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Inspection carried out on 03 Jul 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Mersham Medical Centre on 3 July 2019 as part of our inspection programme. At the last inspection in October 2014 we rated the practice as good in all domains and population groups.

We decided to undertake an inspection of this service following our annual regulatory review of the information available to us. This inspection looked at the following key questions

  • Effective
  • Responsive
  • 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 good overall and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Some of the staff had not completed infection prevention and control and fire safety training appropriate to their role. After we raised this issue with the provider they informed us they had booked training for these staff and sent us evidence to support this the day following the inspection.
  • Patients received effective care and treatment that met their needs.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • This practice ranked second amongst the practices in the local Clinical Commissioning Group (CCG) in the 2017 National GP Patient survey; In the 2018 National GP Patient Survey the practice has scored higher than the CCG average for all the questions.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice, with support of their Patient Participation Group (PPG) ran an over 60’s social club since February 2019 to enable people over 60’s to regularly meet others, make new friends, get involved in fun activities. The club met monthly at a local church for two hours; this was organised by the PPG chair. Every month people were invited to give talks on topics of interest which included Bletchley Park code breaking during World War II, environmental regeneration in the local area, local policing by community support police officers, Sutton Mental Health Foundation’s services for the mentally ill, the legal framework for helping victims of domestic violence, abuse and dealing with perpetrators. The PPG informed us that around 10 to 12 people regularly attend the social club.

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

  • Review service procedures to ensure staff receive training appropriate to their role.
  • Review service procedures to ensure clinical audits are written up for dissemination and learning.

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

Review carried out on 22 May 2019

During an annual regulatory review

We reviewed the information available to us about Mersham Medical Centre on 22 May 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 15 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Mersham Medical Centre, located in Thornton Heath in the London borough of Croydon provides a general practice service to just under 3,000 patients.

We carried out an announced comprehensive inspection on 15 October 2014. The inspection took place over one day and was undertaken by a lead inspector, along with a GP advisor and an Expert by Experience.

Overall the practice is rated as Good.

• The service is safe. There were systems in place for reporting, recording and monitoring significant events to help provide improved care. Staff were clear of their roles in regards to monitoring and reporting of incidents, safeguarding vulnerable people and children, and following infection prevention and control guidelines.

• The service is effective. Staff shared best practice through internal arrangements and meetings and also by sharing knowledge and expertise with external consultants and other GP practices. There was a strong multidisciplinary input in the service delivery to improve patient outcomes.

• The service is caring. Feedback from patients about their care and treatment via the national and practice-run surveys was very positive. Patients were treated with kindness and respect and felt involved in their care decisions. All the comment cards completed by patients who used the service in the two weeks prior to our inspection visit had very positive comments about the care and service provided by the surgery.

• The service is responsive to people’s needs. The practice had an active Patient Participation Group (PPG) and worked with them to improve the service. The practice was responsive to the needs of the vulnerable patients and there was a strong focus on caring and on the provision of a patient-centred care. Information on health promotion and prevention, services provided by the practice and the support available in the community was available for patients.

• The service is well-led. The practice had a clear vision and strategic direction, was well-led, staff were suitably supported and patient care and safety was a high priority.

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

The provider should:

  • Ensure improvements in the documentation of the practice’s vision and strategic aims and objectives.
  • Ensure all staff including those doing sessions have suitable recruitment checks completed before commencing employment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice