The Care Quality Commission
  • Doctor
  • GP practice

Hammond Road Surgery

Overall: Good read more about inspection ratings

95 Hammond Road, Southall, Middlesex, UB2 4EH (020) 8574 5057

Provided and run by:
Hammond Road Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Hammond Road 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 Hammond Road Surgery, you can give feedback on this service.

12 November 2019

During an inspection looking at part of the service

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

We also carried out the inspection to follow-up on a breach of regulation identified at the previous inspection of the service in October 2018 in relation to patient satisfaction with access to appointments.

This inspection focused on the following key questions: effective, responsive and well-led.

Because of the assurance received from our review of information we carried forward the ratings for the following key questions: safe and caring.

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 with the exception of working age people (including those recently retired and students) population group which we rated as requires improvement.

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. However, cervical screening uptake was below the national target.
  • 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.
  • The practice had improved access to appointments since the last inspection with data showing that patients could now 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.

Whilst we found no breaches of regulations, the provider should:

  • Improve cervical screening uptake to bring in line with national targets.
  • Continue to improve childhood immunisation uptake to bring in line with the World Health Organisation (WHO) target.
  • Implement a program of quality improvement including clinical audit to drive improvement in patient outcomes.
  • Implement a leadership development programme, including a succession plan.

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

30 October 2018

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Hammond Road Surgery on 27 July 2017. Although the overall rating for the practice was good, the practice was rated as requires improvement for providing responsive services as patient satisfaction with access to the service was notably below local and national averages. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Hammond Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 30 October 2018 to confirm that the practice had taken action to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 27 July 2017. This report covers our findings in relation to those requirements.

At this inspection the practice provided evidence of an action plan they had implemented to improve access and some evidence of improvement. However, the most recent results from the national GP patient survey published in July 2018 showed patient satisfaction with access was still notably below local and national averages. Consequently, the practice is still rated as requires improvement for providing responsive services.

Our key findings were as follows:

  • The practice had implemented an action plan to improve access to the service.

  • The practice was able to demonstrate some improvement however results from the national GP patient survey published in July 2018 showed patient satisfaction in relation to access was notably below local and national averages.

    There areas of practice where the provider must make improvements are;

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

27 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hammond Road Surgery on 31 May 2016. The practice was rated as requires improvement for providing safe, effective, caring, responsive and well-led services. The overall rating for the practice was requires improvement. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Hammond Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive follow up inspection on 27 July 2017 to check for improvements since our previous inspection. Overall the practice is now rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Results from the national GP patient survey showed satisfaction with access to appointments was consistently below the Clinical Commissioning Group (CCG) and national average and it had only marginally improved since our previous inspection.
  • The practice had adequate facilities and was equipped to treat patients and meet their needs.
  • 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

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

In addition the provider should:

  • Ensure staff are aware of and can locate the business continuity plan, review contents of the emergency medicines list and implement regular fire drills at the branch practice
  • Improve information about opening hours, the appointments system and the complaints procedure at the branch practice
  • Improve patient confidentiality during GP consultations at the branch practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

31 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hammond Road Surgery and its branch practice, Berkerley Avenue Surgery on 31 May 2016. Overall the practice is rated as requires improvement.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. However, there was no formal procedure in place for the dissemination of safety alerts.
  • Risks to patients were not adequately assessed and managed appropriately. Areas of concern included recruitment, staff training, health and safety monitoring and contingency planning.
  • 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. However, there were gaps in mandatory training and staff appraisals were not consistently implemented.
  • Data from the national GP patient survey showed patients rated the practice lower than others for some aspects of care. Patients were mainly dissatisfied with nurse consultations and access to appointments.
  • Although some information on the complaints procedure was available on the practice website, there was no detailed information about how to complain at the main or branch surgeries and there was no complaints policy.
  • The practice had adequate facilities and was equipped to treat patients and meet their needs.
  • 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 complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Implement a system for the dissemination of safety alerts.
  • Review the mandatory training requirements for staff, implement a policy and ensure all staff receive the required training at appropriate intervals.
  • Ensure recruitment arrangements include all necessary employment checks for all staff and develop role specific induction programmes.
  • Improve health and safety monitoring at the main and branch surgeries to include risk assessments for fire, L legionella, the Control of Substances Hazardous to Health, the general environment and carry out regular fire drills at both sites. Introduce a cleaning schedule to monitor cleaning standards and appoint a lead for infection control.
  • Make available children's masks to be used with the oxygen cylinder.
  • Ensure appraisals are consistently implemented for all staff.
  • Implement a complaints policy and provide information on the complaints procedure.

In addition the provider should:

  • Take further action to improve Quality and Outcomes Framework performance particularly the management of diabetes.
  • Take action to improve patient satisfaction with nurse consultations and access to appointments.
  • Provide practice information in appropriate languages and formats.
  • Develop a formal strategy to deliver the practice vision.
  • Update the business continuity plan and locum pack.
  • Consider formalising all meetings and ensure a record is kept of discussions and decisions to form an audit trail.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

14 January 2014

During a routine inspection

We spoke with three people who used the service and four staff including a doctor, a nurse, the practice manager and the senior receptionist. All the people we spoke with told us they were satisfied with the care they were receiving at Hammond Road Surgery. Two of the three people said they had been coming to the surgery for a period of over twenty years and had no complaints. People said they found the receptionists at the surgery helpful and friendly. One person said 'I could not do better than this surgery.'

People were given the necessary information they needed to make informed decisions about their care and treatment. People said they were able to book an appointment when they needed to, and see the doctor of their choice.

Some safeguarding procedures were in place, however, staff had not received adequate training to recognise the signs of possible abuse in both children and adults.

Staff had received sufficient support and training to meet the needs of people using the service.

The provider had effective systems in place to monitor the standards of care and treatment provided including annual satisfaction surveys, an active patient participation group and audits of clinical practice.