The Care Quality Commission
  • Doctor
  • GP practice

Chertsey Health Centre

Overall: Good read more about inspection ratings

Stepgates, Chertsey, KT16 8HZ (01932) 565655

Provided and run by:
Chertsey Health Centre

Important: The provider of this service changed. See old profile
Important: The provider of this service changed. See old profile

All Inspections

During an assessment under our new approach

Assessment date: 21 April 2026. Chertsey Health Centre is a GP practice that delivers services to approximately 22,900 people under a contract held with NHS England. According to the latest available data, the ethnic make-up of the service area is approximately 86% White, 7% Asian, 3% Mixed, 2% Black and 2% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the service population group is in the 8th decile (8 of 10). The lower the decile, the more deprived the service population is relative to others.

This was a focused assessment. We undertook this assessment due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

SAFE - Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. They assessed and managed the risk of infection well and took steps to control the risk of it spreading. There were enough staff with the right skills, qualifications and experience.

EFFECTIVE - Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes.

CARING - Staff treated people with kindness, empathy and compassion, and respected their privacy and dignity.

RESPONSIVE - People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the service and sought ways to address any barriers.

WELL-LED - The practice had a clear vision and strategy, which considered the needs of the people who used their service and the wider community. Staff understood their individual roles and responsibilities, and their wellbeing was supported by a cohesive management team. Leaders accounted for the actions, behaviours and performance of staff through clear and effective governance processes.

2 October 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Chertsey Health Centre on 02 October 2019. This was to follow up on a breach of regulation found at our previous inspection on 07 March 2019, the practice was rated good overall and requires improvement for providing safe services. The details of these can be found by selecting the ‘all reports’ link for Chertsey Health Centre on our website at www.cqc.org.uk.

During the inspection we looked at the following key question

  • Is it safe?

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 the practice as good for providing safe services. The practice remains rated as good overall and good for all population groups.

We found significant improvements:

  • Health and safety risk assessments, including fire, COSHH and liquid nitrogen had been completed and action plans were in place to complete mitigating actions.
  • Infection control audits had been reviewed and action plans completed.
  • Staff immunisation status was monitored in line with current Public Health England guidance.
  • Arrangements were in place to ensure emergency medicines and equipment were regularly checked and fit for use.
  • Protocols for checking pathology results ensured that results were checked within an appropriate timescale reducing reliance on the laboratory to alert the practice to urgent results.
  • The practice had implemented formal clinical supervision arrangements for the nursing team, which included each nurse having a named GP clinical supervisor.
  • The recording of patient safety alerts included completed actions and where no action was required.
  • The process for obtaining and recording consent had been reviewed and improved to ensure where appropriate signed consent forms were attached to the clinical record.

The areas where the provider should make improvements are:

  • Continue to monitor and improve the recording of checks including blank prescription tracking and actions taken from safety alerts.

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

07 March 2019

During a routine inspection

We carried out an announced comprehensive inspection at Chertsey Health Centre on 7 March 2019 as part of our inspection programme.

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 good overall and good for all population groups.

We found that:

  • 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 organised and delivered services to meet patients’ needs. 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.

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

  • The practice did not have clear systems and processes to keep patients safe.
  • The practice did not have appropriate systems in place for the safe management of medicines.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.

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

The areas where the provider should make improvements are:

  • Improve the system for reviewing pathology results to reduce reliance on the laboratory alerting the practice of urgent results.
  • Improve the recording and monitoring of where palliative patients would prefer to die.
  • Improve the recording patient safety alerts to include completed actions.
  • Review formal clinical supervision for the nursing team.
  • Improve the process for signed consent forms being attached to the clinical record.

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