We carried out a review of the data available to us about Dr Scott & Partners 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 Dr Scott & Partners, you can give feedback on this service.
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
Effective -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.
This included:
Our findings
We based our judgement of the quality of care at this service on a combination of:
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:
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
We carried out an announced comprehensive inspection at Dr Scott & Partners (Cheam GP Centre) on 29 April 2021 and a remote clinical review on 27 April 2021 to follow up on breaches of regulations.
The practice was previously inspected on 17 July 2019. Following that inspection, the practice was rated as requires improvement overall (requires improvement in safe, responsive and well-led) for issues in relation to medicines management, management of significant events, maintenance of recruitment records, staff training and governance arrangements.
We based our judgement of the quality of care at this service on a combination of:
We rated the practice as requires improvement for providing safe services.
At this inspection, we found the provider had made some improvements in providing safe services. In particular, the provider had made improvements to their systems and process in relation to safe recruitment and medicines management. However, we found new issues in relation to medicines management and the provider had not actioned some of the issues found in their infection prevention and control audit which were actions identified in their last inspection.
We rated the practice as requires improvement for providing effective services.
We found the provider did not have an effective system to identify patients with commonly undiagnosed conditions, for example diabetes. Their uptake for childhood immunisations and cervical screening were below average and staff appraisals were not appropriately managed.
We rated the practice as good for providing caring services.
We found that the provider had made improvements for providing caring services. In particular the practice enabled people to express their views by carrying out patient surveys and making changes where necessary.
We rated the practice as requires improvement for providing responsive services.
We found that the provider had made some improvements for providing responsive services. In particular, the provider had made changes to improve access to the service. However, we found that access to care had not significantly improved.
We rated the practice as requires improvement for providing well-led services.
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, leadership and governance arrangements in place still required improvement. Risks in relation to staff training, maintenance of staff immunisation records, medicines management, significant events, identifying patients with missed diagnosis had not been identified by the provider’s own governance systems.
We have rated this practice as requires improvement overall and requires improvement for all population groups.
The areas where the provider must make improvements are:
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
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
We carried out an announced comprehensive inspection at Cheam GP Centre on 17 July 2019 as part of our inspection programme.
We decided to undertake an inspection of this service following the merger of the three practices in the Cheam GP Centre.
This location has previously been inspected under the three separate providers.
We based our judgement of the quality of care at this service on a combination of:
We have rated this practice as requires improvement overall and requires improvement for all population groups.
We found that:
The areas where the provider must make improvements are:
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
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
We carried out an announced comprehensive inspection at Dr CAM Brennan and Partners on 26 January 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal incidents were maximised.
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 thoroughly assessed and well managed.
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.
Feedback from patients about their care was consistently and strongly positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
The practice provided a high level of support to patients and their families, who were nearing the end of life.
Information about services and how to complain was available and easy to understand.
The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. For example the practice had invited a number of support organisations to provide a range of educational and advisory events for practice patients.
The practice had good facilities and was well equipped to treat patients and meet their needs.
Patients said they were able to get appointments when they needed them, with urgent appointments available the same day.
Patients did not find it easy to contact the practice via telephone and reported that appointments could be frequently delayed.
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 practice had a robust governance system in place to ensure that risks were identified and monitored and improvements to the service were made.
The provider was aware of and complied with the requirements of the Duty of Candour.
We saw several areas of outstanding practice:
Feedback from patients, carers and families about the care and treatment received was consistently and strongly positive. We found many positive examples to demonstrate how the practice prioritised high quality end of life care and bereavement support for patients, families and carers. For example, the GP partners provided routine home visits for all palliative care patients and one of the partners provided their personal contact details to families for patients in the last few days of life, to ensure they received continuity of care outside of the practice’s standard opening hours.
The practice benefited from a pharmacy co-located next to the health centre and they maintained close links with this service. We were given many examples where GPs were able to take prescriptions and medicines on urgent home visits pre-emptively, so patients received their medicines immediately. Where the medicines were not required by patients, the practice and pharmacy had an arrangement whereby they could be returned to the pharmacy with the prescription. Reception and administrative staff also worked closely with the pharmacy and ensured that those patients’ prescriptions requested at the end of the day were all received by the pharmacy prior to the practice closing to avoid delays in processing of prescriptions.
The practice had arranged for a number of educational and support events for practice patients, in conjunction with the Patient Participation Group (PPG). For example, a diabetes information evening was held in October 2015 where an external speaker from a national diabetic charity offered advice on diet and exercises and provided information leaflets for patients. A practice nurse and a representative from the health lifestyle advisory service were also present to provide information to patients. The practice nurses also used this evening as an opportunity to provide flu immunisations to their diabetic patients and the PPG encouraged patient feedback by promoting the NHS Friends and Family Test. Of those 37 who attended the event across the three practices, 21 patients received the flu immunisation.
The practice had robust governance arrangements in place, which included the use of work plans to address key areas of quality improvement; a comprehensive policy schedule outlining all policies and procedures, all review dates and the named staff member for updating the policy; and a comprehensive programme of continuous internal audits to monitor performance which were discussed in monthly management meetings. All management meetings were between the business manager and the partners of the three practices co-located in the shared premises which encouraged a culture of shared leaning and development.
The areas where the provider should make improvements are:
Implement a clear system for tracking and monitoring the use of prescription pads across the practice.
Provide an online appointment booking facility and establish ways to improve telephone access for patients.
Chief Inspector of General Practice