Background to this inspection
Updated
25 June 2018
Deptford Surgery provides primary medical services in New Cross, London to 5,018 patients and is one of 39 local GP practices in the NHS Lewisham Clinical Commissioning Group (CCG).
The practice population is in the second most deprived decile in England. The practice population’s age demographic is broadly in line with the national average. However, there are proportionally more patients aged between zero and 49 years and proportionally fewer patients aged over 60.
Deptford Surgery is one of four practices operated by the Penrose Group. All of the locations are individually registered with the CQC. The practice is registered as a partnership with the Care Quality Commission (CQC) to provide the regulated activities of treatment of disease, disorder or injury, maternity and midwifery services, surgical procedures, and diagnostic and screening procedures at one location.
The practice has a PMS contract. Personal Medical Services (PMS) agreements are locally agreed contracts between NHS England and a GP practice , and provide a number of local and national enhanced services. (Enhanced services require an enhanced level of service provision above what is normally required under the core GP contract).
The practice is open six days a week, Monday to Friday from 8am to 6.30pm and on Saturday from 8.45am to 12pm. When the practice is closed, patients are directed to contact SELDOC, the local out of hour’s service provider.
Deptford Surgery is operated by one GP partner and one management partner. Three salaried GPs and three locum GPs are employed at the practice. A practice pharmacist works full time.
The nursing team consists of three part time practice nurses and a part time Mental Health Nurse. Deptford Surgery also employs one full time health care assistant. At this inspection, we were not able to speak to a practice nurse.
The practice staff team also includes an Operations Manager. There is a Site Manager, who leads a team of reception and administrative staff.
The practice was previously inspected on 29 June 2015 where the overall rating was found to be Good overall, but Requires Improvement for Effective. At that inspection, it was found that the practice should do the following:
- Take account of results of audits and take action immediately.
- Ensure that non-clinical staff are aware and follow the practice’s protocols relating to patients’ clinical documentation.
Updated
25 June 2018
This practice is rated as Good overall. (Previous inspection June 2015 rated – Good overall, Requires Improvement for Effective)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Good
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 – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Deptford Surgery on 13 April 2018, as part of our inspection programme.
At this inspection, we found:
- The practice had clear 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 had implemented defined and embedded systems to minimise risks to patient safety.
- Staff knew about current evidence based guidance. The practice ensured that staff received training to provide them with the skills and knowledge to deliver effective care and treatment.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. Staff delivered care and treatment according to evidence-based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
- Patients told us that they were always able to make appointments at the practice. The 2017 national patient survey also showed that patients found it easy to make appointments.
- Information about services and how to complain, was available.
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- There was good evaluation of the service provided to patients.
- There was clear leadership and leaders encouraged practice staff to be accountable.
We saw one area of outstanding practice:
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- The practice had identified an area of need for transgender patients requesting hormones from their GP for gender transition. The GPs worked with the CCG to develop a South East London guideline and liaised with local community services in order to educate patients on what their GP can provide outside of gender services. The practice had developed a patient agreement to safeguard patients with gender transition and set out best practice for prescribing bridging prescriptions and Gender Identity clinic referrals.
The areas where the provider should make improvements are:
- The practice should make improvements in relation to patient involvement in decisions about their nursing care.
- The practice should be able to provide evidence that they have considered where new Disclosure and Barring (DBS) checks are needed for clinical staff, to renew their DBS professional registration.
- The practice should have a protocol for taking consent from patients undergoing joint and soft tissue injections.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice