We carried out a review of the data available to us about Pembridge Villas Surgery 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 Pembridge Villas Surgery, you can give feedback on this service.
We undertook a targeted assessment of the responsive key question at Pembridge Villas Surgery. The rating for the responsive key question is Good. As the other domains were not reviewed during this assessment, the rating of good will be carried forward from the previous inspection and the overall rating of the service will remain 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.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pembridge Villas Surgery on our website at www.cqc.org.uk
Why we carried out this assessment
We carried out a targeted assessment of the responsive key question. Targeted assessments enable us to focus on certain key questions to explore particular aspects of care.
How we carried out the assessment.
This assessment was carried out without a site visit
This included:
Our findings
We based our judgement of the quality of care at this service on a combination of:
We found that:
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
We carried out an announced comprehensive inspection at Pembridge Villas Surgery on 14 November 2019 as part of our inspection programme.
We based our judgement of the quality of care at this service on a combination of:
We have rated this practice as good overall and good for all population groups, except for the population group working age people which was rated as requires improvement as cervical screening uptake was below target.
We found that:
Whilst we found no breaches of regulations, the provider should:
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
We carried out an announced comprehensive inspection at 'The Pembridge Villas Surgery' on 21 April 2015. Overall the practice is rated as good.
Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also good for providing services to the six population groups we inspect - People whose circumstances may make them vulnerable; Older people; People with long-term conditions; Families, children and young people; Working age people (including those recently retired and students); and People experiencing poor mental health (including dementia).
Our key findings across all the areas we inspected were as follows:
Chief Inspector of General Practice
The Pembridge Villas Surgery provides GP led primary care services to approximately 9800 patients living in the surrounding areas of Notting Hill and Westbourne Green in the West London borough of Kensington and Chelsea. The population demographics for the area included a higher proportion of 20-39 year olds living in the area, and the most widely spoken languages after English are French and Arabic.
The service is registered with the Care Quality Commission (CQC) to provide the following regulated activities: diagnostic and screening procedures; family planning; maternity and midwifery services; surgical procedures; and treatment of disease, disorder and / or injury.
We carried out an announced inspection on 22 May 2014. During our inspection we spoke with patients, the GPs, practice manager, assistant practice manager, nurse, phlebotomist, health care assistant and reception staff. Patients we spoke with told us they were happy with the service they had received. Staff we spoke with told us they felt supported in their role and enjoyed working at the practice.
The practice provides good care but some areas of the service require improvement, including respecting patients’ privacy and dignity during examinations. Some staff had not received training in infection prevention and control and, protecting vulnerable adults from the risk of abuse.
Systems were in place to ensure clinical staff received information required to deliver good clinical care. There was evidence that the practice had learnt from significant events to minimise the risks to patient safety and systems were in place to safeguard children from abuse. Clinical staff had completed audit cycles to monitor and improve the service. There were clear leadership and governance arrangements in place, with staff describing a positive culture of openness and support within the practice.
Patients were able to access the service via booked appointments or daily walk-in clinics. There were some arrangements in place to respond to the needs of different population groups including seasonal flu clinics for older patients, immunisation clinics for babies and, health clinics to review people with long term conditions. The practice had developed special expertise in caring for homeless patients.