All inspections: North Fulham Surgery - Care Quality Commission

We carried out a review of the data available to us about North Fulham 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 North Fulham Surgery, you can give feedback on this service.

We carried out an announced focused review at North Fulham Surgery on 30 September 2022. Overall, the practice is rated as Good.

Safe - Not inspected, rating of good carried forward from previous inspection

Effective - Good

Caring – Not inspected, rating of good carried forward from previous inspection

Responsive – Not inspected, rating of good carried forward from previous inspection

Well-led – Not inspected, rating of good carried forward from previous inspection

Following our previous inspection in June 2021, the practice was rated good overall and the safe, caring, responsive and well-led led questions and requires improvement for providing effective services.

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

Why we carried out this inspection

This was a focused review of information without undertaking a site visit inspection to follow up on the concerns identified at our inspection in June 2021 regarding the effective key question. At the last inspection we found:

The percentage of patients with chronic obstructive pulmonary disease (COPD) that had a review with a healthcare professional within the last 12 months was significantly below the local and national averages. In addition, performance for two indicators relating to hypertension was below the local and national averages.
The uptake for childhood immunisations was significantly below the local and national averages. The practice had not met the minimum 90% for all five childhood immunisation uptake indicators. The practice had not met the WHO based national target of 95% (the recommended standard for achieving herd immunity) for all five of the childhood immunisation uptake indicators.
The uptake for cervical screening was significantly below the national average.

We followed up on ‘should’ actions identified at the last inspection, specifically:

Continue to take action to improve childhood immunsiations and cervical screening uptake rates.
Continue to take action to improve outcomes for patients with COPD and hypertension.

How we carried out the review

This review was carried out without visiting the location by requesting documentary evidence from the provide and conducting staff interviews using video conferencing.

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 made the necessary improvements to the delivery of care to ensure the effective provision of services. The practice had undertaken projects to review and improve the percentage of patients with chronic pulmonary disease (COPD) that had a review with a healthcare professional within the last 12 months, improve the management of patients with hypertension, and improve the uptake of childhood immunisations and cervical screening.

In particular:

The practice had focused on improving the number of COPD patients reviewed and was projected to meet its targets for reviews in 2022 to 2023. The practice had arranged for training of the clinical team by a consultant respiratory physician and planned to arrange a repeat of this training for the whole clinical team.
The practice had focused on improving hypertension management and was projected to meet its targets in 2022 to 2023. The practice had provided blood pressure monitors to at risk patients during the Covid-19 pandemic for home monitoring. The practice had a process for managing patients with high blood pressure and liaised with its pharmacy team for the future management of these patients. The practice utilised remote systems for patients to share their blood pressure readings by using text responses. The practice planned to evaluated patients who were provided with home blood pressure monitors to review the effectiveness of this intervention.
Whilst the practice had not met the minimum 90% uptake for all of the childhood uptake indicators and had not met the WHO based national target of 95% (the recommended standard for achieving herd immunity) for these indicators, it had put in place a recovery plan to improve the uptake of childhood immunisations. Data provided by the practice demonstrated an improvement in relation to childhood immunisation rates. The practice had liaised with the Primary Care Network (PCN) and had put in place a single immunisations dashboard to reduce the number of searches completed on a weekly basis. The practice had a process for contacting parents and guardians to make appointments for immunisations and a method of escalation if attempts were not successful. The practice monitored rates of immunisation at its weekly management meetings and recorded discussion in the minutes of these meetings.
Whilst the uptake of cervical screening remained below the national average, there was an improvement in uptake (from 59.5% at our last inspection to 66.6%). The practice had put in place a cervical screening record plan and quality improvement project since and provided us with data which demonstrated an improvement in uptake. The practice told us that it was projected to meet the national target by the end of the 2022 to 2023 financial year. The practice discussed the screening programme at its weekly management meeting, where monitoring of live numbers of screening was undertaken. The practice had worked with the West London Cancer Alliance and Jo’s Cervical Cancer Trust to review its approach and to make improvements. The practice liaised with and shared good practice amongst other practices in the PCN.

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

Continue to provide training for staff in relation to COPD management.
Continue with its plans to improve management of COPD, hypertension and improve uptake of childhood immunisations and cervical screening.

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

We carried out an announced inspection at North Fulham Surgery on 3, 10 and 22 June 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Requires Improvement

Caring - Good

Responsive – Good

Well-led - Good

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

Why we carried out this inspection

We had previously inspected the practice in September 2019, we rated the practice as inadequate overall and placed the practice into special measures. We served Warning Notices for breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

On January 30 2021, we inspected the practice to ensure the practice was complaint with the warning notices issued for regulations 12 and 17. The practice rating was not reviewed during this inspection. We found that the practice made improvements and was compliant with the issues set out in the warning notices. However, we identified new areas for improvement and issued a requirement notice breaches of Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The inspection conducted on 3, 10 and 22 June 2021 took place to review the ratings of the practice and determine whether the practice could be removed from special measures. We found no areas of significant concern during this 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:

Conducting staff interviews using video conferencing
Completing clinical searches on the practice’s patient records system and discussing findings with the provider on 3 June 2021
Reviewing patient records to identify issues and clarify actions taken by the provider
Requesting evidence from the provider
Short site visits on 10 and 22 June 2021

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 and for all population groups. We found that:

When something went wrong, there was an appropriate, thorough review that involved all relevant staff. Lessons were learned and communicated to support improvement.
Action had been taken since our January 2021 to address the breaches of regulation identified in the Requirement Notice issued for Regulation 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
Although the practice’s performance for childhood immunisations and cervical screening was lower than the national targets we were assured that the practice had plans in place to address the low uptake rates.
Services were planned and delivered in a way that met the needs of the local population. For example, in house phlebotomy services were maintained throughout the pandemic and a walking group was created to ensure patients were not isolated.
Patient satisfaction was in line with national targets and significantly above targets for some areas. For example, 90.8 percent of patients found it easy to contact the practice by telephone compared to the national average of 67.6 percent.
Leadership, governance and practice management arrangements promoted the delivery of high-quality, person-centred care.

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

Continue to take action to improve childhood immunisations and cervical screening uptake rates.
Continue to take action to improve outcomes for patients with COPD and hypertension.

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

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Dr Rosie Benneyworth BM BS BMedSci MRCGP Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced focused inspection at North Fulham Surgery on 30 January 2020 as part of our inspection programme.

At this inspection we followed up on breaches of regulations identified at the previous inspection on 17 September 2019. Following the September 2019 inspection, the practice was rated as Inadequate overall, in safe, effective and well led domains and in all patient populations and placed in special measures. The practice was rated as good in the caring domain and requires improvement in responsive. We issued warning notices for breaches of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). The practice was required to address these concerns by 27 December 2019 and submitted an appropriate action plan prior to this date.

We did not review the ratings awarded to this practice at this inspection.

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.

At this inspection we found:

We found the provider had made some improvements in providing safe services regarding:

Safeguarding processes and DBS checks for clinical staff.
The practice had appropriate systems in place for the safe management of medicines.
A fail-safe system to monitor and manage patient safety alerts.
The safe management of its prescriptions system.
Cold chain in relation to the safe refrigeration of vaccines.
The implementation and oversight of a safe effective system to monitor and manage emergency medicines and equipment.
The instigation and oversight of a safe effective system to monitor and manage recruitment.
Receptionists had been given guidance on identifying deteriorating or acutely unwell patients. They were aware of actions to take in respect of such patients.
The practice learnt and made improvements when things went wrong.

We found the provider had not made sufficient improvements in providing safe services regarding:

A fail-safe system to monitor and manage patients who had been referred via the urgent two week-wait referral system.
A fail-safe system in place to safely manage and monitor cervical smear screening.
Infection prevention and control practices.

We found the provider had made improvements for providing effective services regarding:

All staff had completed regular training regarding infection control, basic life support, fire safety and information governance.
Clinical supervision for the practice nurse, clinical pharmacist and healthcare assistant.

We found the provider had not made sufficient improvements for providing effective services regarding:

Core specific training for the practice nurse and healthcare assistant.

We found the provider had made some improvements to concerns we found in the well led domain.

We will comprehensively review the effectiveness of the practice’s action plans at the next inspection.

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.

The areas where the provider should make improvements are:

Ensure its register of staff immunisations is completed in line with national guidance.

The service will remain in special measures until we have undertaken the next inspection and this will be reviewed at that time. This 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 judgements are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at North Fulham Surgery on 17 September 2019 as part of our inspection programme.

We inspected this practice on one previous occasion, on 3 October 2014, and the practice was rated as good overall. We rated four domains: safe, well led, effective and caring and all patient population groups as good. Responsive domain was rated as outstanding.

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, well led, caring and responsive.

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, including all population groups, overall.

We rated the practice as inadequate for providing safe services because:

The practice did not have clear systems and processes to keep patients safe.
The practice did not have reliable systems and processes to keep patients safeguarded from abuse.
The provider did not have safe practices regarding emergency medicines and equipment.
The practice did not have reliable infection prevention and control practices in place.
The practice did not maintain adequate records to monitor and manage the cold chain effectively.
The practice did not have complete fire safety systems in place.
The practice did not have reliable systems in place to manage the practice premises safely.
The practice did not have appropriate systems in place for the safe management of medicines.
The practice did not always learn and make improvements when things went wrong.

We rated the practice as inadequate for providing effective services because:

There was limited monitoring of the outcomes of care and treatment.
The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
The practice was unable to show that it always obtained consent to care and treatment.
Some performance data was significantly below local and national averages.

This area affected all population groups; so, we rated all population groups in the effective domain as inadequate.

We rated the practice as inadequate for providing well-led services because:

Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
The practice did not have safe systems regarding the management of patients on high-risk medicines.
The practice did not have a fail-safe system regarding patient safety alerts.
The practice did not have clear and effective processes for managing risks, issues and performance.
The practice did not have an appropriate fail-safe system in place for the safe management of patients who had been referred via the two-week wait urgent referral system.
The practice did not have an appropriate fail-safe system in place to monitor and manage cervical screening for female patients.
The practice did not have an appropriate fail-safe system in place to monitor and manage prescriptions safety.
The provider did not have a safe or effective recruitment system in place.
While the practice had a clear vision, that vision was not supported by a credible strategy.
The practice culture did not effectively support high quality sustainable care.
The overall governance arrangements were ineffective.
The practice did not always act on appropriate and accurate information.
We saw limited evidence of systems and processes for learning, continuous improvement and innovation.

We rated the practice as good for providing caring services because:

Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as requires improvement for providing responsive services because:

Patients could access care and treatment in a timely way.
The provider could not demonstrate their system for dealing with complaints was sufficient. Complaints were not responded to promptly and appropriate information including responsive timescales and a patient’s right to review was promoted and available in the practice premises.

This area affected all population groups; so, we rated all population groups in the responsive domain as requires 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.

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

Letter from the Chief Inspector of General Practice

The Surgery – 82 Lillie Road provides primary medical services to approximately 7,500 patients in Fulham, in the London borough of Hammersmith and Fulham. This is the only location operated by this provider.

We visited the practice on 3rd October 2014 and carried out a comprehensive inspection of the services provided.

We rated the practice as 'Outstanding‘ in the responsive domain and Good’ in the other four domains we inspected - safe, effective, caring, and well-led. We also rated them ‘Good’ for the care provided to all six population groups we looked at including older people, people with long-term conditions, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia)

Our key findings were as follows:

Arrangements were in place to ensure patients were kept safe. The practice learnt when things went wrong and shared learning with all staff to minimise the risk of reoccurrence
Patients’ needs were suitably assessed and care and treatment was delivered in line with current legislation and best practice.
We saw from our observations and heard from patients that they were treated with dignity and respect.
The practice understood the needs of their patients and was provided services that met their needs.
The practice was well-led, had a defined leadership structure and staff felt supported in their roles.
Pre-bookable Saturday morning appointments were available for patients who may have difficulty attending during weekday opening hours
GP’s at the practice attend the local Multi-Agency Safeguarding Hub (MASH) to improve the safeguarding response for children and vulnerable adults through better information sharing and timely safeguarding responses

We saw areas of outstanding practice including:

The practice was open from 7 .00am to 7.30pm Mondays and Thursday, 7.00am to 5.00pm on Fridays and from 8.30am to 11.30am on Saturdays.
The practice had a community psychiatric nurse based there once a week to manage care plans of patients experiencing poor mental health including medication reviews.
The practice facilitated patients’ access to the local Improving Access to Psychological Therapies (IAPT) programme and sign-posted patients to various support groups and organisations including MIND.

However, there were also areas of practice where the provider should make improvements:

The practice should ensure that all staff who are required to chaperone patients receive the appropriate training.

The practice should ensure that all non-clinical staff receives training in safeguarding adults.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

North Fulham Surgery

All Inspections

6 July 2023

During a monthly review of our data

30 September 2022

During an inspection looking at part of the service

3 June 2021, 10 June 2021, 22 June 2021.

During a routine inspection

30 January 2020

During an inspection looking at part of the service

17 September 2019

During a routine inspection

3rd October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)