The Care Quality Commission
  • Doctor
  • GP practice

Hartland Way Surgery

Overall: Good read more about inspection ratings

1 Hartland Way, Shirley, Croydon, Surrey, CR0 8RG (020) 8777 7215

Provided and run by:
Hartland Way Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Hartland Way Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Hartland Way Surgery, you can give feedback on this service.

08 July 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Hartland Way Surgery on 8 July 2022 and a remote clinical review on 4 July 2022 to follow-up on breaches of regulations. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Well-led - Good

Following our previous inspection on 19 May 2021, the practice was rated as Requires Improvement overall (requires improvement in safe, effective and well-led) for issues in relation to recruitment checks, safety systems and records, infection prevention and control, medicines management, identifying patients with commonly undiagnosed conditions, uptake for childhood immunisations and cervical screening and effective staffing.

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

How we carried out the inspection/review

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

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 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.

Whilst we found no breaches of regulations, the provider should:

  • Address all the issues found during the infection prevention and control audit and fire risk assessment and undertake fire drills regularly.
  • Improve monitoring of expiry dates of medicines.
  • Maintain signed DNACPR form in patient records.
  • Review and improve access arrangements in response to patient feedback.
  • Improve staff awareness of freedom to speak up guardian.

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

19 May 2021

During an inspection looking at part of the service

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 remote clinical searches on the practice’s patient records system and discussing findings with the provider
  • Remotely reviewing a selection of patient records to identify issues and clarify actions taken by the provider
  • Requesting documentary evidence from the provider
  • A short site visit

We carried out an announced focused inspection at Hartland Way Surgery on 19 May 2021 and a remote clinical review on 17 May 2021 to follow up on breaches of regulations.

The practice was previously inspected on 13 November 2019. Following that inspection, the practice was rated as requires improvement overall (requires improvement in safe, effective and well-led) for issues in relation to recruitment checks, health and safety checks, fire safety checks, medicines management, management of significant events, staff training and governance arrangements.

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 rated the practice as requires improvement for providing safe services.

At this inspection, we found the provider had made some improvements in providing safe services. In particular, the provider had made improvements to their systems and process in relation to health and safety risk assessments, significant events and medicines management. However, we found new issues in relation to medicines management and the provider had not actioned some of the issues found in their infection prevention and control audit which were actions identified in their last inspection.

We rated the practice as requires improvement for providing effective services.

At this inspection, we found the provider had made some improvements in providing effective services. In particular, the provider had made improvements to their systems and processes in relation to staff training and quality improvement. However, we found the provider did not have an effective system to identify patients with commonly undiagnosed conditions, for example diabetes. Their uptake for childhood immunisations and cervical screening were below average and the provider could not demonstrate the prescribing competence of the pharmacist.

We rated the practice as requires improvement for providing well-led services.

We found the provider had made improvements in providing well-led services in relation to good governance and had implemented systems and process in response to the findings of our previous inspection. However, governance arrangements in place still required improvement especially in relation to identifying, managing and mitigating risks.

We have rated this practice as requires improvement overall and requires improvement for population groups people with long-term conditions and families children and young people.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with fundamental standards of care.

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

The areas where the provider should make improvements are:

  • Improve practice process for recruitment checks.
  • In consultation with the local fire safety team, implement fire drills or suitable alternatives.
  • Improve recording of discussions in meetings.

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

13 Nov 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Hartland Way Surgery on 13 November 2019 as part of our inspection programme. The provider was rated overall as good during our last inspection in May 2016.

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

  • Safe
  • Effective
  • 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 and requires improvement for population groups people with long-term conditions, families, children and young people and working age people.

We found that:

  • The systems and processes in place to keep patients safe required improvement. For example: the practice did not have a robust system in place to manage recruitment, safety systems, infection prevention and control, medicines management and safety alerts.
  • Patients received effective care and treatment that met their needs; however, some of the staff had not completed training appropriate to their role. Uptake of childhood immunisations and cervical screening were below average.
  • The practice was involved in quality improvement activities; however, they did not demonstrate improved outcomes for patients.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care. However, governance arrangements in place required improvement.

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.

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

The areas where the provider should make improvements are:

  • Review procedures in place to demonstrate improved outcomes for patients.
  • Consider providing equality and diversity training for staff.
  • Review procedures in place to appropriately code medicine reviews in the patient management system.
  • Consider ways to improve uptake for cervical screening and childhood immunisations.
  • Review reception and clinical staffing levels in response to staff feedback.

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

17 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hartland Way Surgery on 17 May 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 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.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that 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.

We saw one area of outstanding practice

  • The practice had an in-house pharmacist who was trained as a clinical associate; they ran regular medicines review clinics for patients with long term conditions and also reviewed medicines for patients who had unplanned admissions to ensure safe prescribing. We saw evidence of many cases where the pharmacist had challenged the prescription of medicines from secondary care and had changed them as a result. We also saw evidence that the prescribing of medicines in general was below average when compared to other practices in the local Clinical Commissioning Group (CCG) for example their prescription of antibiotics was below average.

There were areas of practice where the provider should make improvements:

  • Review arrangements in place for monitoring of refrigerator temperatures to ensure staff take appropriate action when temperature is outside of the accepted range.
  • Review arrangements in place to ensure that carers are identified so they can be given the support they need.
  • Review arrangements in place to ensure that all staff have all mandatory training including basic life support.
  • Review the complaints procedure to ensure it contains all the relevant information for patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

22 January 2014

During a routine inspection

During the inspection we spoke with seven patients who use Hartland Way Surgery. We spoke with the three partners at the practice which included two GPs and a pharmacist who worked as a clinical associate. We also met with the practice manager, a medical student and four administrative staff.

All of the patients we spoke with were positive about the practice and the care and treatment that they received. They told us, 'They look after me very well', 'All the doctors are very good here', 'I'm very happy here, the receptionists are lovely, they greet you by your name.'

We saw that staff were polite and attentive when people arrived at the practice and when arranging appointments with people over the telephone.

Records we looked at showed that people who used the practice were involved in any decisions regarding their treatment.

All areas of the practice appeared clean, tidy and hygienic and there were effective systems in place to prevent and control infection.

We found that staff were supported and received appropriate training to help them deliver care to people accessing the practice. We met with a medical student who told us they'd had a 'fantastic experience at this GP.' The people we met described the doctors as 'excellent' 'very good, he always explains the treatment' and 'experienced and capable.'

Effective quality monitoring systems were in place at the practice. There were opportunities for patients and staff to express their views on the quality of the service provided and these were acted on.