The Care Quality Commission
  • Doctor
  • GP practice

Hersham Surgery

Overall: Good read more about inspection ratings

The Surgery, Pleasant Place, Hersham, Walton On Thames, Surrey, KT12 4HT (01932) 229033

Provided and run by:
Hersham Surgery

All Inspections

During an assessment under our new approach

Date of Assessment: 18 May 2026.

Hersham Surgery is a GP practice which delivers services to approximately 9900 people under a contract held with NHS England. According to the latest available data, the ethnic make-up of the practice area is approximately 87% White, 6% Asian, 4% Mixed, 1% Black and 2% Other. Information published by the Office for Health Improvement and Disparities shows deprivation within the practice population group is in the 10th decile (10 of 10). The lower the decile, the more deprived the practice population is relative to others.

This was a focused assessment. We undertook this due to the length of time since our last assessment. We assessed 10 quality statements from across all 5 key questions. This assessment considered the demographics of the people using the practice, the context the practice was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

SAFE - Staff kept facilities clean and maintained equipment appropriately to ensure people were kept safe. They assessed and managed the risk of infection well and took steps to control the risk of it spreading. There were enough staff with the right skills, qualifications and experience.

EFFECTIVE - Staff supported people to live healthier lives, monitoring their care and treatment to ensure they received positive and consistent outcomes.

CARING - Staff treated people with kindness, empathy and compassion, and respected their privacy and dignity.

RESPONSIVE - People could access care, treatment and support when they needed it. Leaders and staff were alert to discrimination and inequality that could disadvantage groups of people who used the practice and sought ways to address any barriers.

WELL-LED - The practice had a clear vision and strategy, which considered the needs of the people who used their service and the wider community. Staff understood their individual roles and responsibilities. Leaders accounted for the actions, behaviours and performance of staff through clear and effective governance processes.

We have not revisited the practice as part of this review because the practice was able to demonstrate that they were meeting the regulations associated with the Health and Social Care Act 2008 without the need for a visit.

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

At our previous comprehensive inspection at Hersham Surgery in Walton On Thames, Surrey on 20 September 2016 we found a breach of regulations relating to the provision of safe services. The overall rating for the practice was good. Specifically, the practice was rated requires improvement for the provision of safe services and good for the provision of effective, caring, responsive and well-led services. The full comprehensive report on the September 2016 inspection can be found by selecting the ‘all reports’ link for Hersham Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 19 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection in September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

We found the practice had made improvements since our last inspection. Using information provided by the practice we found the practice was now meeting the regulations that had previously been breached. We have amended the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, effective, caring, responsive and well-led services.

Our key findings were as follows:

  • We saw the practice had reviewed existing arrangements and all clinical staff had suitable and appropriate indemnity insurance. Indemnity insurance is used for professional negligence claims, or allegations of malpractice, received against a member of staff in the course of their professional duties.
  • Revised recruitment policies and processes had been adopted which reflected national guidance. For example, supporting recruitment documentation that was missing during the September 2016 inspection was now all recorded and documented correctly including registration with the appropriate professional body.
  • The practice had reviewed and updated the practice governance framework. This included a review of policies and procedures. Furthermore, as part of the governance review, updated guidance had been sent to all staff to increase awareness of where policies were stored.
  • Further steps had been taken steps to increase privacy and confidentiality in an upstairs area of the practice. Awareness of the importance of confidentiality has been discussed with all practice staff and continued to be regularly reviewed including in-house observations.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

20 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hersham Surgery on 20 September 2016. Overall the practice is rated as good.

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

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • 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.
  • 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 the exception of recruitment checks.
  • 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.
  • Patients said 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.

We saw one area of outstanding practice:

The practice provided an Excellence in Insulin Management programme for the Clinical Commissioning Group. This improved access to insulin initiation therapy within the community. The programme included:

  • Having appropriately trained and competent staff who could initiate insulin therapy.
  • Staff from the practice training GPs and staff from other local practices.
  • Providing a GP diabetes mentor for other local practices.

The areas where the provider must make improvement are:

  • Ensure that medical indemnity insurance is in place for all clinicians.
  • Ensure that recruitment checks in accordance with practice policy are completed when staff are employed.
  • Ensure that all appropriate policies are up to date and easily accessible to all staff.

The areas where the provider should make improvement are:

  • Review confidentiality in upstairs waiting area.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice