Background to this inspection
Updated
22 October 2018
The registered provider of the service is The Roehampton Surgery. The address of the registered provider is 191 Roehampton Lane, London, SW15 4HN. The practice is registered as a partnership of two partners with the Care Quality Commission to provide the regulated activities of diagnostic and screening services, family planning services, maternity and midwifery services and treatment of disease, disorder or injury.
Regulated activities are provided at one location operated by the provider and at a branch practice known as Ashburton Medical Practice. The practice website is .
The Roehampton Surgery provides services to approximately 5800 patients in Roehampton, London Borough of Wandsworth and is one of 44 member practices of Wandsworth Clinical Commissioning Group (CCG). The practice operates under a General Medical Services (GMS) contract.
The practice is in line with the national averages for their population of children, those of working age and those over 65. Deprivation scores are higher than local and national averages and deprivation affecting children is considerably higher than local and national averages. The practice is in the 5th most deprived decile in England. Of patients registered with the practice, approximately 70% are White or White British, 11% are Black or Black British, 11% are Asian or Asian British, and 8% are other or mixed ethnic backgrounds.
The Roehampton Surgery operates from a converted residential property with three floors. The ground floor of the building is wheelchair accessible via a ramp. On the ground floor there is a reception area, waiting area, treatment room and two consultation rooms. There is also a patient toilet which is wheelchair accessible. On the first floor there are staff facilities, a meeting room, a room used by the local counselling service and a waiting room for their patients. The second floor of the building is not accessed by practice patients.
There are two full-time GPs who are partners and three part-time salaried GPs. Patients are able to see male or female GPs. In total the doctors provide 26 clinical session per week. The nursing team consists of a part-time practice nurse and a part-time health care assistant. The clinical team is supported by an office manager, an operations manager, an IT manager and three administrative and reception staff.
The main practice opens between 8.30am and 6.30pm Monday to Friday. Extended hours are available Monday to Thursday from 6.30pm to 8.00pm. The branch practice is open between the hours of 8.30am and 11.30am Monday to Friday and between 4.00pm and 6.00pm on Friday.
The practice provides medical services to registered patients from two local care homes and a supported living facility.
Out of hours, patients are directed to the local out of hours provider for Wandsworth CCG via 111.
Updated
22 October 2018
This practice is rated as Good overall. (Previous rating 27 July 2017 – Good)
The key questions at this inspection are rated as:
Are services effective? – Good
Are services well-led? – Good
We carried out an announced comprehensive inspection at the Roehampton Surgery on 14 April 2016. The overall rating for the practice was requires improvement and breaches in regulations were identified.
We carried out an announced focussed follow up inspection visit on 12 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our inspection on 14 April 2016. We found that the practice had made improvements and were meeting requirements in some areas, however the overall rating for the practice remained requires improvement.
We carried out an announced follow up comprehensive inspection on 27 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 12 January 2017. We found that the practice had made a number of improvements and the overall rating was good, however they remained rated as requires improvement for effective services, and a breach in regulations was identified.
The full reports for the April 2016, January 2017 and July 2017 inspections can be found by selecting the ‘all reports’ link for The Roehampton Surgery on our website at .
This inspection was an announced focussed follow up inspection visit on 11 September 2018 under Section 60 of the Health and Social Care Act 2008, to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 27 July 2017. This inspection was carried out in line with our next phase inspection programme. This report covers our findings in relation to those requirements and any improvements made since our last inspection. Overall the practice remains rated as good. They remain rated as good for well-led services and the practice are now rated as good for providing effective services.
At this inspection we found:
- Arrangements in respect of identifying, monitoring and managing risks to staff and service users had improved via the use of an overarching action planner, which was used to collate and manage issues identified across the practice’s safety risk assessments.
- 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.
- The practice had implemented a quality improvement programme in response to their performance data. Quality improvement systems included clinical audit, which showed there had been a positive impact on patient care.
- The practice had continued to make improvements in governance arrangements, including a clinical audit programme, systems to manage risk, systems to monitor and improve performance data, improved medicines management systems and improved meeting and communication systems.
- Staff felt supported and valued and demonstrated a commitment to making and sustaining improvements in the service.
- The practice had an operational patient participation group (PPG) however this was not yet fully effective in influencing changes to the service.
The areas where the provider should make improvements are:
- Consider how the responsibilities of staff in leadership and management roles are arranged, to assist with delivering further improvements to the quality of the service.
- Regularly review the central action planner to effectively manage risks.
- Further develop the PPG so it is used to effect and influence improvements in the service.
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