The Care Quality Commission
  • Doctor
  • GP practice

South Norwood Hill Medical Centre

Overall: Requires improvement read more about inspection ratings

103 South Norwood Hill, London, SE25 6BY (020) 8771 0742

Provided and run by:
South Norwood Hill Medical Centre

Important: We are carrying out a review of quality at South Norwood Hill Medical Centre. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

Clinical records review 15 November 2022, inspection site visit 17 November 2022 and discussion following clinical records review 5 December 2022

During a routine inspection

We carried out an announced inspection at South Norwood Hill Medical Centre.

A remote clinical records review was undertaken on 15 November 2022, remote interviews on 16 November 2022, a site visit on 17 November 2022 and a discussion following the clinical records review on 5 December 2022. Overall, the practice is rated as Requires Improvement.

Safe – Requires Improvement

Effective – Requires Improvement

Caring – Good

Responsive - Requires Improvement

Well-led - Requires Improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for South Norwood Hill Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This was a comprehensive inspection as part of our risk-based approach to reviewing and inspecting services and to follow up concerns identified at our previous inspection completed on 14 & 16 March 2022. At that inspection we rated the provider as inadequate overall and in each question as:

  • There were gaps in recruitment checks and one staff member had not complete basic life support training.
  • One significant event raised in a clinical meeting was not dealt with under the practice’s significant event process.
  • The practice’s legionella risk assessment required action in a number of areas and there was not documented evidence that these actions had been completed.
  • Childhood immunisations and cervical screening were below target although the practice outlined actions undertaken to improve uptake.
  • Reviews of patient records indicated that: medicines safety alerts were not actioned in a timely manner and patients on certain medicines that required regular monitoring were not having this completed.
  • The systems for identifying and following up patients who had undiagnosed health conditions; specifically, chronic kidney disease and diabetes were not effective.
  • Feedback from patients raised telephone access and access generally as a concern.
  • Governance processes and systems related to risk management did not operate effectively.

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 aimed to enable 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.

This included:

  • Conducting staff interviews using video conferencing.
  • Requesting staff feedback using surveys.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A site visit where we undertook clinical searches on the practice’s patient records system and discussed our findings with the provider..

Our findings

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.

Our key findings were

  • Concerns from our last inspection related to recruitment, training, significant events and premises had been addressed.
  • Systems for identifying and following up patients with undiagnosed long-term conditions appeared to have improved as these were not flagged for follow up when we undertook searches of patient records.
  • Reviews of clinical records showed that systems for actioning safety alerts needed further refinement, medication reviews were not sufficiently detailed and follow up for a very small proportion of patients with some long-term conditions needed to be improved.
  • Childhood immunisations and cervical screening were still below target although the practice outlined further actions undertaken to improve uptake and there had been a slight improvement in the uptake of cervical screening.
  • Feedback from patients raised telephone access and access generally as a concern. However, patients said they were treated with respect by staff and they felt that the quality of clinical care was of a good standard.
  • It was evident that staff at the practice had undertaken a significant amount of work to rectify the concerns identified at our last inspection. However, this had resulted in additional work for the lead clinician at the service which did not appear to be sustainable. The clinical lead told us of plans to delegate work to other staff after our visit had been completed but these plans were yet to be implemented.
  • Some staff told us that they did not feel encouraged to report concerns.

We found breaches of regulations. The provider must:

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

The provider should:

  • Continue to work to improve the uptake of screening and immunisations.
  • Continue to work to address patient feedback related to access to appointments.
  • Develop a process to oversee the work of pharmacists and physicians’ associates.
  • Work to improve the systems for recalling patients with long term conditions.
  • Take action to ensure the sustainability of the practice’s operating model.

This service was placed into special measures following the last inspection in March 2022. The service made sufficient improvements so that it will now be taken out of special measures.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

Remote interviews 14 March 2022 and site visit 16 March 2022

During a routine inspection

We carried out an announced inspection at South Norwood Hill Medical Centre.

Interviews were held remotely with staff on 14 March 2022 and a site visit was completed on 16 March 2022. Overall, the practice is rated as Inadequate.

Safe – Requires Improvement

Effective – Inadequate

Caring – Good

Responsive - Good

Well-led - Inadequate

The full reports for previous inspections can be found by selecting the ‘all reports’ link for South Norwood Hill Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection as part of our risk-based approach to reviewing and inspecting services and to follow up concerns identified at our previous inspection completed on 15 July 2021. Our previous inspection was a focused inspection that looked at the safe, effective and well-led questions. At that inspection we rated the provider as requires improvmement overall and in each question as:

  • Safeguarding systems were not comprehensive
  • The practice did not have all emergency medicines and defibrillator pads for children.
  • There were gaps in recruitment records.
  • Systems to manage medicines did not ensure appropriate monitoring or risk mitigation including in relation to infection control and fire safety.
  • There was no quality improvement activity that resulted in improved care for patients.
  • The practice had not met targets for childhood immunisation and cervical screening.
  • Governance systems did not operate effectively; particularly in respect of risk management.
  • The patient participation group was not active.

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 aimed to enable 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.

This included:

  • Conducting staff interviews using video conferencing.
  • Requesting staff feedback using surveys.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A site visit where we undertook clinical searches on the practice’s patient records system and discussed our findings with the provider..

Our findings

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 Inadequate overall.

Our key findings were

  • Some improvements had been made including in respect of safeguarding systems and processes, the monitoring of some high risk medicines and audits being completed that demonstrated quality improvement.
  • Gaps in recruitment checks and one staff had not complete basic life support training.
  • One significant event raised in a clinical meeting was not dealt with under the practice’s significant event process.
  • The practice’s legionella risk assessment required action in a number of areas and there was not documented evidence that these actions had been completed.
  • Childhood immunisations and cervical screening were still below target although the practice outlined actions undertaken to improve uptake.
  • Reviews of patient records indicated that: medicines safety alerts were not actioned in a timely manner and patients on certain medicines that required regular monitoring were not having this completed.
  • The systems for identifying and following up patients who had undiagnosed health conditions; specifically, chronic kidney disease and diabetes were not effective.
  • Feedback from patients raised telephone access and access generally as a concern.
  • Governance processes and systems related to risk management did not operate effectively.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

  • Continue to work to improve the uptake of screening and immunisations.
  • Continue to work to address patient feedback related to access to appointments and interactions with reception staff.
  • Improve the system to effectively identify, record and act upon significant eventsand complaints inline with the provider’s policy and procedure

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration. Special measures will give people who use the service the reassurance that the care they get should improve.

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

15 July 2021

During an inspection looking at part of the service

We carried out an announced focused inspection at South Norwood Hill Medical Centre on 15 July 2021 and a remote clinical review on 13 July 2021 to follow up on breaches of regulations. Overall, the practice was rated as requires improvement.

The practice was previously inspected on 11 March 2020. Following the last inspection, the practice was rated as requires improvement overall (requires improvement in safe and effective) for issues in relation to recruitment records, medicines management; uptake for childhood immunisations and cervical screening; medicines reviews for patients with long-term conditions and learning disability health checks.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for South Norwood Hill Medical centre on our website at www.cqc.org.uk

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.

This included:

  • 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

Our findings

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 rated the practice as Requires Improvement for providing safe services.

At this inspection we found the provider had made some improvements in providing safe services. In particular, the provider had made improvements to their systems and process in relation to staff vaccination records. However, we found new issues in relation to safeguarding, recruitment records, safety systems and records and medicines management.

We rated the practice as Requires Improvement for providing effective services.

At this inspection we found the provider had made some improvements in providing effective services. In particular, carrying out medicines’ reviews for patients. However, outcomes for patients with long-term conditions were significantly below average, the provider had not demonstrated improved patient outcomes through quality improvement activities or clinical audits and uptake for childhood immunisations and cervical screening were below target.

We rated the practice as Requires Improvement for providing well-led services.

We found the provider had made improvements in providing well-led services in relation to good governance and had implemented systems and process in response to the findings of our previous inspection. However, the governance arrangements in place still required improvement especially in relation to identifying, managing and mitigating risks.

We have rated this practice as requires improvement overall, requires improvement in safe, effective and well-led and inadequate for population group people with long-term conditions and requires improvement for population groups families, children and young people and working age people.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way for patients.
  • Establish effective systems and processes to ensure good governance in accordance with fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Improve discussion and learning from significant events.
  • Improve recording of DNACPR decisions.

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

11 Mar 2020

During a routine inspection

We carried out a comprehensive inspection of this service (South Norwood Hill Medical Centre) on 11 March 2020 following our annual regulatory review of the information available to us including information provided by the practice. This inspection was scheduled to ascertain if the changes the provider had made since coming out of special measures had been sustained.

The provider was rated overall as good during our last inspection in February 2018.

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 and requires improvement for population groups: families, children and young people; working age people and people whose circumstances make them vulnerable.

We found that:

  • The systems and processes in place to keep patients safe required improvement. For example, the practice did not have a robust system in place for monitoring patients on high-risk medicines.
  • Patients received effective care and treatment, although the uptake for childhood immunisations and cervical screening were below average and patients with a learning disability were not routinely offered an annual health check.
  • Staff dealt with patients with kindness and respect and patients we spoke to indicated that they were involved in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • The provider knew the challenges they were facing and had plans to address them.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Ensure that care and treatment meet the needs of patients.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review antibiotic prescribing for uncomplicated urinary tract infection.
  • Consider ways to improve uptake for cervical screening.
  • Review staffing levels in response to staff feedback.

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

15 February 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection 01 Feb 2017 – rated Inadequate)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

During the announced comprehensive inspection carried out on 5 May 2016 the practice was rated overall as inadequate and was placed in special measures. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for South Norwood Hill Medical Centre on our website at www.cqc.org.uk.

Following the period of special measures we undertook an announced comprehensive inspection on 1 February 2017 to follow-up on the breaches of regulation and the practice remained rated as overall as inadequate. The full comprehensive report on the February 2017 inspection can be found by selecting the ‘all reports’ link for South Norwood Hill Medical Centre on our website at www.cqc.org.uk.

We carried out an announced comprehensive inspection at South Norwood Hill Medical Centre on 15 February 2018 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 the previous inspection on 1 February 2017. The provider had made significant improvements since the last inspection and addressed the concerns identified in the last inspection. The provider informed us that they had worked closely with the local Clinical Commissioning Group, NHS England and Royal College of General Practitioners to improve their services.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • 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.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and patients we spoke to during the inspection reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Review the results of the national GP patient survey and continue to address low scoring areas to improve patient satisfaction.
  • Consider improving access for patients with hearing impairments.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

14 September 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 at South Norwood Hill Medical Centre on 5 May 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months.

We carried out an announced comprehensive inspection on 1 February 2017. Although there had been some improvement, this was insufficient and the provider remained rated inadequate and was subject to a second period of special measures, to enable them to make the required improvements.

The report of all the previous inspections can be found by selecting the ‘all reports’ link for South Norwood Hill Medical Centre on our website at www.cqc.org.uk.

This inspection was an unannounced focused inspection carried out on 14 September 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations related to safety in particular infection control related to minor surgical procedures that we identified in our previous inspections. This report covers our findings in relation to those requirements and also some additional improvements made since our last inspection.

This was a focused inspection to check on the safety of the practice. As the provider is in special measures this inspection does not alter the provider’s rating, which will be assessed at the next comprehensive inspection.

Our key findings were as follows:

  • There was a lack of effective oversight of infection and prevention control as a whole, both in policy and in practice.
  • The practice systems were not always effective at identifying issues that required action before they were identified by other organisations. Once identified, the practice reacted, but not always sufficiently to complete address the issue.
  • Infection prevention and control systems had improved, with improved cleanliness and systems, but there were still some issues with ensuring the practice was appropriately and consistently clean.
  • Checks of medicines and related equipment stored in the practice were not carried out consistently to ensure that they remained safe and effective.
  • A consistent system of recruitment checks was now in place to ensure that all staff employed by the practice were suitable for their roles.

Therefore the provider must continue to make improvements in order to meet the legal requirements.

The provider must:

  • Ensure care and treatment is provided in a safe way to patients. Please see the requirement notice section for more information.

The provider should also:

  • Review the template for recording significant events, so it records the name of the people involved and completing the record, and the date that the template was completed.

At the last inspection we said that the provider should repeat the audit of post-operative infection rates. The practice did not show us this, although we saw evidence that it was reviewed by NHS England. 

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

1 February 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at South Norwood Hill Medical Centre on 5 May 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for South Norwood Hill Medical Centre on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 1 February 2017. Overall the practice still rated as inadequate.

Our key findings were as follows:

  • There was not a consistent system in place for reporting and recording significant events, and there was no system in place to record action taken in response to patient safety alerts.
  • The practice did not have systems in place to ensure that all staff (including those employed temporarily) had received relevant recent training in safeguarding children and vulnerable people and basic life support.
  • The practice was not taking appropriate action to prevent and control the spread of infections, although there was some improvement since the last inspection.
  • The practice did not have valid Patient Group Directions (PGDs) in place for all the nurses working in the practice, and some of the PGDs in place were out of date. (PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.)
  • Appropriate recruitment checks had not been undertaken and documented for non-permanent staff employed.
  • Not all risks to patients were assessed and well managed, and not all of the emergency medicines needed to treat common medical emergencies were available.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average.
  • Results from the national GP patient survey published in July 2016 showed patient satisfaction with their involvement in planning and making decisions about their care and treatment was below average for several aspects of care, and had deteriorated since the results published in January 2016. Results relating to access to care and treatment showed an improvement in some areas but others remained below average.
  • The practice did not have an effective system in place for handling complaints and concerns. Although information was available for patients about how to complain and we saw evidence that patients who complained were contacted and, where appropriate, received an apology; none of the complaints we looked had been handled in line with the practice policy and national guidance.
  • Arrangements for identifying, recording and managing risks, issues and implementing mitigating actions were not embedded in the culture of the practice. For example, when we inspected in 2016, we found there was no process to ensure that sharps bins were emptied regularly. Although systems had since been established to manage sharps bins safely, they were not effective.
  • Governance structures and processes were not in place to ensure that a comprehensive understanding of the performance of the practice was maintained and that practice was able to deliver good quality care.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Implement systems to assess, monitor and mitigate risks, including those related to managing the risk of infection, staff areas and cleaning chemicals.
  • Ensure significant events are consistently analysed and documented so that future risks are reduced.
  • Ensure the proper and safe management of medicines, including the use of valid Patient Group Directions for all nurses providing vaccinations.
  • Ensure that necessary recruitment records are kept in relation to all persons employed in the carrying on of the regulated activity, including non-permanent staff.
  • Ensure that non-permanent staff receive training necessary for their role, and that records of this training is kept.
  • Operate effectively a system for recording, handling and responding to complaints.

In addition the provider should:

  • Repeat the audit of post-operative infection rates.
  • Monitor and continue to take action to improve patient satisfaction as demonstrated in the national GP patient survey.

This service was placed in special measures in May 2016. Insufficient improvements have been made such that there remains a rating of inadequate for safety and being well led. We previously issued enforcement action in relation to safety, we have taken action in line with our enforcement procedures. 

If the provider fails to make improvements such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

5 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at South Norwood Hill Medical Centre on 5 May 2016. Overall the practice is rated as Inadequate.

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

  • Patients were at risk of harm because systems and processes were not in place to keep them safe.
    • The practice was not taking appropriate action to assess the risk of, prevent and control the spread of infections.
    • Arrangements for managing medicines and dealing with medical emergencies were not sufficient to keep patients safe.
    • Most staff in the practice had not completed recent training in safeguarding children or adults at the levels required for their roles, including the lead GP for safeguarding.
    • The practice had not carried out appropriate Disclosure and Barring Service (DBS) checks prior to employment or when staff moved between roles.
    • Not all of the staff we spoke to were clear about the practice procedure when acting as a chaperone, meaning that they may not be able to properly perform the role. The practice had not carried out DBS checks on staff who acted as chaperones or documented a risk assessment for this decision.
  • Paper copies of patient notes were not stored securely and staff had not completed the required training in information governance.
  • Results from the national GP Patient Survey showed that patients’ satisfaction with how they could access care and treatment was below local and national averages. Patients we spoke to were positive about their interactions with staff and said they were treated with compassion and dignity, but told us that they were not always able to get appointments when they needed them. Patients told us that they felt that they sometimes had to wait too long at the practice to be seen. The practice was unaware of the deterioration in patient satisfaction.
  • Information was available about the complaints system and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes overall were in line with the national average. However, measures of performance for some particular patient populations were below average.

The areas where the provider must make improvements are:

  • Implement effective systems to keep patients safe including processes to prevent and control infection and safe and proper management of medicines, with monitoring of the use of blank prescription forms. Ensure that all medicines are stored securely, and that systems ensure all medicines kept within the premises are in date and are sufficient to deal with medical emergencies, taking into account the patient population and the services provided.
  • Ensure that consent is obtained in line with practice policy and national guidance.
  • Implement formal governance structures for assessing and monitoring all risks, including those that relate to the triageprocedures ; employment checks (upon recruitment and if staff change role) ; and for ensuring that the practice can continue to operate in the event of an incident affecting the premises, equipment or systems.
  • Ensure that all staff complete mandatory training in safeguarding, information governance and infection control and that staff acting as chaperones have a clear understanding of their role.
  • Disclosure and Barring Service (DBS) checks must be in place or risk assessments carried out for all staff undertaking clinical or chaperoning duties .
  • Ensure that systems are in place to act on patient feedback.

The areas where the provider should make improvements are:

  • Continue to take action to improve the care of people with long-term conditions and poor mental health, as measured by the Quality Outcomes Framework.
  • Ensure systematic monitoring of all samples taken for the cervical screening programme.
  • Take measures to increase the number of patients identified as carers and improve the services they are offered.

CQC issued a warning notice to the practice related to infection prevention and control and medicines management.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice