Background to this inspection
Updated
1 October 2021
Triangle Group Practice is located in Lewisham, south east London at:
2 Morley Road
Lewisham
London
SE13 6DQ
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning and treatment of disease, disorder or injury and surgical procedures.
The practice operates from premises that were converted in 1990. There is step free access into the premises and to all floors.
The practice is situated within the London Borough of Lewisham and is part of the South East London Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 7086. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices, Lewisham Alliance PCN.
Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (three of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 11% Asian, 50% White, 27% Black, 8% Mixed, and 3% Other.
There is a team of four GPs who work at the practice. The practice has one nurse. At the time of this inspection the practice had recently employed a Health Care Assistant (HCA). The GPs are supported at the practice by a practice manager and a team of reception/administration staff. The practice provides 29 GP sessions per week.
There is a Minor Surgery clinic once a week which offers joint injections, incision and drainage and the removal of moles, skin tags and other lesions. Other services provided on site by Lewisham Clinical Commissioning Group (CCG) include a counsellor who visits the practice once a week, a dietician who visits once every two weeks and a bereavement counsellor who attends the practice as and when required.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a pre-allocated appointment.
Extended access is provided locally by GP Extended Access Service (GPEA) at University Hospital Lewisham, where late evening and weekend appointments are available. Out of hours services are provided by SELDOC and NHS 111.
Updated
1 October 2021
We carried out an announced inspection at Triangle Group Practice on 26/07/2021. Overall, the practice is rated as requires improvement. The inspection looked at the following key questions:
Safe - Requires improvement
Effective – Good
Well-led – Requires improvement
At the last inspection, the caring and responsive key questions were rated good. These ratings have been amalgamated with the ratings of this inspection.
Following our previous inspection on 26 November 2019, the practice was rated requires improvement overall but rated inadequate for providing safe services and we served a Warning Notice for a breach of regulation 12 (safe care and treatment) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
We carried out an announced focused inspection on 27 January 2020 to follow up the concerns identified in the Warning Notice. At that inspection the practice had demonstrated improvement and concerns in the safe key question had been addressed. The focused inspection was unrated. The published unrated report is available on our CQC website.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Triangle Group Practice on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a rated focused inspection to follow up on areas for improvement identified on 26 November 2019.
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 shorter 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 requires improvement overall and requires improvement for the population group families, children and young people.
We found that:
- Although there were some strong systems and processes to manage risks to patients, there were some risks that were not well managed and required improvement. For example, there were some areas where these were not effectively managed, related to documentation of high-risk medicine reviews.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets. Uptake rates for the vaccines given were below the target of 95% in five areas where childhood immunisations are measured.
- The practice had not demonstrated it had an effective strategy to improve its performance for cervical screening which was lower than CCG and England averages.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care. However, overall governance arrangements in place required improvement.
- We saw evidence of systems and processes for learning, continuous improvement and innovation.
We found breaches of regulations. The provider must:
- 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.
The provider should:
- Continue engaging with all patients to understand, and if possible address, why they are not participating in screening and immunisation programmes.
- Improve compliance with policies and procedures; for example, the appraisal policy.
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