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Pembridge Villas Surgery Good


Inspection carried out on 14 November 2019

During a routine inspection

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:

  • 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, except for the population group working age people which was rated as requires improvement as cervical screening uptake was below target.

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 had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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. In particular, patients said they found it easy to make an appointment and feedback was positive about the practice’s daily walk-in appointment system.
  • There was a clear leadership structure and staff felt supported by management.
  • 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:

  • Review the cleaning and storage of cleaning equipment at the practice.
  • Continue to review and improve the uptake of cervical screening and the childhood immunisation programme.

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

Inspection carried out on 21 April 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

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:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.

  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • There was a good skill mix amongst the GPs with some clinicians having specialised areas of expertise.
  • 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 and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment and were complimentary about the practice’s walk-in service as this accommodated patients who required urgent appointments the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice sought feedback from staff during practice meetings, appraisals, and away days.
  • A practice had an active patient participation group (PPG). The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and the PPG.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 22 May 2014

During a routine inspection

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.

Inspection carried out on 22 May 2014

During Reference: R6 not found