We carried out a comprehensive inspection at Dr Scott & Partners (Cheam GP Centre) on 25 February 2022 and a remote clinical review on 22 February 2022 to follow up on breaches of regulations. Overall, the practice is rated as Good.
Safe – Good
Caring – Good
Responsive – Requires Improvement
Well-led - Good
Following our previous inspection on 29 April 2021, the practice was rated as Requires Improvement overall (requires improvement in safe, effective, responsive and well-led) for issues in relation to safeguarding training, staff vaccination records, infection prevention and control, medicines management, management of significant events, identification of patients with commonly undiagnosed conditions, uptake for childhood immunisations and cervical screening, appraisals for staff, quality improvement and access to care and treatment.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Scott & Partners on our website at www.cqc.org.uk
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.
- 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 short site visit.
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 rated the practice as Good for providing safe services.
At this inspection we found the provider had made improvements in providing safe services. In particular, the provider had made improvements to their systems and process in relation to safeguarding training, staff vaccination records, infection prevention and control, medicines management and management of significant events.
We rated the practice as Good for providing effective services.
At this inspection we found the provider had made improvements in providing effective services. In particular, the provider had made improvement to their systems and processes in relation to identifying patients with commonly undiagnosed conditions, uptake for cervical screening, staff appraisals and quality improvement. However, the uptake for childhood immunisations were below target.
We rated the practice as Good for providing caring services.
At this inspection we found that the staff treated patients with kindness, respect and compassion. However, the national GP patient survey indicators for 2021 in relation to listening to patients, treating them with care and concern, confidence and trust in the healthcare professional and overall experience of the GP practice were below average.
We rated the practice as Requires Improvement for providing responsive services.
At this inspection we found that the provider had made some changes to improve telephone access to the service; however, many patients reported they were not able to access the GP practice on the phone. The national GP patient survey indicators for 2021 in relation to access to appointments were below average.
We rated the practice as Good for providing well-led services.
At this inspection we found the provider had made improvements in providing well-led services in relation to good governance and had implemented systems and process in response to the findings of our previous inspection. However, the provider had frequent changes in practice management since the last inspection and only had an interim practice manager in place.
We have rated this practice as Good overall and Requires Improvement in Responsive.
Whilst we found no breaches of regulations, the provider should:
- Improve monitoring of patients with hypothyroidism and insomnia.
- Improve uptake for childhood immunisations.
- Review service procedures to improve patient satisfaction especially in relation to telephone access as demonstrated by the national GP patient survey.
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