The Care Quality Commission
  • Doctor
  • GP practice

Suthergrey House Medical Centre

Overall: Good read more about inspection ratings

37a St Johns Road, Watford, Hertfordshire, WD17 1LS (01923) 224424

Provided and run by:
Suthergrey House Medical Centre

All Inspections

28/11/2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Suthergrey House Medical Centre on 28 November 2019 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: Safe, Effective and 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 good overall. We rated the practice as requires improvement for providing Well-Led services. We rated the population group people with long-term conditions as requires improvement. We rated the other population groups as good.

We rated the practice as requires improvement for providing Well-Led services because:

  • Overall QOF scores were lower than expected compared to the CCG and England averages. These were more evident in relation to the monitoring of people with long term conditions. While interventions made had shown improvements to clinical quality, the practice had not developed systems to continually monitor clinical data and staffing, so sustained improvements in line with CCG and England averages could be demonstrated.
  • Overall exception reporting was lower than the CCG and England averages. The practice needed to implement systems to understand the impact of exception reporting (now replaced in 2019/20 with Personalised Care Adjustment (PCA)) on the overall QOF scores.
  • The cervical cancer screening uptake was lower than expected compared to CCG and England averages.
  • Some policy documents we saw needed a review and amendments.
  • The practice had not developed systems to demonstrate the efficacy of measures implemented to try and improve patient satisfaction.

We rated the population group people with long-term conditions in the effective domain as requires improvement because:

  • Clinical outcomes for this population group were lower than expected compared to CCG and England averages.

We found that:

  • 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 organised and delivered services to meet patients’ needs. However, patients reported they could not always 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. However, the practice needed to introduce systems to continually monitor clinical data and staffing so sustained improvements in line with CCG and England averages could be demonstrated.

We found the following areas where the provider must improve:

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

We found the provider should:

  • Complete the updating of the spreadsheet of safety alerts received and acted upon.
  • Implement systems to understand the impact of exception reporting (now replaced in 2019/20 with Personalised Care Adjustment (PCA)) on the overall QOF scores.
  • Act to achieve the 95% WHO based target for childhood immunisations.
  • Act to achieve the cervical cancer screening 80% national programme coverage measure set by Public Health England.

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

18 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Suthergrey House Medical Centre on 18 January 2017. The overall rating for this service is good.

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

  • The practice was aware of and provided services according to the needs of their patient population.
  • Risks to patients were assessed and well managed.
  • Patients told us they were treated with dignity and respect and that they were fully involved in decisions about their care and treatment.
  • There were processes and procedures to keep patients safe. These included a system for reporting and recording significant events, keeping these under review and sharing learning where this occurred. However, reported accidents should be reviewed to identify any changes to practise and potential learning opportunities.
  • The practice was aware of the requirements of the duty of candour and systems were ensured compliance with this.
  • Staff received regular training and skill updates to ensure they had the appropriate skills, knowledge and experience to deliver effective care and treatment.
  • Regular meetings and discussions were held with staff and multi-disciplinary teams to ensure that patients received the best care and treatment in a coordinated way.
  • There was a clear leadership structure and staff told us they felt supported by management.
  • There was a culture of openness and accountability.
  • The practice had an active Patient Participation Group (PPG). The PPG was proactive in representing patients and assisting the practice in making improvements to the services provided.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about services and how to complain was available and patients told us that they knew how to complain if they needed to.

However, the area where the provider should make improvement is:

  • Take action to ensure that all accidents are reviewed so that all learning opportunities are maximised.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

4 February 2014

During a routine inspection

During our inspection we spoke with seven patients and six members of staff.

When patients received care or treatment they were asked for their consent and their wishes were listened to. One patient told us: "Yes. On the odd occasion I have just checked with them before saying yes". We found that when minor surgery had been carried out that written consent had been requested from patients before the surgery had commenced.

We saw that patients' views and experiences were taken into account in the way the service was provided and that they were treated with dignity and respect. The patients we spoke with provided positive feedback about their care. A patient told us: "It's very good. it's not a problem". Patients received their medicines when they needed them.

Staff had received training in safeguarding children and vulnerable adults. They were aware of the appropriate agencies to refer safeguarding concerns to that ensured patients were protected from harm.

We found that staff had received appropriate training for the roles they carried out. They also had regular appraisals. This meant that they had been adequately assessed regarding their competency.

The provider had an established system in place for monitoring the quality of service provision. There was an established system to regularly obtain opinions from patients about the standards of the services they received. This meant that on-going improvements could be made by the practice staff.