The Care Quality Commission
  • Doctor
  • GP practice

HMC Health Feltham

Overall: Good read more about inspection ratings

3rd Floor The High Street, Feltham, TW13 4GU (020) 8104 0840

Provided and run by:
Hounslow Medical Centre

Important: The provider of this service changed. See old profile

All Inspections

During an assessment under our new approach

Date of Assessment: Remote Clinical Searches date 22/01/2025 and Site visit date- 23 /01/2025. This location was assessed due to emerging risks.

HMC Health Feltham is a GP Practice and delivers service to 12,567 patients under a contract held with NHS England. Its parent provider is Hounslow Medical Centre and there are three other Alternative Provider Medical Services (APMS) sites managed by Hounslow Medical Centre together with HMC Health Feltham. The National General Practice Profile states that the population make up for this location is 51.5% White, 30.2% Asian, 8.1% Black, 4.6% Mixed and other ethnicity/ demographic is 5.6%. Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 5th decile (5 of 10). The lower the decile the more deprived the practice population is relative to others.

There were no breaches currently at this location and what we found is as follows:

Safe: People and staff were kept safe and protected. Managers investigated incidents rigorously and the service had a good log of significant events and complaints in place. Learning outcomes were discussed at both clinical and administrative meetings; however, details of action plans were not always clear. Staff understood and managed risks. The service had a very robust Infection Prevention and Control (IPC) system with regular audits completed and records seen. Managers ensured that the staff received training and regular appraisals. The staff managed medicines well and involved people in planning any changes.

Effective: People were involved in assessments of their needs. Staff invited patients for health check reviews and completed as many reviews as possible. Evidence- based care in line with good practice was delivered. The service worked together with other stakeholders involved in people’s care for the best outcomes. Information was provided to patients to help them make informed decisions about their health.

Caring: People were treated with kindness and compassion. The dignity and privacy of patients were respected. Staff who were trained to be chaperones provided this service to patients who required it. The wellbeing of staff was supported by the management.

Responsive: People were involved in decisions about their care and information needed to make decisions were provided by the location. Service delivery was provided at this location in line with the Equality Act. Interpreting service was available for the patients who needed it. Complaints were handled thoroughly; however, a clearer complaints process was needed to be made available to the patient population.

Well-led: Leaders and staff had a shared vision and culture based on open-door policy. The leadership had a clear understanding of equality, human rights and safe compassionate care. Staff understood their roles and responsibilities and felt supported.

 

08 September 2021

During a routine inspection

We carried out an announced inspection at HMC Health Feltham on 6, 7 and 8 September 2021. Overall, the practice is rated as Good

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 8 January 2020, the practice was rated Requires Improvement overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for HMC Health Feltham on our website at www.cqc.org.uk.

Why we carried out this inspection

This was a comprehensive inspection to follow up on breaches of Regulation 17 Good governance and Regulation 18 Staffing.

At this inspection we covered all key questions:

  • Are services safe?
  • Are services effective?
  • Are services caring?
  • Are services responsive?
  • Are services well-led?

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.

We have rated this practice as Good overall and good for all population groups, with the exception of working age people (including those recently retired and students), which is rated as requires improvement.

We found that:

  • The practice had demonstrated improvements in governance arrangements compared to the previous inspection.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Continue to encourage and monitor cervical, breast and bowel cancer screening and childhood immunisation uptake.
  • Take action to ensure all the staff are aware how to access the policies.
  • Take necessary steps to establish an active patient participation group (PPG).

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

8 January 2020

During a routine inspection

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