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The Clapham Family Practice Good

Inspection Summary

Overall summary & rating


Updated 23 January 2020

We carried out an announced comprehensive inspection at Clapham Family Practice on 3 December 2019 to follow up on the breaches of regulations identified in the last inspection (November 2018).

At the last inspection in November 2018 we rated the practice as requires improvement overall with requires improvement in safe and effective because:

  • The provider did not have systems in place for safe management of high-risk medicines and security of prescriptions.
  • Systems in place to manage infection prevention and control required improvement.
  • The practice did not have a formalised risk register in place, but individual risk strategies were in place where they had been identified.
  • The practice was not able to provide appraisal documentation for some staff.
  • The practice had undertaken a number of audits, but only one was two cycle, and this had not shown improvement from the first cycle to the second.
  • There was no formal system in place to follow-up two week wait referrals.

At this inspection, we found that the provider had addressed these areas; however, we identified some new issues.

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, with requires improvement for effective and outstanding for the population group people whose circumstances make them vulnerable.

We found that:

  • There were appropriate processes in place to keep patients safe.
  • The provider had not considered some incidents as significant events.
  • Some of the staff had not received training relevant to their role.
  • Patients received effective care and treatment that met their needs; however, the uptake for cervical screening and childhood immunisations were slightly below average.
  • 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. However, some of the patients we spoke to indicated it was difficult to get appointments.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care; however, governance systems in place required some improvement.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.

We rated the practice as outstanding for providing responsive services to people whose circumstances make them vulnerable because:

  • Services were tailored to meet the needs of patients within this group. They were delivered in a flexible way that ensured choice and continuity of care, particularly for people in the LGBT community.
  • There were innovative approaches to providing integrated person-centred care.
  • The practice had identified areas where there were gaps in provision locally and had taken steps to address them.

We observed one area of outstanding practice:

  • The practice had recently won a Gold Award for excellence in lesbian, gay, bisexual and trans healthcare. To win this award, the practice had created a Trans register and had developed new patient registration forms to include sexual orientation and trans status monitoring. They also redesigned their website to include information on health screenings specific to trans people who might otherwise be missed. The practice assigned a nominated GP LGBT Staff Champion and updated their policies to be more LGBT inclusive.
  • Patient feedback indicated that GP’s were very supportive of Trans people and especially the correct use of pronouns when addressing them. They also stated that they had been referred to specific LGBT trans counselling and support groups and had signposted friends in the LGBT community to the Clapham Family Practice.
  • A Pride in Practice co-ordinator who the practice works with also spoke highly of the level of training and commitment to the LGBT community the practice have shown and acknowledged that many patients have commented with positivity, pride, thanks and enthusiasm on the work and the service being provided for LGBT patients.

The areas where the provider must make improvements:

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

The areas where the provider should make improvements are:

  • Continue with current staff recruitment drive to increase staffing levels and help improve staff satisfaction.
  • Review procedures for the recording of meeting minutes.
  • Review procedures in place for identifying carers so they are identified, and their specific needs can be met.
  • Consider ways to improve uptake for childhood immunisations and cervical screening.
  • Review procedures for the recording of induction procedures for new staff.

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

Inspection areas


Requires improvement
Checks on specific services

People with long term conditions


Families, children and young people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable