The Care Quality Commission
  • Doctor
  • GP practice

Earl's Court Surgery

Overall: Requires improvement read more about inspection ratings

269 Old Brompton Road, London, SW5 9JA (020) 7370 2643

Provided and run by:
The Surgery

Important: The provider of this service changed - see old profile

All Inspections

02 September 2021

During an inspection looking at part of the service

We carried out an announced focused inspection at Earl’s Court Surgery, with the remote clinical review on 1 September 2021 and site visit on 2 September 2021. Overall, the practice is rated as requires improvement.

Safe – Good

Effective – Requires improvement

Caring – Not inspected

Responsive – Not inspected

Well-led – Requires improvement

Following our previous inspection on 7 January 2020, the practice was rated requires improvement overall and specifically requires improvement for providing safe, effective and well-led services. We rated the practice as good for providing caring and responsive services.

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

Why we carried out this inspection

This inspection was a focused inspection to follow up on whether:

  • Care and treatment was being provided in a safe way to patients.
  • There were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.
  • There were sufficient numbers of suitably qualitied, competent, skilled and experienced persons were deployed to meet the fundamental standards of care and treatment.

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.
  • 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 requires improvement overall. The population groups have been rated as requires improvement for people with long term conditions; families, children and young people; working age people (including those recently retired and students); and people whose circumstances make them vulnerable. We have rated the practice as good for older people and people experiencing poor mental health (including people with dementia).

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

  • We found that blank prescriptions were kept in a locked cupboard but that there was not a log kept of prescriptions allocated out and received back.
  • We observed that emergency medicines on site were organised, in date and effectively managed.
  • We found that monitoring for patients prescribed DMARDs, and the high risk drugs Mirebegron and Spironolactone was completed appropriately.
  • The practice had made improvements in relation to their infection prevention and control procedures and this was being managed effectively.
  • The premises were well managed and there were effective systems for managing staff and training records.

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

  • We found that patient treatment was not always regularly reviewed and updated. We found issues with the management of medicines and the following of national clinical guidance. In particular:
  • Medication reviews were not always completed in detail in the medical records.
  • We found that reviews of learning disability patients and palliative care patients were not always completed in detail.
  • The practice had not met the minimum 80% uptake for all five of the childhood immunisation uptake inductions and the WHO based national target of 95%. The practice was working to improve the uptake of childhood immunisation.
  • The practice’s uptake for cervical screening was lower than the 80% coverage target for the national screening programme. The practice had a failsafe policy in place and the nursing staff were working toward improving the uptake in cervical smears.

We have rated the practice as requires improvement for providing well-led services because:

  • The practice had a governance framework, however it was not always effectively managing risks. These included risks associated with prescribing medicines that required ongoing monitoring and reviewing patients prescribed repeat or multiple medicines in line with guidelines.
  • The practice was not always keeping accurate or comprehensive clinical records.
  • There were outstanding actions following the fire, disability access and legionella risk assessments carried out in November 2020.
  • The practice had developed a system for monitoring two week wait referrals and conducted regular meetings and audits to detect delays.
  • There was a process in place for do not attempt cardiopulmonary resuscitation (DNACPR) decisions and we found one patient who had been coded but the relevant form had not been completed.
  • We received feedback from the Patient Participation Group that the practice was open, sympathetic, helpful and had made its best efforts for patients during difficult circumstances.
  • Staff spoke positively about their employment at the practice and felt supported.

We found breaches of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

In addition to the above, the practice should:

  • Review the process for the security of blank prescription forms in line with national guidance.
  • Review the process for prescribing medicines to patients living abroad and duration of supply of medication.
  • Review the process for the recording and audit of DNACPR decisions.
  • Review the practice process for monitoring patients at risk of female genital mutilation.
  • Ensure sharps bins are signed and dated when assembled consistently.
  • Ensure there is a system in place for the summarising of new patient notes and clear the backlog of records waiting to be summarised.

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

07/01/2020

During a routine inspection

We carried out an announced comprehensive inspection at Earls Court Surgery on 7 January 2020 as part of our inspection programme.

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

Is it safe?

Is it effective?

Is it caring?

Is it responsive?

Is it 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 Requires Improvement overall.

We rated the practice as Requires Improvement for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe.

We rated the practice as Requires Improvement for providing effective services because:

  • Some performance data was significantly below local and national averages.
  • The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.

We have rated all population groups as good except for Working age people including those recently retired and students and Families, children and young people for the same reasons as given above.

We rated the practice as Requires Improvement for providing well-led services because:

  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.

We rated the practice as good for providing caring and responsive services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced persons are deployed to meet the fundamental standards of care and treatment.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Improve the practice's recruitment policy and procedures to ensure accurate, complete and detailed records are maintained for all staff.
  • Review practice protocols and procedures to ensure staff are up to date with their mandatory training.
  • Review the system for recording, investigating and reviewing incidents or significant events with a view to preventing further occurrences and ensuring that improvements are made as a result.

The service will be kept under review and if needed could be escalated to special measures action. Where necessary, another inspection will be conducted within a further six months.

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

1 June 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Earl’s Court Surgery on 14 April 2016. The overall rating for the practice was Good. The full comprehensive report on the April 2016 inspection can be found by selecting the ‘all reports’ link for Earl’s Court Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 1 June 2017 to confirm that the provider had taken the action we said they should take to address concerns that we identified in our previous inspection on 14 April 2016. This report covers our findings in relation to improvements made in response to those concerns since our last inspection.

Overall the practice is rated as Good.

Our key findings were as follows:

At the inspection on 14 April 2016, the practice was rated overall as ‘good’. However, within the key question caring, areas were identified as ‘requires improvement’, as the practice was not taking sufficient action to identify and support carers. We told the provider it should take action to review systems to improve the identification of carers and provide support.

At our inspection on 1 June 2017, the practice was able to demonstrate improvement in identifying and supporting carers, although the system of alerts on patient records and a carers register were not put in place until immediately after the inspection.

Other areas identified where the practice was advised they should make improvements within the key question caring included:

  • Advertise translation services are available.

There was now a poster on display in the reception area informing patients about the availability of translation services.

In addition we identified areas where the practice was advised they should make improvements within the key questions of safe, effective and well-led which included:

  • Complete a written policy on safeguarding of vulnerable adults and arrange relevant formal training for all practice staff.

  • Where telephone references are taken prior to employment, ensure these are fully documented in staff files.

  • Ensure more clinical audits are completed through the full audit cycle where the improvements made are implemented and monitored.

  • Consider putting on display within the practice for the benefit of patients and staff the practice’s mission statement.

  • Arrange for clinical meetings to be minuted to provide an audit trail of discussion and agreed decisions and actions.

At our June 2017 inspection we reviewed the practice’s progress since the full inspection in the areas identified and looked at a range of supporting documents and records relevant to the action taken to demonstrate improvement.

At our June 2017 inspection we found the practice had not developed its own policy on safeguarding of vulnerable adults but had adopted the ‘London Multi Agency Adult Safeguarding Policy and Procedures’. A printed copy of this was available to staff within the practice along with a link to an internet copy. Staff also had access to details of local safeguarding contacts.

At our April 2016 inspection, the majority of practice staff had not completed formal training in safeguarding of vulnerable adults. However, we were told the practice was putting arrangements in place to address this. At our June 2017 inspection the practice manager told us they had been attempting since the previous inspection to arrange local classroom training but without success. We were shown some of the recent correspondence on this. They had in the meantime decided to pursue on-line training. All administrative staff had commenced this and were at various stages of completion of the on-line modules. None of the three GP Partners had initiated this training at the time of our inspection. However, immediately after the inspection the practice manager circulated a memo within the practice setting this in train and we saw a copy of this.

Following our previous inspection the practice undertook to obtain written references for one member of staff for whom telephone references had originally been taken but not documented. At our latest inspection we were told this action had not been taken because one of the GP Partners had worked with the member of staff concerned at another practice and on this basis was prepared to vouch for their suitability for the role. There had been no further recruitment since our previous inspection.

The practice had participated in two clinical audits since our previous inspection. These were initiated by NHS West London CCG in 2016/17 under the prescribing standardisation scheme (PSS). They covered patients who had been issued with asthma reliever inhalers and patients currently on repeat prescription rapid correction doses of vitamin D. The first cycle of each audit was completed in December 2016 and January 2017 respectively and action points and learning points identified. For example, the asthma inhaler review had alerted the practice to check regularly how many inhalers were prescribed and monitor potential overuse. The second cycle of these audits was due to be completed later this year. There had been no further practice initiated completed clinical audits since our previous inspection.

The practice vision and values were now on display in the reception area.

At our April 2016 inspection we noted the practice’s governance arrangements included weekly clinical meetings which were relatively informal. The practice recognised that these meetings needed to be minuted to provide documentary evidence of discussion and agreed decisions and actions. We said the provider should take this action but they had not done so at our latest inspection. However, they undertook to review this further with a view to introducing an action log for the meetings.

Whilst there had been some improvements since our previous inspection, areas of practice remained where the provider needs to make further improvements. In particular, the provider should:

  • Ensure training in safeguarding of vulnerable adults currently in progress for administrative staff and planned for clinical staff is completed without further delay.

  • Secure written references for all future staff prior to employment.

  • Carry out practice initiated clinical audits and re-audits to improve patient outcomes.

  • Ensure the system for identifying and supporting carers is fully embedded and maintained within the practice.

  • Consider further the minuting of weekly to provide an audit trail of discussion and agreed decisions and actions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Earls Court Surgery on 14 April 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. However, the practice had not proactively identified carers to offer them additional support.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Complete a written policy on safeguarding of vulnerable adults and arrange relevant formal training for all practice staff.
  • Where telephone references are taken prior to employment, ensure these are fully documented in staff files.
  • Ensure more clinical audits are completed through the full audit cycle where the improvements made are implemented and monitored.
  • Review systems to improve the identification of carers and provide support.
  • Advertise translation services are available.
  • Consider putting on display within the practice for the benefit of patients and staff the practice’s mission statement
  • Arrange for clinical meetings to be minuted to provide an audit trail of discussion and agreed decisions and actions.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice