The Care Quality Commission
  • Doctor
  • GP practice

Archived: Theobald Centre

Overall: Good read more about inspection ratings

119- 121 Theobald Street, Borehamwood, Hertfordshire, WD6 4PT (020) 8953 3355

Provided and run by:
Theomed Limited

Important: The provider of this service changed. See new profile
Important: The provider of this service changed. See old profile

All Inspections

24 March 2020

During an annual regulatory review

We reviewed the information available to us about Theobald Centre on 24 March 2020. 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.

11 October 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Theobald Centre on 5 September 2017. The overall rating for the practice was requires improvement. We found that the practice needed to make a number of improvements to the premises and improve the governance arrangements in place at the practice. The full comprehensive report on the September 2017 inspection can be found by selecting the ‘all reports’ link for Theobald Centre on our website at www.cqc.org.uk.

This inspection was an announced follow up comprehensive inspection carried out on 11 October 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation related to good governance that we identified in our previous inspection on 5 September 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as Good.

Our key findings were as follows:

  • The premises had been subject to a refurbishment programme and several improvements had been made to the cleanliness and suitability of the environment.
  • 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 patients and treated them with compassion, kindness, dignity and respect.
  • Patients were positive about the GPs working at the practice and had confidence in the care and treatment they received.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it. Patient feedback was positive.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • There was effective and efficient use of IT systems within the practice which enabled good quality assurance processes to monitor quality of care and treatment.
  • The staff team were happy in their work and felt supported by the provider and their colleagues. There was a positive and supportive culture within the practice.

The areas where the provider should make improvements are:

  • Review recruitment procedures to ensure that all staff are subject to full recruitment checks as required by law.
  • Review storage arrangements for emergency equipment and medicines in order that these are stored appropriately to reduce risk and are easily accessible for staff.
  • Establish a mechanism to enable the practice to to obtain effective lines of communication between patients and the provider and management at the service.
  • Review and work to improve patient uptake in relation to national screening programmes in particular, bowel and cervical screening.
  • Continue to monitor and improve national GP patient survey results and patient satisfaction in particular, areas relating to telephone access.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

05 September 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Theobald Centre on 5 September 2017. Overall the practice is rated as requires improvement.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events. Lessons learnt were shared to make sure action was taken to improve safety in the practice.

  • Staff were aware of current evidence based guidance.

  • 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.

  • The latest national GP patient survey results published July 2017 showed lower than local and national average scores for some aspects of care including interaction with patients as well as access to services. The practice was aware of the lower results in some areas and had implemented measures to ensure improvement along with plans to monitor its effectiveness.

  • The practice was aware of issues related with infection control of its premises and had a refurbishment plan and was in negotiations with the local Clinical Commissioning Group (CCG) for support with the implementation.

  • All applicable staff had been checked for their immunisation status related Hepatitis B. However at the time of our inspection the practice was in the process of reviewing the immunisation status of applicable clinical and non clinical staff in relation to other immunisations recommended by the Health and Safety at Work Act 1974.

  • Following external fire risk and health and safety assessments the practice had an improvement plan. However completion milestones for improvement work had yet to be finalised.

  • A clinical staff member recruited in 2005 and in continuous employment with the practice since then had not been checked through the Disclosure and Barring Service (DBS) or risk assessed for need of a DBS check. After our inspection the practice confirmed that a satisfactory DBS check had been received.

  • Patients we spoke with said they found it easy to make an appointment with a 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 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 must make improvement are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please refer to the requirement notice section at the end of the report for more detail).

The areas where the provider should make improvement are:

  • Continue to monitor and ensure improvement to national GP patient survey results.

  • Continue to identify and support carers.

  • Continue to encourage patients to attend national cancer screening programmes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice