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Belmont Hill Surgery Good Also known as The Surgery


Review carried out on 22 August 2019

During an annual regulatory review

We reviewed the information available to us about Belmont Hill Surgery on 22 August 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 18 May 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 14 April 2016 at Belmont Hill Surgery. At that inspection the practice was rated good overall, but as requires improvement for some aspects of providing safe services. The full comprehensive report on the 14 April 2016 inspection can be found by selecting the ‘all reports’ link for Belmont Hill Surgery on our website at

This inspection was a desk-based review carried out on 18 May 2017 to check that the practice had followed their plan to address the findings we had identified in our previous inspection on 14 April 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as good. Following the desk-top review we found the practice to be good for providing safe services.

Our key findings were as follows:

  • Cleaning arrangements for the practice had been reviewed which included the implementation of a comprehensive cleaning schedule and audit process.
  • Findings from the infection prevention and control audit had been addressed and improvements identified and actioned.
  • Processes had been put in place to check emergency medical equipment was fit for use.
  • Systems had been implemented to ensure blank printer prescription security and to track their use through the practice in line with national guidance.
  • Improvement grant funding had been approved in principle to make adaptations in the practice relating to auditory privacy and accessible toilet facilities.
  • An event had been arranged in the practice with Carers Lewisham to promote the identification of carers in the practice.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 14 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Belmont Hill Surgery on 14 April 2015. Overall the practice is 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 an effective system in place for reporting and recording significant events.
  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not in all instances implemented well enough to ensure patients were kept safe, specifically in relation to infection control, cleaning arrangements and the checking of emergency medical equipment.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available 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 proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Implement actions identified from the infection control audit and review the cleaning arrangements for the practice.
  • Ensure there is an effective system for checking emergency medical equipment is fit for use.

The areas where the provider should make improvement are:

  • Consider how people who use the accessible toilet facility would alert staff in the event of an emergency.
  • Review the policy to offer patients with ambulatory difficulties consultations on the ground floor.
  • Implement a procedure to track blank prescriptions through the practice in line with national guidance.
  • Review how carers are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
  • Review auditory privacy within the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 14 April 2014

During an inspection looking at part of the service

We carried out this visit to check that the provider had taken steps to rectify the gaps in recruitment we found at our previous inspection in February 2014.

We found that the provider had introduced a new pre-employment check policy, the gaps previously found in employment histories for two staff had been rectified, and the provider was able to show us a list of professional registration checks they had carried out with the General Medical Council and the Nursing and Midwifery Council.

On this occasion we did not speak with users of the service.

Inspection carried out on 7 February 2014

During a routine inspection

We spoke with six patients. One patient told us, �The GPs are lovely. They treat me as a person and spend enough time with me�. Another patient told us, �I find the GPs nice. They take their time and explain things�.

We saw the GPs kept patients records up to date. Patients told us they were satisfied they were referred on to specialists when needed, and that they were also able to get test results back quickly and easily.

Staff were provided with policies and procedures relating to child protection and the protection of vulnerable adults, and they were able to describe possible signs of abuse and knew who to report concerns to.

The practice had recruitment and selection processes in place but we found they were not robust enough. Not all appropriate checks were undertaken before staff began work.

The practice had a number of systems in place to assess the quality of the service it provided, including surveying patients to gather their views. It had a patient participation group, which gave us positive feedback during our inspection.