Background to this inspection
Updated
22 December 2021
Upton Road Surgery (also known as Watford Health Centre) is located in Watford, Hertfordshire at:
Colne House
21 Upton Road
Watford
Hertfordshire
WD18 0JP
The provider is registered with CQC to deliver the Regulated Activities: Diagnostic and screening procedures; maternity and midwifery services; treatment of disease, disorder or injury; family planning; and surgical procedures.
The practice is situated within the Herts Valleys Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of approximately 18,700 at the time of this inspection. This is part of a contract held with NHS England.
The practice is part of a wider network of local GP practices.
Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (six of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 24% Asian, 7% Black, 4% Mixed, 1% Other, and 64% White.
The practice staff includes seven GP partners; five salaried GPs; one advanced nurse practitioner; two practice nurses; three health care assistants; four pharmacy staff; one first contact physiotherapist; one drug and alcohol support worker; and two vulnerable patient support workers. Additionally the practice employed two managers, one operational lead, and a team of 24 patient advisors/administrators.
Due to the enhanced infection prevention and control measures implemented since the pandemic and in line with the national guidance, some GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then this service was offered. Non-urgent online consultation were also available.
Additional same day and booked appointments are provided by clinical staff including outside of the core General Practice hours. Patients can also access extended hours services nearby as part of the local extended access hub.
When the practice is closed patients are directed to contact the local out-of-hours GP services by calling the NHS 111 service.
Updated
22 December 2021
We carried out an announced inspection at Upton Road Surgery (also known as Watford Health Centre) on 29 September 2021. Overall, the practice is rated as Good.
Safe - Good
Effective – Requires Improvement
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection published in October 2019, we rated Upton Road Surgery as Requires Improvement overall. We rated the practice as Requires Improvement for providing Effective, Responsive and Well-led services; and as Good for providing Safe and Caring services.
The full report for the previous inspection can be found by selecting the ‘all reports’ link for Upton Road Surgery on our website at www.cqc.org.uk.
Why we carried out this inspection
This inspection was a comprehensive, follow-up inspection, to review breaches of regulations identified at our previous inspection, and to ensure required actions had been taken.
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 and telephone calls.
- 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, data and information from the provider.
- Carrying out desktop reviews of documentary evidence, including policies and procedures.
- Reviewing information from stakeholders.
- 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.
- information from the provider, patients, the public and other organisations.
We have rated this practice as Good overall and Good for Older people; People with long-term conditions; People whose circumstances may make them vulnerable; and People experiencing poor mental health (including people with dementia).
We have rated this practice as Requires Improvement for Families, children and young people and Working age people (including those recently retired and students).
We found that:
- The practice had made and sustained some of the improvements required to address the concerns identified at our last inspection. Systems had been implemented to monitor clinical and quality monitoring.
- Childhood immunisation uptake rates were below the World Health Organisation (WHO) targets.
- The practice’s cervical cancer screening rate was below the national target.
- 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.
- The practice had clear and effective systems to ensure patients on medicines received regular monitoring in a timely way.
- 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 take action to further increase the uptake of childhood immunisations.
- Continue to take action to further increase the uptake of cervical screening.
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