The Care Quality Commission
  • Doctor
  • GP practice

Hammersmith Surgery

Overall: Good read more about inspection ratings

1 Hammersmith Bridge Road, Hammersmith, London, W6 9DU (020) 8741 3944

Provided and run by:
Hammersmith Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Hammersmith Surgery 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 Hammersmith Surgery, you can give feedback on this service.

31/08/2021 01/09/2021

During an inspection looking at part of the service

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 www.cqc.org.uk.

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 www.cqc.org.uk

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

25 September 2019

During a routine inspection

We carried out an announced comprehensive inspection at Hammersmith Surgery on 25 September 2019 as part of our inspection programme.

We inspected this practice on one previous occasion, on 2 October 2014, and the practice was rated as good overall. We rated five domains: safe, effective, caring, responsive and well led as good including the patient population groups.

We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions: safe, effective, caring, responsive and well led.

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 have rated this practice as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe.
  • The practice did not have reliable systems and processes to keep patients safeguarded from abuse.
  • The practice did not have reliable infection prevention and control practices in place.
  • The practice did not monitor and manage the cold chain effectively.
  • The practice did not have complete fire safety systems in place.

We rated the practice as requires improvement for providing effective services because:

  • There was monitoring of the outcomes of care and treatment.
  • The practice was able to show that staff had the skills, knowledge and experience to carry out their roles.
  • Some performance data was below local and national averages.

We rated the practice as requires improvement for providing well-led services because:

  • The practice did not have a fail-safe system regarding patient safety alerts.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not have an appropriate fail-safe system in place to monitor and manage cervical screening for female patients.
  • The provider did not have a safe or effective recruitment system in place.
  • While the practice had a clear vision, that vision was not supported by a credible strategy.
  • The practice culture did not effectively support high quality sustainable care.
  • The overall governance arrangements were ineffective.

These areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as good for providing caring and responsive services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review clinical staff training for Gillick competency and Fraser guidelines for the care and treatment of patients under the age of 16.
  • Continue to monitor the uptake of childhood immunisations and cervical screening data.

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

02/10/2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Hammersmith Surgery provides primary medical services to approximately 9,400 patients in the Bridge Road area of Hammersmith in West London. This is the only location operated by this provider.

We visited the practice on 2 October 2014 and carried out a comprehensive inspection of the services provided.

We rated the practice as ‘Good’ for the service being safe, effective, caring, responsive to people’s needs and well-led. We rated the practice ‘Good’ for the care provided to older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

  • There were arrangements in place to ensure patients were kept safe.
  • Patients’ needs were suitably assessed and care and treatment was delivered in line with current legislation and best practice.
  • We saw from our observations and heard from patients that they were treated with dignity and respect.
  • The practice understood the needs of their patients and was responsive to them.
  • The practice was well-led, had a defined leadership structure and staff felt supported in their roles.
  • Pre-bookable Saturday morning appointments were available for patients who may have difficulty attending during weekday opening hours.
  • The practice conducted 100% peer review of all referrals made to secondary care.

We saw an area of outstanding practice:

  • Community Matron employed part time by the practice who provided support and management of patients with complex needs and the frail elderly. Since commencement of the role in July 2014 records showed that 3.7% of the practice population had a care plan in place. This was almost double the Clinical Commissioning Group (CCG) target of 2%.

However, there were also areas of practice where the provider should make improvements:

  • The practice should produce a written mission statement to be shared with members of the public.
  • The practice should review the publically accessed practice information leaflets to ensure information is consistent.
  • The practice should review policies to ensure the most up to date contact details of external organisations are recorded.
  • The practice should consider maintaining mandatory training records for the GP’s.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice