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HMC Health Feltham Requires improvement

The provider of this service changed - see old profile

Inspection Summary

Overall summary & rating

Requires improvement

Updated 25 February 2020

We carried out an announced comprehensive inspection at HMC Health Feltham on 8 January 2020 as part of our inspection programme.

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 and requires improvement overall for all population groups.

We rated the practice as r

equires improvement for providing safe, effective, caring, responsive and well-led services because:

  • Risks to patients were assessed and well managed in some areas, with the exception of those relating to the fire safety and infection control procedures, some recruitment checks and staff vaccinations.
  • The practice was unable to demonstrate that all staff had received annual appraisals and some nursing staff had not received childhood immunisations and travel immunisations training updates in the last 12 months.
  • Feedback from some patients reflected that they were not satisfied about the way staff treated them and they were not always involved in decisions about care and treatment.
  • The practice had not assured that confidential documents were disposed of in a safe manner and the computer screen was always locked when the clinician was not in the consulting room.
  • Feedback from patients reflected that they were not always able to access care and treatment in a timely way.
  • The practice’s uptake of the national screening programme for cervical, breast and bowel cancer screening and childhood immunisations rates were below the national averages.
  • A hearing induction loop and baby changing facilities were not available on the premises.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
  • There was a clear leadership structure and staff felt supported by the management.
  • There was a lack of good governance in some areas.

We rated all population groups as requires improvement for providing effective and responsive services because they were all affected by the issues identified. 

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

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

The areas where the provider should make improvements are:

  • Improve the monitoring of blank prescription forms in line with national guidance.
  • Improve the identification of carers to enable this group of patients to access the care and support they need.
  • Continue to encourage and monitor the cervical, breast and bowel cancer screening and childhood immunisation uptake.
  • Take action to ensure the practice takes into account the needs of patients with hearing difficulties and baby changing facilities.
  • Review the patient participation group (PPG) feedback.
  • Take necessary action to resolve the CQC registration issues.

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


Requires improvement


Requires improvement


Requires improvement


Requires improvement


Requires improvement
Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement