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Inspection Summary

Overall summary & rating


Updated 14 October 2021

We previously carried out an announced comprehensive inspection at Hammersmith Surgery on 25 September 2019. The overall rating for the practice was requires improvement, with the exception of key question Effective which was rated good. The full report on the 25 September 2019 inspection can be found by selecting the ‘all reports’ link for Hammersmith Surgery on our website at

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Good

This inspection was an announced comprehensive follow-up inspection carried out on 1 September 2021 to confirm that the practice continued to make improvements on areas that we had identified at our previous inspection held on 25 September 2019. This report covers our findings in relation to those improvements and also additional improvements made since our last inspection. This review of information was undertaken without carrying out a site visit.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hammersmith Surgery on our website at

Why we carried out this inspection

This inspection was a comprehensive follow-up inspection to review progress against previous breaches of regulation

  • The practice did not have reliable systems in place to manage the practice premises safely. This included fire safety systems, infection prevention and control (IPC) practices.
  • The provider could not demonstrate they operated safe recruitment systems within the practice. This included ensuring that all staff had the skills, knowledge and experience to carry out their roles safely and effectively. The provider could not demonstrate that all staff had formal appraisals undertaken on a regular basis, and that all staff had completed safeguarding training relevant to their role.
  • The provider could not demonstrate they have an effective system in place to safely manage patients who had been referred via the urgent two week-wait system and that they have an effective system in place to safely manage regarding patient safety alerts. The provider could not demonstrate they have a fail-safe system in place to safely manage and monitor cervical smear screening.
  • The provider could not demonstrate they had a fail-safe process in place regarding significant events.

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 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.

At this inspection we found there had been sufficient improvement to rate the safe, effective and well-led key questions good. The ratings for the practice is now good overall.

We found that:

  • The practice had developed systems and processes to keep patients safe. This included recruitment checks, staff immunisations, equipment checks, fire and health and safety, infection control and mandatory staff training.
  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate, we reviewed the recruitment and training files for two members of staff and found that all of the recommended checks and training had been completed.
  • All staff received up-to-date safeguarding and safety training appropriate to their role.
  • The service used information about care and treatment to make improvements. The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients.

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

  • Continue to review and improve the uptake of cervical screening and the childhood immunisation programme.

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

Inspection areas










Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable