The Care Quality Commission
  • Doctor
  • GP practice

Ravensbury Park Medical Centre

Overall: Good read more about inspection ratings

Ravensbury Lane, Mitcham, Surrey, CR4 4DQ

Provided and run by:
Ravensbury Park Medical Centre

Important: The provider of this service changed - see old profile

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Ravensbury Park Medical Centre 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 Ravensbury Park Medical Centre, you can give feedback on this service.

10 August 2021

During a routine inspection

We carried out an announced comprehensive inspection at Ravensbury Park Medical Centre on 10 August 2021 as part of our inspection programme. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective – Good

Caring - Good

Responsive Good

Well-led – Good

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

Why we carried out this inspection

At our last inspection in October 2019 we rated the practice as Requires Improvement overall. We served the practice with a requirement notice during that inspection.

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.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections. 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

  • Requesting evidence from the provider in advance of the 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 have rated this practice as Good overall and requires improvement for one population groups; children and families though there were significant improvement on uptake rates for childhood immunisations.

We found that:

  • The practice had made significant improvements. The practice leaders had recognised the impact the issues regarding disputes within the partners were having on the practice management and patient care. The disputes had been settled.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Sufficient clinical staff were in post to provide clinical cover.
  • 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.
  • Access to care had been improved at the practice with patients’ feedback largely positive about their experience of accessing the practice.
  • 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 provider should:

  • Should continue efforts to increase childhood immunisations uptake and cervical smear screening.

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

9 October 2019

During a routine inspection

We carried out an unannounced comprehensive inspection at Ravensbury Park Medical Centre on 09 October 2019 as part of our inspection. The practice was inspected in September 2018 and was rated Good.

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 requires improvement overall.

We have rated all population groups as requires improvement due to concerns with patients’ access to appointments.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. However the process for covering staff absence was not always sufficient, there was limited clinical cover.
  • There was evidence of some patients receiving effective care, however, data showed patients with long term conditions did not always receive appropriate care. During the inspection period, the practice sent us data that showed the current outcomes for patients with long term conditions had slightly improved.
  • Some patients reported that the manner of some reception staff did not meet their expectations.
  • Patients reported difficulties accessing appointments at the practice.
  • There were divides within the partnership team and the way the practice was led did not consistently promote a culture or the provision of high-quality, person-centre care and treatment.

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.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

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

The areas where the provider should make improvements are:

  • Maintain a locum pack with sufficient information.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

18 September 2018

During a routine inspection

This practice is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at Ravensbury Park Medical Centre on 11 January 2017, when the service was provided by Dr Titus Keyamo. The overall rating for the practice was inadequate and multiple breaches in regulations were identified. The service was placed in special measures for six months. The practice received input from a number of organisations in this time to assist in improving the quality and the safety of the service.

We carried out an announced follow up comprehensive inspection on 26 September 2017 to review if improvements had been made. We found that whilst some improvements were made, there were insufficient improvements overall, such that the practice remained rated as inadequate and breaches in regulations were identified. Therefore, we took action in line with our enforcement procedures to prevent the provider from operating the service and we began the process to cancel the provider’s registration.

The service was registered under a new provider, Wide Way Surgery, in January 2018, to ensure that practice services could continue to be provided for patients. The practice received input and support to improve and develop the service under this provider. The service provider is now newly registered as Ravensbury Park Medical Centre, and under this arrangement, improvements are still supported by key partners from the previous provider.

This inspection is an announced comprehensive inspection carried out at Ravensbury Park Medical Centre on 18 September 2018 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was carried out in line with our next phase inspection programme.

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 understood the needs of its population and tailored services in response to those needs.
  • Most patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a renewed focus on continuous learning and improvement, however governance and communication arrangements required a review to ensure quality improvements could be sustained across the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

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

The areas where the provider should make improvements are:

  • Review and act on performance data, specifically related to patients with high blood pressure, including those with diabetes.
  • Review systems used to identify carers in order to further expand the carers’ register.
  • Monitor the vision for the leadership and management structure to ensure quality can be sustained long-term.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.