• Doctor
  • GP practice

Churchill Medical Centre

Overall: Good read more about inspection ratings

Clifton Road, Kingston Upon Thames, Surrey, KT2 6PG (020) 3727 2230

Provided and run by:
Churchill 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 Churchill 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 Churchill Medical Centre, you can give feedback on this service.

31 October and 1 November 2023

During a routine inspection

We carried out an announced comprehensive inspection at Churchill Medical Centre on the 31 October and 1 November 2023. Overall, the practice is rated as good.

Safe – good.

Effective – good.

Caring – good.

Responsive – good.

Well-led – good.

Following our previous inspection on 2 June 2015, the practice was rated good overall and for all key questions.

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

Why we carried out this inspection.

We carried out this comprehensive inspection because the practice has not been inspected since 2015.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included.

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A short 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 found that:

  • The practice had clear systems, practices, and processes to keep people safe and safeguarded from abuse.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • 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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • As part of the practices work to offer healthcare to the vulnerable and disadvantaged in society, and as part of the commitment to safe surgeries a project was started in early 2022 to try to improve the access to primary care amongst local asylum seekers and refugees.
  • Staff had access to a broad range of Wellness resources within a dedicated Wellness Hub.
  • The practice encouraged a culture which drove quality sustainable care.
  • There was compassionate, inclusive, and effective leadership at all levels.
  • There were responsibilities, roles and systems of accountability to support good governance and management.

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

  • Take steps to check all equipment has been calibrated.
  • Take action to attach the blind cords safely in the Surbiton branch.
  • Continue to improve the uptake of childhood immunisations.
  • Continue to improve patient access to the practice.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

2 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Churchill Medical Centre on 2 June 2015. Overall the practice is rated as good. Specifically, we found the practice to be good for providing safe, well-led, effective, caring and responsive services. It was also good for providing services to the six population groups we inspect - People whose circumstances may make them vulnerable, Older people; People with long-term conditions; Families, children and young people; Working age people (including those recently retired and students); and People experiencing poor mental health (including dementia).

Our key findings across all the areas we inspected 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.
  • 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.
  • 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.
  • Staff were aware of the practice’s vision and values and contributed towards them. The practice had achieved an Investors in People award.
  • The practice proactively sought feedback from staff and patients, which it acted on. This included creating a specific children’s waiting area.
  • The practice has a schedule of audits, which included re-auditing.
  • Patients appreciated the flexibility of being able to access services at any one of three sites.
  • Parentcraft classes were provided and the cost covered by the practice.
  • The practice had some satisfactory Quality Outcome Framework (QOF) outcomes but was below the national average in a number of areas including diabetes and dementia.
  • Patient satisfaction with the appointment system and the availability of their preferred GP fell below the Commissioning Contracting Group (CCG) and national averages.
  • We found some out of date oxygen masks, although the practice did also have masks that were within their expiry date.

We saw several areas of outstanding practice including:

  • The practice had won a NICE (National Institute for Health and Care Excellence) shared learning award in 2014 for its antibiotic prescribing programme which was adopted by the CCG.
  • The health care assistants ran a ‘Weigh to go’ exercise and healthy eating class in the evenings and leaflets advertising this were on display in the waiting room.

However there were areas of practice where the provider needs to make improvements. Importantly the provider should:

  • Ensure all equipment, including oxygen masks are within their use by date.
  • Provide health care assistants with identified clinical supervision.
  • Ensure all clinical staff have up to date hepatitis B vaccination.
  • Ensure established protocols regarding immunisations are in place, particularly regarding patient specific directions.
  • Introduce a cleaning checklist so staff know what has been cleaned and when.
  • Ensure that fire emergency action plans are regularly rehearsed, and the fire risk assessment periodically reviewed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice