The Care Quality Commission
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Archived: Edridge Road Community Health Centre

Overall: Inadequate read more about inspection ratings

Impact House, 2 Edridge Road, Croydon, Surrey, CR9 1PJ (020) 3040 0800

Provided and run by:
The Practice Surgeries Limited

Important: This service was previously registered at a different address - see old profile

All Inspections

02 August 2018

During a routine inspection

This practice is rated as Inadequate overall. (Previous rating February 2018 – Inadequate)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Inadequate

Are services well-led? - Inadequate

During the announced comprehensive inspection carried out on 24 November 2017 the practice was rated as inadequate and was placed into special measures. The full comprehensive report on the November 2017 inspection can be found by selecting the ‘all reports’ link for Edridge Road Community Health Centre on our website at www.cqc.org.uk.

Following the period of special measures, we undertook an announced comprehensive inspection on 2 August 2018 to follow up on breaches of regulations that we identified in the previous inspection on 24 November 2017. The provider had made improvements since the last inspection and addressed some of the concerns identified in the last inspection; however, some of the concerns were not fully addressed and the practice remains rated as inadequate.

At this inspection we found:

  • The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines; however, they still needed to improve care of patients with long-term conditions, improve identification of patients with cancer, uptake of childhood immunisations, uptake of cervical screening and undertake learning disability health checks.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use; however, some of the patients reported difficulty in getting appointments.
  • The results of the national GP patient survey indicated that patient satisfaction was generally below average.
  • While there was a focus on learning and improvement at all levels of the organisation there were areas that needed improving such as patient experience and engagement of patients.

The areas where the provider must make improvements are:

  • Ensure care and treatment of the service users met their needs.

The areas where the provider should make improvements are:

  • Provide protected learning time for all staff.
  • Consider ways to identify carers to ensure their needs are known and can be met.

This service was placed in special measures in 7 February 2018. Insufficient improvements have been made such that there remains a rating of inadequate for effective, responsive and well-led. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

24 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Inadequate overall. (At the comprehensive inspection in October 2014 the practice was rated Good; at the inspection in June 2016 we rated the practice as Requires Improvement in Safe. Since the last inspection the provider was no longer providing a walk in service.

The practice is managed by The Practice Surgeries Limited, Corporate provider.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Inadequate

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? - Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) - Inadequate

We carried out an announced comprehensive inspection at Edridge Road Community Health Centre on 24 November 2017 to follow up on breaches of regulations.

At this inspection we found:

  • The patients were at risk of harm as the system in place for the monitoring of patients on high risk medicines was ineffective; the provider did not have a system to manage and follow up patients who had been referred for suspected cancer; the provider did not have safety netting in place to ensure the cervical smear test results are appropriately disseminated to relevant clinicians.
  • The practice did not have clear systems to manage risk so that safety incidents were less likely to happen. We saw significant events were not always recorded contemporaneously to ensure dissemination and learning.
  • The practice did not always review the effectiveness and appropriateness of the care it provided. The practice did not have multi-disciplinary team meetings to ensure effective care and treatment was provided to patients.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use; however some of the patients we spoke to during the inspection reported difficulty in accessing appointments. Some of the Care Quality Commission comment cards we received confirmed this.
  • There was limited focus on continuous learning and improvement at all levels of the organisation.
  • The provider had limited oversight of the issues in the practice and did not ensure that systems and processes operated effectively to ensure good governance.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way for patients including the safe management of medicines, significant events, two week wait referrals, cervical smear results and record keeping.
  • Ensure that systems and processes operated effectively to ensure good governance including complete and contemporaneous record keeping, a recall system in place to manage patients with long-term conditions and regular multidisciplinary team meetings.

The areas where the provider should make improvements are:

  • Recording the details of fire drills for staff learning.
  • Document discussions from meetings for sharing and learning amongst staff.
  • Improve the uptake of childhood Immunisations and cervical screening.
  • Undertake regular health checks for all patients with a learning disability.
  • Improve the identification of carers.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

22 June 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We undertook this focused, unannounced inspection on 22 June 2016 in response to concerns expressed to the Care Quality Commission. This report covers our findings in relation to those concerns.

Following the inspection we found the practice to require improvement in the “Safe” domain. We reviewed one area in the “Responsive” domain and one in the “Well Led” domain; however, we did not look into these areas in sufficient detail to generate a rating. As we did not review all domains, we have not given an overall rating. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Edridge Road Community Health Centre on our website at www.cqc.org.uk.

Our key findings across all the areas we inspected were as follows:

  • The practice had a designated infection prevention and control lead, although not all clinical staff were aware who this was.

  • There was an infection prevention and control policy in place. We found the practice was not following this with regards to staff training.

  • There was no clearly defined system for cleaning equipment.

  • We found improvements were needed in the management of medicines.

  • The practice had an effective system in place for handling complaints and concerns. The allegation we received that a complaint had been discarded was not substantiated.

  • There were a number of complaints regarding the way patients were spoken to and questioned by reception staff. We observed some staff to be impatient and ask unnecessary questions.

  • Staff commented it was a good place to work. They felt supported by local management but not at corporate level.

  • A number of staff commented on the lack of support for ongoing professional development.

The areas where the provider must make improvements are:

  • Carry out adequate monitoring and recording of the vaccine fridge temperature in line with current guidance, and additionally record the reason and any action taken for temperatures readings which are out of range.

  • Take appropriate steps to ensure the security of blank prescription pads.

  • Put in place and monitor a system to ensure equipment has been cleaned appropriately.

  • Provide infection prevention and control training to staffin line with the provider’s own policy.

In addition the provider should:

  • Review staff training records to assure themselves that clinical staff have access to, and are undertaking, relevant continuous professional development training.

  • Take appropriate steps to ensure staff are courteous and helpful to patients and treat them with dignity and respect.

  • Record complaints in the appropriate log, and not in patients’ medical records.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Edridge Road Community Health Centre provides a GP service to 5,400 patients in the Norbury and Upper, South and West Norwood areas of Croydon and a Walk in Service for people in Croydon and those who live outside the area and or unregistered patients.

We carried out an announced comprehensive inspection on 8 October 2014. The inspection took place over one day by a lead inspector and a GP specialist advisor with an observer from the Department of Health.

Overall the practice is rated as good.

Our key findings were as follows:

  • We found the practice was caring, patients felt their privacy and dignity were respected, that they received good or appropriate care and treatment, that the doctor or nurse had time to listen to them and explain any treatment, medicines or referrals to them. Patients said the repeat prescription process worked for them.
  • We found the practice was safe with suitable systems in place to deal with medical emergencies, to monitor infection control, to protect children and vulnerable adults from harm and to manage medicines.
  • We found the practice was effective. Staff were up to date with best practice guidance. There were lead GPs for long term conditions. Systems were in place to work with other health and social care providers.

We saw several areas of outstanding practice including:

  • The service provision and shared care arrangements for people with mental health problems. The use and review of care plans to prevent hospital admission the number of regular health checks completed with patients seen at the walk in centre rather than being referred to mental health services.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • register with CQC to provide the regulated activity family planning.

In addition the provider should:

  • continue work to address the issues with telephone answering and waiting times;
  • complete appraisals for all staff;
  • provide supervision for all reception staff and
  • provide training for new reception staff on dealing with difficult situations.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

 

4 December 2013

During a routine inspection

On the day of our inspection at Edridge Road Community Health Centre we spoke with four people who used the service some of whom were visiting the health centre as a walk in patient. We spoke with the practice manager, three registered general practitioners including the centres clinical lead, the practice nurse who is also the centres infection control lead, two reception staff and personal from the providers practice support centre.

Most people that we spoke with who used the service on the day of our visit were complimentary of the medical professionals and service received by reception staff. People also commented that they were happy with the practice environment. People's comments included "They are all polite here', 'I have had no problems with anything and the doctors are very kind', 'I have only been for minor things but have been happy with the service provided' and 'The building is lovely, it's always nice and clean'.

We found that people using the service were protected from the risk of abuse because procedures were in place at the health centre for safeguarding children and vulnerable adults from abuse. Members of staff we spoke with demonstrated that they were aware of safeguarding procedures and knew how to report their concerns.

During our inspection we observed the health centre and main reception area to be visibly clean, thoroughly maintained and well lit. The health centre had disabled person's access including wide doorways for wheelchair use and a disabled toilet. There was also disabled parking and access to the rear of the building. Facilities were also available for mothers and babies. We found that the provider had appropriate infection control measures in place to reduce the risk of cross infection at the health centre.

People's views and experiences were taken into account in the way the service was provided and delivered and there were effective systems in place to regularly assess and monitor the quality of service that people receive.