Exmoor Surgery

Updated 27 January 2022

Exmoor Surgery is a GP practice located in the London Borough of Kensington and Chelsea in West London. Services are provided from a single location located within the St Charles Centre for Health and Wellbeing run by the Central London Community Healthcare NHS Trust and the practice is part of the NHS North West London CCG. The practice provides services to approximately 5,477 patients. The practice merged with Practice Beacon in October 2020 (a previous neighbouring practice). Exmoor Surgery is one of nine practices that make up NeoHealth Primary Care Network (PCN). The practice provides extended access in conjunction with the PCN. The practice is open from 8am to 6.30pm Monday to Friday and from 8am to 1pm on Saturday. The practice is part of the West London GP Federation and patients have access to GP led services via the extended hours hub for acute problems. The Federation operates from two hubs located at St Charles Centre for Health and Wellbeing and Violet Melchett Health Centre.

The practice is registered with the CQC to provide the regulated activities: diagnostic and screening procedures; maternity and midwifery services; surgical procedures; and treatment of disease, disorder or injury.

The practice has one GP partner, three salaried GPs/ GP registrars, one PCN pharmacist, physician associates, two practice nurses, two healthcare assistants/ phlebotomists, one practice manager, two deputy practice managers and a team of administrative and reception staff.

According to the latest available data, the ethnic make-up of the practice is 53% White, 18% Black, 11% Asian, 11% Other ethnic groups and 7% Mixed. Information published by Public Health England rates the deprivation within the practice population as two, on a scale of one to ten. Level one represents the highest level of deprivation and ten the lowest. The majority of the practice demographic is people of working age. The practice has a high prevalence of patients with mental health conditions and chronic diseases. The practice had an approximately 15 to 20% of patients in its practice population who had been affected by the Grenfell Tower fire, both residents of the Tower and residents of the local community.

Updated 27 January 2022

We carried out an announced inspection at Exmoor Surgery, with the remote clinical searches on 16 November 2021 and site visit on 17 November 2021. Overall, the practice is rated as good.

Set out the ratings for each key question

Safe - Good

Effective - Requires improvement

Caring - Good

Responsive - Good

Well-led – Good

Following our previous inspection on 19 November 2015, the practice was rated good overall and for all key questions.

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

Why we carried out this inspection

This inspection was a comprehensive inspection focusing on:

• Ensuring care and treatment was being provided in a safe way to patients.
• Establishing if there were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.
• Risks identified at a monitoring meeting in July 2021.

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
• Remotely 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.

We rated this practice as good for providing safe services because:

• The practice had clear systems, practices and processes to keep people safe from abuse.
• The practice held regular internal and multidisciplinary team meetings to discuss the care of patients, including safeguarding concerns and care of vulnerable patients.
• The practice used technology to develop ways to ensure that staff had the information they needed to deliver safe care and treatment.
• The premises were well managed and there were effective systems for managing staff and training records.
• Emergency medicines on site were organised, in date and effectively managed.
• Medication reviews were completed appropriately.

We rated this practice as requires improvement for providing effective services because:

• We identified some issues with the monitoring of long-term conditions.
• The practice’s uptake for cervical screening remained markedly lower than the 80% coverage target for the national screening programme. The practice had also not met the 90% uptake for all of the childhood immunisations indicators, or the WHO based national target of 95%. The practice had started to put in place systems to address barriers to the uptake of screening and immunisations.
• The practice had worked towards providing effective care for patients during the Covid-19 pandemic.

We rated this practice as good for providing caring services because:

• The practice tailored its approach to meet the needs of its practice population. It had a dedicated approach to patients affected by the Grenfell Tower fire, mental health patients and patients with long-term conditions.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice had arrangements for providing interpreters for patients who did not have English as a first language and made adjustments for patients to ensure access.
• The practice offered longer appointments for patients with complex needs, carers and patients who required interpreters.

We rated this practice as good for providing responsive services because:

• We found that people’s needs were met through the way services were organised and delivered.
• The importance of flexibility, informed choice and continuity of care was reflected in the services provided by the practice. People’s needs and preferences were considered and acted on to ensure that services were delivered in a way that was convenient.
• The practice had improved services in response to patient feedback, for example it had improved its telephone service in September 2021 to improve access.

We rated this practice as good for providing well-led services because:

• The practice analysed and understood the needs of its practice population. The leadership was knowledgeable about issues and priorities for the quality and sustainability of services, understood what the challenges were and acted to address them.
• There was a clear statement of vision and values, driven by quality and sustainability. This was translated into a robust and realistic strategy and well-defined objectives which were achievable and relevant. The vision, values and strategy were developed through a structured planning process in collaboration with people who used the service, staff and external partners. The strategy was aligned to local plans in the wider health and social care economy and services were planned to meet the needs of the relevant population.
• The practice was a leader in providing input for care of patients affected by the Grenfell Tower fire and worked with external organisations to provide holistic care to these patients.
• The practice was transparent, collaborative and open with all relevant stakeholders about performance, to build a shared understanding of challenges to the system and the needs of the population and to design improvement to meet them.

We saw some areas of outstanding practice when we inspected. In particular:

• During the Covid-19 pandemic, the practice was proactive in its response and developed a template to conduct welfare checks on vulnerable patients. This template was adopted across the primary care network (PCN), clinical commissioning group (CCG) and North West London Sustainability and Transformation Partnership.
• The practice had developed a supportive environment for patients affected by the Grenfell Tower fire and had become a leading practice in providing a targeted, caring and supportive service for patients. The practice had developed strong links with external organisations, including the North Kensington Recovery Team and health partners and the lead GP provided input at meetings and was an advocate in other surgeries.

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

• Continue to review and monitor patients with long-term conditions, including respiratory conditions, diabetes and hypothyroidism.
• Continue to monitor patients on high risk medicines in line with clinical guidance.
• Keep under review staff immunisations in line with Public Health England guidance.
• Continue to monitor staff compliance with mandatory training.

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