Background to this inspection
Updated
8 July 2021
Dr Christopher John George Wright (also known as The Deerbrook Surgery) is located in London at:
216 Norwood Road
SE27 9AW
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning services, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.
The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.
The practice is situated within the South East London Clinical Commissioning Group (CCG) and delivers Personal Medical Services (PMS) to a patient population of about 4808. This is part of a contract held with NHS England. The practice is part of the HBD Group Primary Care Network.
Information published by Public Health England shows that deprivation within the practice population group is in the fourth lowest decile (four 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 6% Asian, 56% White, 27% Black, 9% Mixed, and 2% Other.
The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.
There is a team of four GPs who provide cover at the practice. The practice employs a part-time nurse and a part time healthcare assistant. The GPs are supported at the practice by a team of reception/administration staff. The practice manager and assistant practice manager provide managerial oversight.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
Updated
8 July 2021
We carried out an announced inspection at Dr Christopher John George Wright (also known as The Deerbrook Surgery) on 26 May 2021. Overall, the practice is rated as Good.
Safe - Requires improvement
Effective - Good
Well-led - Good
Following our previous inspection on 22 to 23 October 2019, the practice was rated requires improvement overall and good for the key questions caring and responsive. The practice was rated as requires improvement for providing safe, effective and well-led services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Christopher John George Wright on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused inspection to follow up on breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance. At the previous inspection we found:
- There was no formal process for reviewing patients prescribed one high risk medicine to monitor their health.
- There was no system in place to ensure blood test referrals were completed or recorded accurately.
- There was limited action taken in response to the lack of clinical and non-clinical staff reported by staff.
- The leadership governance and culture did not always support the delivery of high-quality person-centred care. The arrangement for governance and performance management was not fully clear or did not always operate effectively.
We also followed up on areas we identified the practice should improve at the last inspection. Specifically to:
- Undertake an assessment of how clinical incidents can be identified, recorded and analysed for improvements.
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 good overall and requires improvement for the key question safe and for the population group people with long-term conditions.
We found that:
- The practice had systems for the appropriate and safe use of medicines in most respects. However, the practice had not undertaken required monitoring for three patients prescribed one high-risk medicine.
- The provider did not stock all medicines recommended for treating medical emergencies and they did not have appropriate risk assessments in place to justify these ommisions.
- Although the practice had processes in place to respond to safety alerts, they were not always effective.
- The practice had a system in place for ensuring that clinical staff were registered and indemnified; however, we found one instance where this was not effective.
- The cleaning checklist had not been completed by cleaning staff; and the mops in the cleaning cupboard had not been stored properly and in accordance with the colour codes assigned to each cleaning area.
- The practice had above average exception reporting for patients with some long-term conditions.
- 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 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.
- There was a clear leadership structure and staff felt supported by management.
- There was evidence of quality improvement activity.
The areas where the provider must make improvements as they are in breach of regulations are:
- Ensure care and treatment is provided in a safe way to patients.
The areas where the provider should make improvements are:
- Review the process for monitoring indemnity arrangements and professional registrations of clinical staff.
- Implement a cleaning schedule to be assured that appropriate standards of cleanliness and hygiene are met.
- Continue efforts to reduce higher than average rate of exception reporting and improve clinical outcomes for patients with long term conditions to be assured that conditions are being well-managed.
- Continue efforts to improve rates of cancer screening and childhood immunisation uptake.
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