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Inspection carried out on 03 March 2020

During a routine inspection

We carried out an announced comprehensive inspection at Colliers Wood Surgery on 3 March 2020 as part of our inspection programme. At our last inspection in November 2018 we rated the service as requires improvement overall. Safe was rated as inadequate and well led was rated as requires improvement. We served the practice with Requirement Notices. We undertook a further inspection in August 2019 to review Safe. We found that satisfactory improvements had been made and safe was rated as Good. During this inspection, we found that the practice had satisfactorily addressed all areas from the 2018 inspection.

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 the following key ratings;

Safe- Good

Effective- Requires Improvement

Caring- Good

Responsive- Good

Well – Led- Good

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

We rated the practice as requires improvement for providing effective services because:

  • Whilst some patients received effective care and treatment that met their needs, data relating to the monitoring of patients with high blood pressure was low. The practices uptake for cervical cancer and bowel cancer screening were low compared to local and national averages. The uptake for childhood immunisations was also low.

Whilst we found no breaches of regulations, the provider should:

  • Improve clinical outcomes for patients with high blood pressure, increase the uptake for cervical and bowel cancer screening as well as childhood immunisations.

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 carried out on 13 August 2019

During an inspection looking at part of the service

We carried out an announced comprehensive follow up inspection of Colliers Wood Surgery on 28 November 2018. We rated the practice as inadequate for safe and requires improvement overall. The full comprehensive report on the 28 November 2018 inspection can be found by selecting the ‘all reports’ link for Colliers Wood on our website at .

Due to the inadequate rating awarded to safe we carried out an announced focused inspection on 13 August 2019 to confirm that the practice had made improvements. This report covers our findings in relation to those requirements and changes made since our last inspection.

We did not review the ratings awarded to this practice at this inspection.

At this inspection we found that actions had been taken to improve the provision of safe services. Specifically:

The practice had developed systems and processes to keep patients safe.

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 carried out on 28 November 2018

During a routine inspection

We carried out an announced comprehensive inspection at Colliers Wood Surgery on 28 November 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 good for all population groups

.

We rated the practice as inadequate for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe.
  • The practice did not have appropriate systems in place for the safe management of medicines.

We rated the practice as requires improvement for providing well-led services because:

  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.

We rated the practice as good for providing effective, caring and responsive services because:

  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the 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:

  • Continue to address the below-target uptake for childhood immunisations.
  • Complete appraisals for all staff.
  • Continue to embed the new prescription security arrangements at the branch practice site.
  • Put in place a locum information pack.
  • Continue the monitoring of care outcomes for patients with hypertension, and (where necessary) take any necessary action to address below average achievement.
  • Consider whether patients would find it helpful if leaflets in languages other than English and in easy read format were available in the waiting area.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 30 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 at Colliers Wood Surgery on 24 November 2016. The overall rating for the practice was Requires Improvement as:

  • The procedures for managing uncollected prescriptions did not ensure safe care and treatment of service users.
  • The procedures for managing blank prescriptions did not keep them safe and secure.
  • The registered person did not ensure the premises were safe to use for their intended purpose by having an up to date fire risk assessment carried out.
  • Data from the GP Patient survey and patient comments showed service users had difficulty accessing appointments and were not satisfied with practice opening times.
  • Patient comments showed female service users had difficulty accessing appointments with a female GP.

We also asked the practice to:

  • Review how the chaperone system is advertised to patients.
  • Implement, monitor and review systems to ensure basic life support training is carried out at the required intervals for all staff.
  • Review processes and procedures to improve uptake in the cervical screening programme.
  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
  • Continue to engage with patients through the development of the practice patient participation group (PPG).

The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Colliers Wood Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 30 May 2017 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 our previous inspection on 24 November 2016. This report covers our findings in relation to those requirements and also any additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • The practice reviewed its policy and procedures for managing uncollected prescriptions and made changes including weekly checks by dedicated members of staff for uncollected prescriptions.
  • The practice had reviewed the systems for recording and issuing blank prescriptions and blank prescriptions were removed from printers and stored overnight in a lockable cupboard.
  • The practice had carried out a fire risk assessment.
  • The practice had improved access to appointments by providing 34 new GP appointments and eight nurse appointments and extended opening hours to 8.00pm three days per week.
  • The practice had a female GP providing 26 appointments per week. These appointments were advertised in patient areas and on the practice website.

The practice also demonstrated they had:

  • Reviewed how the chaperone system is advertised to patients and had included posters in clinical rooms and all patient areas.
  • The practice had put in place measures to ensure basic life support training is carried out at the required intervals for all staff through a training database and calendar system.
  • Reviewed processes and procedures to improve uptake in the cervical screening programme, including engaging with a local cancer research facilitator and providing advertising materials and information from a local cancer charity. The practice also trained two staff to become cancer champions, encouraging patients in all aspects of cancer screening including cervical cancer. However the practice were not able to demonstrate the impact this had on uptake for the cervical screening programme.
  • Reviewed how patients with caring responsibilities were identified by improving advertising in patient areas, ensuring carers were recorded on the computer system and providing a carers pack with information and signposting carers to further support. However the practice were not able to demonstrate an increase in numbers of carers as a result.
  • Continued to engage patients through the practice patient participation group (PPG) and had agreed terms of reference for the group. We saw evidence that the group were meeting on a quarterly basis.

The areas where the provider should make improvement are:

  • Review processes and procedures to improve uptake in the cervical screening programme.
  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 24 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Colliers Wood Surgery on 24 November 2016. Overall the practice is rated as requires improvement.

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

  • The practice systems, processes and practices did not always keep patients safe and safeguarded from abuse; for example, with regards to the management and security of prescriptions including blank prescriptions and uncollected prescriptions. The practice provided a chaperone service however this was not well advertised in the practice.

  • Risks to patients were assessed and well managed, with the exception of those related to fire safety.
  • There was an effective system in place for reporting and recording significant events.
  • 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, with the exception of basic life support training for some staff.
  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were comparable to other practices locally and nationally, with the exception of performance related to the practice cervical screening programme.

  • Patient comments and satisfaction survey data showed they found it difficult to access appointments; satisfaction with opening times was below local and national averages and patients found it difficult to get an appointment with a female GP. However, there was continuity of care, and urgent appointments were available the same day.
  • 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk; however, these arrangements were not always effective, for example with regards to fire safety, prescription management and prescription security.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had a patient participation group (PPG) and had started making changes in the practice suggested by the group. At the time of the inspection the group was meeting informally and the local clinical commissioning group were involved in developing terms and conditions for the group.

The areas where the provider must make improvement are:

  • Review, improve and monitor the effectiveness of procedures for the safe and secure management of prescriptions, including blank prescriptions and uncollected prescriptions.

  • Ensure an up to date fire risk assessment is carried out and actions identified addressed.

  • Review and improve patient access to appointments to ensure the needs of service users are met.

  • Review and improve governance arrangements including systems and processes used to evaluate service provision and make improvements.

The areas where the provider should make improvement are:

  • Review how the chaperone system is advertised to patients.

  • Implement, monitor and review systems to ensure basic life support training is carried out at the required intervals for all staff.

  • Review processes and procedures to improve uptake in the cervical screening programme.

  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to them.
  • Continue to engage with patients through the development of the practice patient participation group (PPG).

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice