The Care Quality Commission
  • Doctor
  • GP practice

Auckland Surgery

Overall: Good read more about inspection ratings

84a Auckland Road, Upper Norwood, London, SE19 2DF (020) 8653 5146

Provided and run by:
Auckland Surgery

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

All Inspections

14 and 15 December 2022

During a routine inspection

We carried out an announced comprehensive inspection at Auckland Surgery on 14 December 2022. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection in April 2022, the practice was rated requires improvement overall and for key questions effective and well-led but inadequate for the key question safe. Caring and responsive were rated good. A warning notice was served, which required the practice to make improvements in medicines management, monitoring of patients, and staff training.

An announced focused inspection was carried out in July 2022 to check whether the provider

had addressed the issues in the warning notice served following the last inspection. We found that the provider had improved to comply with the regulations and staff were continuing to progress and embed those improvements.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities and to check whether the provider has managed to sustain and build on improvements made since the last inspection.

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.

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 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 found that:

  • The practice was monitoring patients on high risk medicines adequately.
  • The practice was monitoring patients with long-term conditions adequately.
  • There was safeguarding registers in place.
  • Patient Group Directives were being completed correctly.
  • Staff training was being routinely carried out.
  • There was evidence of governance and quality assurance processes in place for patient monitoring, clinical audits, significant events, complaints, safeguarding and patient feedback.
  • Patients told us they received caring and efficient treatment at this practice.
  • Feedback and complaints were responded to in a timely manner.
  • The practice were proactive in implementing improvements and considering feedback.

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

  • Implement systems and processes to link and code families where a safeguarding concern is identified.
  • Take action to safely dispose of out of date emergency medicines in a timely manner.
  • Implement formal, documented reviews of prescribing for non-medical prescribers and ensure all staff are receiving formal supervision in addition to annual appraisals.
  • Continue to consider ways to improve childhood immunisations and cervical screening uptake.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

25 April 2022

During a routine inspection

We carried out an announced inspection at Auckland Surgery on 25 April 2022. Overall, the practice is rated as requires improvement.

Safe - Inadequate

Effective – Requires Improvement

Caring - Good

Responsive - Good

Well-led – Requires Improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Auckland Surgery on our website at www.cqc.org.uk. An inspection on 5 October 2016 rated this service as requires improvement overall with requires improvement in safe and well led and good in effective, caring and responsive. A further inspection on 18 May 2017 found improvements had been made and the practice was rated good in all areas and overall.

Why we carried out this inspection

We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

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 Requires Improvement overall

We found that:

  • The practice was not always monitoring patients on high risk medicines and there were patients at risk of harm.
  • The practice was not always reviewing or monitoring patients with long-term conditions and there were patients at risk of harm.
  • There was no complete safeguarding register being audited by the practice.
  • Some Patient Group Directives had been signed retrospectively.
  • The practice had not acted in response to all safety alerts which had left some patients at risk of harm.
  • The majority of staff had not completed recommended training.
  • There was no clear governance or quality assurance process in place for patient monitoring, clinical audits, significant events, complaints, safeguarding or patient feedback.
  • Patients told us they received caring treatment and interaction at this practice.
  • Feedback and complaints were always responded to in a timely manner.
  • The practice management team were proactive in implementing improvements and considering feedback.

We found two breaches of regulations. The provider must:

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

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 May 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Auckland Surgery on 5 October 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Auckland Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 18 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 5 October 2016. 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 practice had taken action to address on all of the issues identified at the previous inspection.
  • There were effective systems in place for acting on patient safety alerts, monitoring prescription forms, ensuring emergency medicines availability on home visits, and monitoring uncollected test request forms and prescriptions.
  • Patient group directions were in place to allow a nurse to administer medicines in line with legislation.
  • There was support and oversight of all clinicians, including the independent nurse prescribers.
  • There was a system to ensure all staff received an annual appraisal.
  • The practice were taking active steps to monitor and improve its identification and recording of patients with long-term conditions, including Coronary Heart Disease, and to improve the identification of patients with learning disabilities and the support provided to them.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

5 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Auckland Surgery on 5 October 2016. Overall the practice is rated as requires improvement.

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

  • There were arrangements in place for managing risks, but we identified some significant areas of risk that had not been addressed, relating to patient safety alerts, monitoring the collection of prescriptions and test request forms and for managing emergency medicines (including access to emergency medicines on home visits). We brought these to the attention of practice staff, who took swift action and made improvements.
  • Annual appraisals had not been happening consistently. The practice had employed an assistant practice manager and developed a new GP timetable to allow more resource for such activities, and the outstanding appraisals had been scheduled.
  • Two of the nurses had qualified as independent prescribers and could therefore prescribe medicines for specific clinical conditions. There was no specific support for the nurses with independent prescribing responsibilities, to support this extended role.

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named 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.
  • We heard examples of practice staff providing extra support for patients; when following up test results, supporting changes in accommodation or care arrangements or by proving cups of tea in reception or help with taxis.
  • 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.

The areas where the provider must make improvement are:

  • Review the new systems put in place for acting on patient safety alerts, monitoring prescription forms, monitoring of emergency medicines and taking emergency medicines on home visits, and monitoring uncollected test request forms and prescriptions to ensure they are working effectively.

  • Ensure that signed patient group directions are in place to allow the nurse who is not an independent prescriber to administer medicines in line with legislation.

  • Establish a system of support and oversight to ensure that the prescribing of the nurses with independent prescribing responsibilities is within competence and in line with best practice.

  • Ensure that all staff receive an annual appraisal.

The areas where the provider should make improvement are:

  • The practice should continue to monitor and improve its identification and recording of patients with long-term conditions, including Coronary Heart Disease.

  • The practice should consider methods to verify if all of the patients with a learning disability have been identified and recorded, and to ensure that these patient receive an annual health check.  


Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

21 January 2014

During a routine inspection

During this inspection we spoke with the practice manager, a General Practitioner (GP), a nurse practitioner, a receptionist and one person using the service.

The person using the service said the GP's were very understanding and listened to what they had to say. They always had time with the GP or the practice nurse to go through their health issues and discuss and agree appropriate treatment options.

Information had been posted on the practice website advising people about this inspection. Two people contacted the practice with written comments about the practice and another left a letter for the inspector. In the letter to the inspector a couple said they had been patients at the practice for 36 years. In that time they had experienced unfailing courtesy, high standards of professional expertise and genuine interest in their well-being. They said if there was a special excellence award for GP practices that attain the highest standards then this surgery would be in the running.

We saw that the practice had safeguarding policies that related to adults and children. We saw the practice was clean and well maintained throughout. We saw that the practice had effective systems in place to regularly assess and monitor the quality of service that people received.