in providing effective services. However, outcomes for patients with long-term conditions were significantly below average, the provider had not demonstrated improved patient outcomes through quality improvement activities or clinical audits, process of appraisals and clinical supervision of non-medical prescribers were not satisfactory.

We rated the practice as Good for providing caring services.

We found that the staff treated patients with kindness, respect and compassion. However, we found that the provider had not enabled people to express their views by carrying out patient surveys.

We rated the practice as Good for providing responsive services.

We found that the provider had made some changes to improve access to the service; however, the provider informed it is still work in progress.

We rated the practice as Requires Improvement for providing well-led services.

We found the provider had made improvements in providing well-led services in relation to good governance and had implemented systems and process in response to the findings of our previous inspection. However, the governance arrangements in place still required improvement especially in relation to identifying, managing and mitigating risks.

We have rated this practice as Requires Improvement overall, requires improvement in safe and well-led and requires improvement for population group people with long-term conditions.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way for patients.
  • Establish effective systems and processes to ensure good governance in accordance with fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Improve uptake for learning disability health checks.
  • Improve staffing levels in response to staff feedback.
  • Consider all staff meetings to enable staff to discuss issues and improve learning.
  • Seek and act on feedback from patients and the Patient Participation Group.

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

19 June 2019

During a routine inspection

We carried out an announced comprehensive inspection at Beeches Surgery on 19 June 2019 as part of our inspection programme.

The practice was inspected on 13 January 2015 and was rated inadequate and placed in special measures. Concerns included not having appropriate arrangements in place for processing prescriptions, inadequate systems for the reduction of healthcare associated infection control processes, inadequate systems to safeguard patients from abuse and poor leadership structures. We inspected on 19 November 2015 and found improvements but also found two breaches of regulations concerning recruitment checks and managing risks. The practice was rated as requires improvement. When we inspected on 16 May 2017 we found no breaches and the practice was rated as good.

We decided to undertake an inspection of this service to check that the practice had sustained the improvements that were made between 2015 and 2017. This inspection looked at the following key questions:

  • Are services safe?
  • Are services effective?
  • Are services caring?
  • Are services responsive?
  • Are services well-led?

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 requires improvement for all population groups.

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

  • There were systems to ensure the safety in the practice, but they were not consistently effective. When things went wrong, action was taken, but the learning and action was poorly recorded.

We rated the practice as good for effective, and all of the population groups as good for effective, apart from people with long-term conditions. We rated the population group people with long-term conditions as requires improvement for effective because:

  • Most patients received effective care and treatment that met their needs. However, patient outcomes for asthma and hypertension were significantly below average in 2017/18 and there was evidence that performance deteriorated further in 2018/19 (for asthma, hypertension and other long-term conditions). The practice told us of actions taken to improve, but it was too early to demonstrate that these were effective.

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

  • Complaints were not all being managed in line with legislation, and there was no effective system to monitor compliance.
  • Individual complaints were responded to and action taken to resolve individual issues but learning and action was not effectively documented.

These impacted all population groups and so we have rated all population groups as requires improvement for being responsive.

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

  • The practice had not taken effective action to improve areas of below average clinical performance in 2017/18. Performance in these indicators deteriorated further in 2018/19.
  • There was no effective monitoring system for complaints to ensure that legislation was being followed. There was no effective monitoring of appointment availability.
  • There was no effective system to document actions and learning from complaints or significant events. Meeting minutes were not effective as a record of the meeting for those who could not attend or as a reference.
  • The system to ensure that governance documents were up-to-date was not consistently implemented.

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.

The provider should:

  • Monitor appointment availability.
  • Improve the identification of carers to enable this group of patients to access the care and support they need.

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

16 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Beeches Surgery on 16 May 2017. We carried out this inspection to check that the practice was meeting regulations.

Our comprehensive inspection carried out on 13 January 2015 found concerns including not having appropriate arrangements in place for processing prescriptions, inadequate systems for the reduction of healthcare associated infection control processes, inadequate systems to safeguard patients from abuse and poor leadership structures, and the practice was rated as inadequate and placed into special measures.

When we re-inspected on 19 November 2015 we found that the practice had made significant improvements. However there were still two breaches of regulations concerning recruitment checks and managing risks.

The previous reports can be found by selecting the ‘all reports’ link for Beeches Surgery on our website at www.cqc.org.uk.

Overall the practice is now rated as good.

Our key findings were as follows:

  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • Risks to patients were assessed and well managed.
  • Recruitment checks had taken place, but had not all been fully documented.
  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were generally in line with the national average, and the practice had taken action to improve indicators where performance was weak. Some exception rates were above average, although the overall exception rate was low.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
  • Care plans were inconsistently completed, and some dementia care plans had insufficient detail recorded to be considered as an adequate care plan.
  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • The practice had identified 32 patients as carers (0.5% of the practice list).
  • Since the last inspection, the practice had installed a new phone system with more incoming lines and call waiting information.
  • People told us on the day of the inspection that they were able to get urgent appointments when they needed them, but told us of waits of 2 – 3 weeks for routine appointments (longer for particular GPs). The practice told us that they were keeping the situation under review and had various plans underway to improve appointment access.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised, although national guidance on written responses was not consistently followed.
  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.
  • There was a strong focus on continuous learning and improvement at all levels.

However, there were also areas of practice where the provider should still make improvements.

The provider should:

  • Ensure that all recruitment checks are documented.
  • Monitor QOF exception rates and take action to ensure that patients are only excepted appropriately.
  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
  • Monitor the updated complaints policy to ensure it is effective.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

19 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Beeches Surgery on 19 November 2015. Overall the practice is rated as requires improvement.

We carried out this inspection to check that the practice was meeting regulations. Our previous comprehensive inspection carried out in January 2015 found breaches of regulations relating to the safe, effective and well led domains. Improvements were also required for responsive and caring domains. Concerns included not having appropriate arrangements in place for processing prescriptions, inadequate systems for the reduction of healthcare associated infection control processes, inadequate systems to safeguard patients from abuse and poor leadership structures.

In addition all population groups were rated as inadequate due to the concerns found in safe, effective and well led. The overall rating from this inspection in January 2015 was inadequate and the practice was placed into special measures for six months.

Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance.

The inspection carried out on 19 November 2015 found that the practice had made significant improvements and they were meeting some regulations they were previously in breach of. However we identified two breaches of regulations on this inspection.

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. Reviews and investigations were thorough enough.
  • Risks to patients were assessed and managed, with the exception of those relating to recruitment checks and fire risks.
  • Urgent appointments were usually available on the day they were requested.
  • Access to the practice was limited due to an inadequate telephone system that could not manage patient demands effectively.
  • The practice had a number of policies and procedures to govern activity
  • The practice had proactively sought feedback from patients and had an active patient participation group.
  • 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.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services was available.
  • Patients knew how to complain and information was readily available.
  • The practice had facilities and was equipped to treat patients and meet their needs although access for wheel chair users was limited.
  • 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 and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Ensure recruitment arrangements include all necessary employment checks for all staff including carrying out disclosure and barring services checks prior to employment.

  • Ensure an appropriate fire risk assessment is carried out.

In addition the provider should:

  • Review arrangements for wheelchair users accessing the building by ensuring they have appropriate facilities to alert staff they require assistance to enter the building.

  • Review the availability of an alarm in the disabled accessible toilet ensuring patients are able to alert staff if they need assistance.

  • Review the induction process and ensure it covers all relevant areas specific to individual roles.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

13 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

Beeches Surgery, located in Carshalton area of the London Borough of Sutton provides a general practice service to approximately 5600 patients.

We carried out an announced comprehensive inspection at Beeches Surgery on 13 January 2015. The inspection took place over one day and was undertaken by a Care Quality Commission (CQC) inspector along with a GP advisor and practice manager advisor.

Overall the practice is rated as inadequate and improvements are required.

Specifically, we found the practice inadequate for providing safe and effective services and in being well led. It was also inadequate for providing services for all population groups. Improvements were also required for providing caring and responsive services.

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

  • Systems were not in place to ensure the arrangements for prescribing, recording and handling prescriptions and repeat prescriptions kept people safe.
  • Disclosure and Barring Service (DBS) checks had not been undertaken for non-clinical staff who undertook chaperoning activities.
  • Significant events were being recorded but the practice was not recording incidents or near misses and staff were not clear about reporting incidents. There was little evidence of learning and communication with staff.
  • There were insufficient systems in place to protect patients from the risk of healthcare associated infections.
  • The practice had no clear leadership structure and limited formal governance arrangements.
  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity.
  • Urgent appointments were usually available on the day they were requested.

The areas where the provider must make improvements are:

  • Ensure there are appropriate arrangements in place for safe processing of prescriptions and storage of blank prescription forms.
  • Take action to address identified concerns with Healthcare associated infection prevention and control practice.
  • Ensure Disclosure and Barring Service (DBS) checks are undertaken for all staff who take on chaperoning duties.
  • Ensure availability of oxygen and an automated external defibrillator (AED) or undertake a risk assessment if a decision is made to not have oxygen or an AED on-site.
  • Ensure non-clinical staff receive training in safeguarding of children and vulnerable adults.
  • Ensure audits of practice are undertaken, including completed clinical audit cycles.
  • Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.
  • Ensure staff have appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.
  • Clarify the leadership structure and ensure there is leadership capacity to deliver all improvements.
  • Ensure feedback is sought from patients, carers and staff and that this feedback is used to develop the service
  • Ensure that all clinical staff have an awareness of the requirements of the Mental Capacity Act (2005), Gillick competencies, Deprivation of Liberties (DoLS) and general issues relating to consent to care and treatment
  • Ensure that people with long-term conditions are reviewed regularly and their care is planned appropriately.
  • Ensure a fire risk assessment of the premises is undertaken.

The areas where the provider should make improvement are:

  • Ensure incidents and near misses are recorded and discussed to promote learning.
  • Ensure all patients with a learning disability receive an annual health check and have a care plan in place and it is reviewed at least annually.
  • Ensure all patients with dementia have a care plan in place and it is reviewed at least annually.
  • Ensure that staff are supported with appropriate development opportunities.
  • Consider maintaining a list of patients who are vulnerable or at risk so that the needs of these patients can be better planned for and met.
  • Ensure patient confidentiality is maintained at all times especially as regards the location where patients leave prescription requests.

On the basis of the ratings given to this practice at this inspection, I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice