The Care Quality Commission
  • Doctor
  • GP practice

O'Flynn - Hampton Wick Also known as Hampton Wick Surgery

Overall: Requires improvement read more about inspection ratings

Tudor House, 26 Upper Teddington Road, Kingston Upon Thames, Surrey, KT1 4DY (020) 8977 2638

Provided and run by:
O'Flynn - Hampton Wick

Important: We are carrying out a review of quality at O'Flynn - Hampton Wick. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

24 November 2022

During a routine inspection

We carried out an announced comprehensive inspection at O’Flynn Hampton Wick on 22 and 24 November 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - requires improvement

Well-led - requires improvement

Following our previous inspection on 28 March 2022, the practice was rated inadequate overall and for the safe, effective and well-led key questions. This resulted in breaches of regulations 12 and 17. We asked the provider to make improvements regarding the following areas:

  • The practice was not monitoring all patients on high risk prescription medicines as required.
  • The practice was not reviewing or monitoring all patients with long-term conditions.
  • Medication reviews were not always completed.
  • The practice had no system in place to complete scheduled MHRA searches of its patients
  • There were no premises risk assessments or health and safety checks or audits carried out or completed.
  • There was no effective system for identifying, monitoring or communicating internally about vulnerable patients or safeguarding concerns.
  • There were no consistent detailed minutes or records of clinical meetings being held between clinical staff.
  • There were no records or audits of staff surveys.
  • There were no audits or records of patient survey analysis or feedback.
  • There were no audits of complaints and some complaints had not been recorded as having had a response.
  • Some staff did not have recruitment checks in place.
  • Staff told us that there were not enough staff to cope with the administration of the practice.
  • Many clinical and non-clinical staff had failed to complete recommended training.
  • Staff did not know how to safely use the clinical record system.
  • There was poor governance of the entire service and little or no assurance of processes or systems had been completed.

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

Why we carried out this inspection

We carried out this inspection to follow up concerns and breaches of regulations 12 and 17 from our last inspection in March 2022.

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 had a system in place to monitor and action safety alerts but it was not completely robust or effective.
  • The practice was not always monitoring all patients on high risk prescription medicines as required.
  • The practice was not always reviewing or monitoring all patients with long-term conditions.
  • The practice retained records for all of its patients with do not attempt resuscitation (DNARs). However, the practice did not have records of the mental capacity assessments or best interests considerations.
  • The practice was still improving its access for patients.
  • There were premises risk assessments and health and safety checks audits carried out and completed.
  • There was an effective system for identifying, monitoring or communicating internally about vulnerable patients or safeguarding concerns.
  • There were consistent, detailed minutes of clinical meetings being held between clinical staff.
  • There were records and audits of staff and patient surveys, feedback and complaints.
  • Recruitment checks had been completed for all staff.
  • All staff had completed recommended training.
  • Staff knew how to safely use the clinical record system.
  • There was organised governance of the entire service with assurance processes and systems in place.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The way the practice was led and managed promoted a caring culture.

We found a breach of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.

The provider should:

  • Improve its record keeping concerning mental capacity assessments and best interest considerations for patients who lack capacity.
  • Continue to improve its cancer screening statistics.

This service was placed into special measures following the last inspection in March 2022. The service made sufficient improvements so that it will now be taken out of special measures.

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

20 May 2022

During an inspection looking at part of the service

We carried out an announced inspection at Hampton Wick O’Flynn on 20 May 2022.

Why we carried out this inspection

This inspection was undertaken to confirm that the practice had carried out their plan to meet the legal requirements set out in warning notices we issued to the provider in relation to regulation 12 Safe care and treatment and regulation 17 Good governance.

At the last inspection in April 2022 we rated the practice as Inadequate overall. This will remain unchanged until we undertake a further full comprehensive inspection.

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:

  • 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 provider had mostly complied with the warning notices we issued and had taken the action needed to comply with the legal requirements.
  • We found that patients who were treated with medicines that required additional monitoring had received, or were due to receive the appropriate blood tests and follow up in line with safe prescribing guidelines.
  • The practice had reviewed and improved systems to manage patient safety alerts. Records we checked showed that alerts were actioned appropriately.
  • The practice had reviewed and improved their systems to manage patients with long term conditions.
  • The practice had reviewed and improved processes to effectively manage recruitment files and staff training information.
  • The provider had reviewed systems to ensure relevant premises risk assessments were being completed and necessary actions being taken.
  • The provider was able to demonstrate that all staff had the skills, knowledge and experience to carry out their roles and they had implemented a system to provide clinical supervision to non-medical prescribers.
  • The provider had reviewed and improved systems to manage complaints and demonstrated complaints had been responded to appropriately.
  • The provider had reviewed governance arrangements and implemented new governance processes and structures to enable them to deliver safe and effective care. Where we identified that processes had not been fully embedded, we discussed these with the provider during the inspection.
  • The provider had correctly coded all relevant patients with do not attempt cardiopulmonary resuscitation (CPR) codes but still needed to ensure all forms were compliant with legislation and best interests for patients who lacked capacity.

Whilst we found no breaches of regulations. The provider should:

  • Continue to review, improve and embed newly implemented systems and processes. For example, systems to manage staff information, high risk medicines and the coding of records.
  • Ensure all staff have completed equality and diversity training
  • Ensure that all do not attempt CPR forms are compliant with legislation and consider patient best interests if they lack capacity.

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

28 March 2022 and 1 April 2022

During a routine inspection

We carried out an unannounced inspection at O'Flynn Hampton Wick on 28 March 2022 and completed staff interviews and evidence collection until 1 April 2022. Clinical records reviews were carried out remotely on 28 March 2022. Overall, the practice is rated as Inadequate.

Safe - Inadequate
Effective - Inadequate
Caring - Good
Responsive - Requires Improvement
Well-led - Inadequate

The full reports for previous inspections can be found by selecting the ‘all reports’ link for O'Flynn Hampton Wick on our website at www.cqc.org.uk.

Why we carried out this inspection
This inspection was a responsive comprehensive inspection to follow-up on concerns identified during our inspection of another service on the same premises on 16 March 2022.

How we carried out this 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 Inadequate overall

We found that:

  • The practice was not monitoring all patients on high risk prescription medicines as required.
  • The practice was not reviewing or monitoring all patients with long-term conditions.
  • Medication reviews were not always completed.
  • The practice had no system in place to complete scheduled MHRA searches of its patients
  • There were no premises risk assessments or health and safety checks or audits carried out or completed.
  • There was no effective system for identifying, monitoring or communicating internally about vulnerable patients or safeguarding concerns.
  • There were no consistent detailed minutes or records of clinical meetings being held between clinical staff.
  • There were no records or audits of staff surveys.
  • There were no audits or records of patient survey analysis or feedback.
  • There were no audits of complaints and some complaints had not been recorded as having had a response.
  • Some staff did not have recruitment checks in place.
  • Some staff had not had appraisals.
  • Competency checks had not been completed for all staff.
  • Staff told us that there were not enough staff to cope with the administration of the practice.
  • Many clinical and non-clinical staff had failed to complete recommended training.
  • Staff did not know how to safely use the clinical record system.
  • There was poor governance of the entire service and little or no assurance of processes or systems had been completed.

We found breaches of regulations. The provider must:
• Ensure care and treatment is provided in a safe way to patients.
• Ensure that patients' assessments, care and treatment are provided effectively.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

27 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at O’Flynn – Hampton Wick also known as Hampton Wick Surgery on 27 September 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 with the exception of the storage of emergency medicines.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with 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. 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.
  • 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 should make improvement are:

  • Update and review practice policies and procedures at regular intervals.

  • Review storage facilities for emergency medicines or undertake a suitable risk assessment to demonstrate that all potential risks have been considered and mitigated against.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice