The Care Quality Commission
  • Doctor
  • GP practice

The Mitcham Medical Centre

Overall: Good read more about inspection ratings

81 Haslemere Avenue, Mitcham, Surrey, CR4 3PR (020) 8648 3234

Provided and run by:
The Mitcham Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Mitcham Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Mitcham Medical Centre, you can give feedback on this service.

01 October 2021

During a routine inspection

We carried out an announced comprehensive inspection at The Mitcham Medical Centre on 29 & 30 September and 1 October 2021 as part of our inspection programme. Overall, the practice is rated as Good. The practice was previously inspected in December 2019. Following that inspection, the practice was rated as requires improvement overall (requires improvement in safe, effective, caring, responsive and well-led) for issues in relation to safe care and treatment, low patient outcomes, patient experience and governance arrangements. All population groups were rated as requires improvement.

The ratings for each key question are:

Safe Good

Effective Requires improvement

Caring Good

Responsive Good

Well-led Good

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

Why we carried out this inspection

This inspection was to follow up the breaches of regulation identified at the previous 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.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections. 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

  • Requesting evidence from the provider in advance of the 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 have rated this practice as Good overall and requires improvement for effective due to improvements still required in increasing patient clinical outcomes. We have rated population groups: people with long term conditions, children & families and the working age people as requires improvement due to low uptake of childhood immunisations and cervical smears.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. The practice had made improvements to the process of monitoring high risk medicines. Rolling audits were used to monitor progress. However, the recording of instances when a patient did not engage or respond to follow ups needs to be strengthened.
  • Whilst some patients received effective care and treatment that met their needs, data relating to the monitoring of patients with long term conditions was low. The practice were aware of this and were working to improve. The practice’s uptake for childhood immunisations and cervical cancer were low compared to local and national averages. However, data provided by the practice showed some improvement.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patient access to care had been improved at the practice with patients’ feedback largely positive about their experience of accessing the practice. Indication from internal surveys carried out by the practice showed the practice to be in line with local and national averages.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic and were currently providing face to face appointments as required.
  • Patients could access care and treatment in a timely way.
  • The practice had made significant improvements to their governance and systems.

The provider should:

  • Improve the process of recording medication reviews in instances when patients failed to engage with the practice.
  • Continue efforts to increase clinical outcomes for patients with long term conditions, increase the uptake for childhood immunisations and cervical cancer screening.
  • Maintain arrangements for managing patients on high risk medicines

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

17 Dec 2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Mitcham Medical Centre on 17 December 2019 as part of our inspection programme. The provider was rated overall as good during our last inspection in December 2015.

We decided to undertake an inspection of this service following our annual review of the information available to us.

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 all population groups.

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 medicines management.
  • Patients received effective care and treatment that met their needs; however, outcomes for patients with diabetes and atrial fibrillation were below average and exception reporting for patients with long-term conditions were above average.
  • The uptake for childhood immunisations and cervical screening were 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; however, patient satisfaction was below average.
  • The practice organised and delivered services to meet patients’ needs. However, some of the patients we spoke to indicated they had difficulty in getting appointments.
  • The results of the national GP patient survey indicated that the practice scored below average in relation to patient satisfaction of the service.
  • The governance systems in place for safe and effective running of the practice required improvement.

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:

  • Review procedures in place for appropriate coding of medicines reviews.
  • Review staff induction and appraisal procedures in place.
  • Review patient access to health checks.
  • Consider ways to improve uptake for childhood immunisations and cervical screening.
  • Review reception, administrative and clinical 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

31 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 17 December 2015. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of regulation 17(1) Good Governance of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this desk-based focussed inspection on 31 August 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for The Mitcham Medical Centre on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

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

Risks to patients were assessed and well-managed, including those related to recruitment checks and fire safety.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

17 Dec 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mitcham Medical Centre on 17/12/2015. 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.
  • Risks to patients were assessed and well managed with an exception of those relating to recruitment checks and fire safety.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had 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.
  • Patients said they found it easy to make an appointment with a named GP 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.
  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group.

We saw one area of outstanding practice:

The practice worked closely with the local mosque to improve health in the local community for instance they had held a smoking cessation session at the mosque and had distributed leaflets in relevant languages.

However there were areas of practice where the provider must make improvements:

  • Ensure suitable arrangements for staff to receive training to carry out their role and to have an annual appraisal of their work.

The areas where the provider should make improvements are:

  • Ensure that the system for recording of significant events is robust and that the lessons learnt are shared with all staff.

  • Ensure that action plans from audits, risk assessments, incidents and complaints are clearly documented and followed up.

  • Ensure that a fire risk assessment and COSHH (Control of Substances Hazardous to Health) risk assessment and legionella risk assessment is completed.

  • Ensure that patients on the practice’s learning disability register have access to annual health checks.

  • Ensure that complaints are acknowledged and responded to in line with contractual requirements and a clear record of correspondence is kept.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice