27 June 2022
Heathcot Medical Centre is based in a purpose built two storey health centre. There are treatment and consulting rooms on both floors. The health centre also includes another GP practice and a community pharmacy.
The practice offers services from the main practice and has two branch surgeries. Patients can access services at all surgeries. During our inspection we visited the main surgery and both the branch surgeries.
Services are provided from the following locations:
York House Medical Centre, Heathside Road Woking, Surrey, GU22 7XL
Brewery Road Surgery, 54 Brewery Road, Horsell, Woking, Surrey, GU21 4NA
Knaphill Surgery, Redding Way, Knaphill, Woking Surrey, GU21 2DN
The provider is registered with CQC to deliver the Regulated Activities;
- Diagnostic and screening procedures,
- Maternity and midwifery services
- Treatment of disease, disorder or injury
- Surgical procedures
- Family Planning
Information published by Public Health England shows that deprivation within the practice population group is rated 10 out of 10. The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 11.5% Asian, 83.2% White, 1.6% Black, 2.5% Mixed, and 1.5% Other.
There is a team of five GPs partners and six salaried GPs (male and female) who provide cover at all surgeries. There is a team of four nurses who provide nurse led clinics across the surgeries. The practice also employs healthcare assistants, a clinical pharmacist and two further members of the pharmacy team. The GPs are supported at the practice by a team of reception/administration staff. The practice manager, deputy practice manager and clinical manager provide managerial oversight.
The practice is part of a federation of GP practices that offer evening appointments until 9pm and weekend appointments 9am until 12pm. These appointments are run from locations in Walton-on-Thames, Ashford, Sunbury-on-Thames and Woking.
27 June 2022
We carried out an announced inspection at Heathcot Medical Centre on 9 - 12 May 2022. Overall, the practice is rated as Requires Improvement
Set out the ratings for each key question
Safe - Requires Improvement
Effective - Requires Improvement
Caring – Good
Responsive – Requires Improvement
Well-led - Requires Improvement
Following our previous inspection on 5 November 2018, the practice was rated Good overall and for the well led key question, we carried over the ratings for the other domains that were all rated as Good:
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Heathcot Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive inspection looking at all of the domains. Safe, effective caring, responsive and well led.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
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.
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A short site visit
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 Requires Improvement overall
We found that:
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Staff told us they felt well supported and that leaders were approachable.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- There was a lack of monitoring of staff immunisations and risk assessments had not been undertaken to mitigate risks associated with a lack of immunisation.
- Although the provider had a system in place to record and act on recent safety alerts, we identified a historic alert which had not been acted upon.
- We found gaps in processes relating to the monitoring of vaccine fridge temperatures to ensure those medicines remained safe to use.
- Staff recruitment files contained all of the required information.
- Medicine reviews were not always completed in the required time frames.
- Staff mandatory training was not up to date.
- We saw evidence that clinicians took part in multi-disciplinary team meetings to discuss patient care.
- The practice was innovative in the use of technology.
- Urgent cancer referrals were not always being monitored to ensure that an appointment had been offered in the required time frames.
- We found evidence of insufficient monitoring of a number of patient during our searches of patient records. This included high risk medicines, the follow up of abnormal test results and requests for repeat medicines.
- The internal fire risk assessment did not cover all notable risks and there was no fire risk assessment completed for Knaphill Surgery.
- Complaints investigation needed to be reviewed to ensure all of the concerns raised were investigated.
- The details recorded for complaints and significant events needed to be strengthened to ensure trend analysis and the wider learning for all staff.
We found breaches of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients
- Ensure persons employed in the provision of the regulated activity receive the appropriate training necessary to enable them to carry out the duties.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
The provider should:
- Review and continue to monitor cervical screening uptake to meet the Public Health England screening rate target.
- Continue to plan and carry out staff appraisals.
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