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Review carried out on 7 March 2020

During an annual regulatory review

We reviewed the information available to us about Stanhope Mews Surgery on 7 March 2020. 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 5 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection 16 June 2015 – Good)

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

We carried out an announced comprehensive inspection at Stanhope Mews Surgery on 5 December 2017 as part of our inspection programme.

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 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:

  • Continue to review processes to improve uptake of cervical smears.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 16 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Stanhope Mews Surgery on 16 June 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive and well-led services. It was also good for providing services for people with long-term conditions, families, children and young people, people whose circumstances may make them vulnerable, people experiencing poor mental health (including people with dementia), working age people (including those recently retired and students) and for the care of older people.

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, including those relating to recruitment checks.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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.
  • Patients said they found it easy to access the GPs and that 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.

We saw areas of outstanding practice:

  • Proactive care of older patients; The practice had 393 care plans in place and worked closely with other health care professionals to ensure the needs of older patients were met.
  • The practice had a ‘surgery pod’ which was accessible for patients to use at the practice without needing an appointment with a GP or nurse. (The ‘surgery pod’ is a touchscreen computer that enables patients without clinical supervision, to measure their own vital signs for example, blood pressure and pulse rate, or basic information including weight and height).

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Ensure prescription pads are stored securely.
  • Review procedures for the prescribing of anti-malarial medicines.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 14 May 2014

During a routine inspection

Stanhope Mews Surgery is a general medical practice providing the regulated activities: diagnostics and screening procedures; family planning; maternity and midwifery; treatment of disease disorder or injury and surgical procedures to around 9,400 patients in the High Street Kensington area of Central West London.

We carried out an announced inspection of the service on the 14 May 2014. The team, led by a CQC inspector, included a GP, CQC Inspector Manager and another CQC Inspector.

We found that the practice was effective, caring, responsive and well-led and required improvement to be safe. We made a compliance action regarding staff recruitment procedures to include complete reference checks.

Systems were in place to ensure the appropriate infection control procedures were followed. Vaccinations and other injections were stored in refrigerated conditions that were monitored effectively. Regular checks of the environment were undertaken to ensure that it was a safe place for patients to visit and staff to work in. The practice had working relationships with other local allied health professionals to ensure effective care and treatment was delivered to patients. Measures were in place to meet the varying needs of the registered patient population.

The practice was involved in continued professional development with annual staff appraisal and they discussed and learned from significant incidents and complaints to improve the service for their patients. The leadership team was visible and staff understood their roles and responsibilities.

All the patients we spoke with praised the practice and the services provided and spoke highly about the care and treatment they received from staff.