South Norwood Hill Medical Centre in London is a Doctors/GP specialising in the provision of services relating to diagnostic and screening procedures, family planning services, maternity and midwifery services, services for everyone, surgical procedures and treatment of disease, disorder or injury. The last inspection date here was 21st April 2020
South Norwood Hill Medical Centre is managed by South Norwood Hill Medical Centre.
Contact Details:
Address:
South Norwood Hill Medical Centre 103 South Norwood Hill London SE25 6BY United Kingdom
Letter from the Chief Inspector of General Practice
This practice is rated as Good overall. (Previous inspection 01 Feb 2017 – rated Inadequate)
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
During the announced comprehensive inspection carried out on 5 May 2016 the practice was rated overall as inadequate and was placed in special measures. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for South Norwood Hill Medical Centre on our website at www.cqc.org.uk.
Following the period of special measures we undertook an announced comprehensive inspection on 1 February 2017 to follow-up on the breaches of regulation and the practice remained rated as overall as inadequate. The full comprehensive report on the February 2017 inspection can be found by selecting the ‘all reports’ link for South Norwood Hill Medical Centre on our website at www.cqc.org.uk.
We carried out an announced comprehensive inspection at South Norwood Hill Medical Centre on 15 February 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in the previous inspection on 1 February 2017. The provider had made significant improvements since the last inspection and addressed the concerns identified in the last inspection. The provider informed us that they had worked closely with the local Clinical Commissioning Group, NHS England and Royal College of General Practitioners to improve their services.
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 routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
Staff involved and treated patients with compassion, kindness, dignity and respect.
Patients found the appointment system easy to use and patients we spoke to during the inspection reported that they were able to access care when they needed it.
There was a strong focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider should make improvements are:
Review the results of the national GP patient survey and continue to address low scoring areas to improve patient satisfaction.
Consider improving access for patients with hearing impairments.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at South Norwood Hill Medical Centre on 5 May 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months.
We carried out an announced comprehensive inspection on 1 February 2017. Although there had been some improvement, this was insufficient and the provider remained rated inadequate and was subject to a second period of special measures, to enable them to make the required improvements.
The report of all the previous inspections can be found by selecting the ‘all reports’ link for South Norwood Hill Medical Centre on our website at www.cqc.org.uk.
This inspection was an unannounced focused inspection carried out on 14 September 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations related to safety in particular infection control related to minor surgical procedures that we identified in our previous inspections. This report covers our findings in relation to those requirements and also some additional improvements made since our last inspection.
This was a focused inspection to check on the safety of the practice. As the provider is in special measures this inspection does not alter the provider’s rating, which will be assessed at the next comprehensive inspection.
Our key findings were as follows:
There was a lack of effective oversight of infection and prevention control as a whole, both in policy and in practice.
The practice systems were not always effective at identifying issues that required action before they were identified by other organisations. Once identified, the practice reacted, but not always sufficiently to complete address the issue.
Infection prevention and control systems had improved, with improved cleanliness and systems, but there were still some issues with ensuring the practice was appropriately and consistently clean.
Checks of medicines and related equipment stored in the practice were not carried out consistently to ensure that they remained safe and effective.
A consistent system of recruitment checks was now in place to ensure that all staff employed by the practice were suitable for their roles.
Therefore the provider must continue to make improvements in order to meet the legal requirements.
The provider must:
Ensure care and treatment is provided in a safe way to patients. Please see the requirement notice section for more information.
The provider should also:
Review the template for recording significant events, so it records the name of the people involved and completing the record, and the date that the template was completed.
At the last inspection we said that the provider should repeat the audit of post-operative infection rates. The practice did not show us this, although we saw evidence that it was reviewed by NHS England.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at South Norwood Hill Medical Centre on 5 May 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for South Norwood Hill Medical Centre on our website at www.cqc.org.uk.
This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 1 February 2017. Overall the practice still rated as inadequate.
Our key findings were as follows:
There was not a consistent system in place for reporting and recording significant events, and there was no system in place to record action taken in response to patient safety alerts.
The practice did not have systems in place to ensure that all staff (including those employed temporarily) had received relevant recent training in safeguarding children and vulnerable people and basic life support.
The practice was not taking appropriate action to prevent and control the spread of infections, although there was some improvement since the last inspection.
The practice did not have valid Patient Group Directions (PGDs) in place for all the nurses working in the practice, and some of the PGDs in place were out of date. (PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.)
Appropriate recruitment checks had not been undertaken and documented for non-permanent staff employed.
Not all risks to patients were assessed and well managed, and not all of the emergency medicines needed to treat common medical emergencies were available.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average.
Results from the national GP patient survey published in July 2016 showed patient satisfaction with their involvement in planning and making decisions about their care and treatment was below average for several aspects of care, and had deteriorated since the results published in January 2016. Results relating to access to care and treatment showed an improvement in some areas but others remained below average.
The practice did not have an effective system in place for handling complaints and concerns. Although information was available for patients about how to complain and we saw evidence that patients who complained were contacted and, where appropriate, received an apology; none of the complaints we looked had been handled in line with the practice policy and national guidance.
Arrangements for identifying, recording and managing risks, issues and implementing mitigating actions were not embedded in the culture of the practice. For example, when we inspected in 2016, we found there was no process to ensure that sharps bins were emptied regularly. Although systems had since been established to manage sharps bins safely, they were not effective.
Governance structures and processes were not in place to ensure that a comprehensive understanding of the performance of the practice was maintained and that practice was able to deliver good quality care.
There were areas of practice where the provider needs to make improvements.
Importantly, the provider must:
Implement systems to assess, monitor and mitigate risks, including those related to managing the risk of infection, staff areas and cleaning chemicals.
Ensure significant events are consistently analysed and documented so that future risks are reduced.
Ensure the proper and safe management of medicines, including the use of valid Patient Group Directions for all nurses providing vaccinations.
Ensure that necessary recruitment records are kept in relation to all persons employed in the carrying on of the regulated activity, including non-permanent staff.
Ensure that non-permanent staff receive training necessary for their role, and that records of this training is kept.
Operate effectively a system for recording, handling and responding to complaints.
In addition the provider should:
Repeat the audit of post-operative infection rates.
Monitor and continue to take action to improve patient satisfaction as demonstrated in the national GP patient survey.
This service was placed in special measures in May 2016. Insufficient improvements have been made such that there remains a rating of inadequate for safety and being well led. We previously issued enforcement action in relation to safety, we have taken action in line with our enforcement procedures.
If the provider fails to make improvements 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.
Special measures will give people who use the service the reassurance that the care they get should improve.
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at South Norwood Hill Medical Centre on 5 May 2016. Overall the practice is rated as Inadequate.
Our key findings across all the areas we inspected were as follows:
Patients were at risk of harm because systems and processes were not in place to keep them safe.
The practice was not taking appropriate action to assess the risk of, prevent and control the spread of infections.
Arrangements for managing medicines and dealing with medical emergencies were not sufficient to keep patients safe.
Most staff in the practice had not completed recent training in safeguarding children or adults at the levels required for their roles, including the lead GP for safeguarding.
The practice had not carried out appropriate Disclosure and Barring Service (DBS) checks prior to employment or when staff moved between roles.
Not all of the staff we spoke to were clear about the practice procedure when acting as a chaperone, meaning that they may not be able to properly perform the role. The practice had not carried out DBS checks on staff who acted as chaperones or documented a risk assessment for this decision.
Paper copies of patient notes were not stored securely and staff had not completed the required training in information governance.
Results from the national GP Patient Survey showed that patients’ satisfaction with how they could access care and treatment was below local and national averages. Patients we spoke to were positive about their interactions with staff and said they were treated with compassion and dignity, but told us that they were not always able to get appointments when they needed them. Patients told us that they felt that they sometimes had to wait too long at the practice to be seen. The practice was unaware of the deterioration in patient satisfaction.
Information was available about the complaints system and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff.
Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
Data from the Quality and Outcomes Framework (QOF) showed patient outcomes overall were in line with the national average. However, measures of performance for some particular patient populations were below average.
The areas where the provider must make improvements are:
Implement effective systems to keep patients safe including processes to prevent and control infection and safe and proper management of medicines, with monitoring of the use of blank prescription forms. Ensure that all medicines are stored securely, and that systems ensure all medicines kept within the premises are in date and are sufficient to deal with medical emergencies, taking into account the patient population and the services provided.
Ensure that consent is obtained in line with practice policy and national guidance.
Implement formal governance structures for assessing and monitoring all risks, including those that relate to the triageprocedures ; employment checks (upon recruitment and if staff change role) ; and for ensuring that the practice can continue to operate in the event of an incident affecting the premises, equipment or systems.
Ensure that all staff complete mandatory training in safeguarding, information governance and infection control and that staff acting as chaperones have a clear understanding of their role.
Disclosure and Barring Service (DBS) checks must be in place or risk assessments carried out for all staff undertaking clinical or chaperoning duties .
Ensure that systems are in place to act on patient feedback.
The areas where the provider should make improvements are:
Continue to take action to improve the care of people with long-term conditions and poor mental health, as measured by the Quality Outcomes Framework.
Ensure systematic monitoring of all samples taken for the cervical screening programme.
Take measures to increase the number of patients identified as carers and improve the services they are offered.
CQC issued a warning notice to the practice related to infection prevention and control and medicines management.
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.
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