The Care Quality Commission
  • Doctor
  • GP practice

Novum Health Partnership

Overall: Requires improvement read more about inspection ratings

Primary Care, Hawstead Road, London, SE6 4JH (020) 7138 7150

Provided and run by:
Novum Health Partnership

Important: We are carrying out a review of quality at Novum Health Partnership. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

11 October 2023

During a routine inspection

We carried out an announced comprehensive inspection at Novum Health Partnership on 11 October 2023. As part of this inspection, we also visited the branch surgery site Baring Road Medical Centre.

Overall, the practice is rated as requires improvement

Safe - inadequate

Effective – requires improvement

Caring - good

Responsive – Requires improvement

Well-led – Requires improvement

Following our previous inspection in March 2016, the practice was rated good overall and requires improvement for providing safe services. We issued an RN for breach of Regulation 12 HSCA (RA) Regulations 2014 Safe care and treatment.

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection in line with our inspection priorities.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. As part of the inspection there was a remote review of clinical records on 10 October 2023, prior to the visit.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A site visit.
  • Reviewing direct feedback from patients and staff.
  • Reviewing recent patient survey data.
  • Obtaining feedback from stakeholders.

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 found that:

  • The practice did not have clear systems, practices and processes to keep people safe.
  • Care and treatment did not always reflect prescribing standards and best practice. For example, records we reviewed showed some patients had not received monitoring in line with current guidance and recommendations.
  • Recruitment checks were not always carried out according to Schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
  • There were gaps in systems to monitor and assess risks related to the health and safety of patients, staff and visitors.
  • The provider could not evidence staff vaccination status. For example, the practice could not demonstrate that staff received the immunisations that are appropriate for their role.
  • Safety alerts were not always managed effectively to keep patients safe.
  • The system to monitor staff mandatory training was not effective. We found gaps in records of staff training.
  • We found Do Not Resuscitate (DNR) decisions had not been documented effectively in patient records. For example, there was no record of decision about Mental Capacity recorded in five patient records we looked at.
  • Patients could not always access care and treatment in a timely way. Improvements to the appointment system were not yet reflected in patient feedback and the practice’s National GP Patient Survey results were below average in some areas.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The overall governance arrangements were ineffective. The practice did not have clear and effective processes for managing risks, issues and performance.

We found breaches of regulations. 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 persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are:

  • Continue with work to improve the uptake rates for childhood immunisations and cervical cancer screening.
  • Continue with action taken to improve patients’ access to the service.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

30 March 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 10 June 2015. Breaches of legal requirements were found such that the safe domain was rated as Requires Improvement. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 12 (1) (2) (a) (b) (g) (h) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this focussed inspection on 30 March 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Rushey Green Group Practice on our website at www.cqc.org.uk.

Overall the practice is now rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

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

Care and treatment for service users was being provided in a safe way as the practice had taken steps to make suitable arrangements for emergency equipment and infection control and prevention.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Rushey Green Group Practice on 10 June 2015. Overall the practice is rated as good.

Specifically, we found the practice was good for providing an effective, caring, responsive and well-led service. The practice was rated requires improvement for providing safe services.

The practice was good for providing services for the six population groups we report on: older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), and people experiencing poor mental health (including people with dementia), and people whose circumstances may make them vulnerable

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, with the exception of those relating to infection control, and medicines management.
  • Data showed patient outcomes were mostly above average for the locality.
  • Audits had been carried out and were driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments.
  • The practice had a number of policies and procedures to govern activity
  • The practice had proactively sought feedback from staff or patients.

We found the following areas of outstanding practice at Rushey Green Group Practice:

  • The practice has supported, from its infancy, the Rushey Green Time Bank, which is a community development time-exchange charity, based at the practice. Older, isolated people particularly find the time bank a useful resource, and participated in various events and activities such as monthly meetings, chair-based exercise sessions, walking group, befriending service and telephone after discharge service.
  • The practice was open 8am – 8pm Monday to Friday and Saturday morning 9am – 12 noon. They told us this equated to one of the longest surgery opening hours in Lewisham. The practice offered long opening hours in response to patient demand.
  • The practice was particularly focussed on the provision of care to meet the needs of patients in vulnerable circumstances. One of the GP partners is the named GP for Lewisham for safeguarding children, and one of the practice GPs is the Substance misuse Lead for the CCG. The practice had registered patients at a male homeless unit, several mental health and neurodisability units, a probation home with patients with significant forensic histories and a home for looked after young people. Two of the practice GPs ran a locality-wide drug and alcohol community detoxification service together with a specialist nurse and a key worker.

The areas where the provider must make improvements are:

  • Ensure infection prevention and control arrangements are in place.
  • Ensure an automated external defibrillator (AED) is in place, or a risk assessment in place outling the justification for not having the equipment in place

In addition the provider should:

  • Ensure there is proper management of prescription pads in the practice

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8th July 2014

During a routine inspection

Rushey Green Group Practice provides GP primary care services to people living in the borough of Lewisham and  is a GP training practice. It has just over 12000 patients registered.

During our visit , we spoke with the GPs, the deputy practice manager, nurses, health care assistant (HCA) and administrative staff. We spoke with eight patients and a representative of the practice’s patient participation group (PPG). Sixteen patients completed comments cards telling us what they thought of the care they had received from the service. 

All the patients were satisfied with the quality of care and support offered by the surgery. The practice had an active patient participation group (PPG) that met bi-monthly and contributed to the annual patient surveys which were carried out.

The practice had a clear vision statement and an accessible leadership team. Staff told us the practice had a supportive open culture and were fully aware of the governance arrangements in place. Staff were well supported in their work and were given protected time for mandatory training each year.

There were processes in place to report significant events and any incidents that occurred at the practice. We saw evidence of learning from incidents and appropriate safeguarding policies and procedures were in place.

Treatment was delivered in line with recognised national guidance including the National Institute for Health and Care Excellence (NICE) and they participated in clinical audits and peer reviews.

The practice demonstrated an understanding of the needs of the local population. However, we found improvements were required to ensure the practice is more responsive to people’s needs, as patients told us they found it extremely difficult to get an appointment at the surgery.