Background to this inspection
Updated
7 December 2018
The Ashchurch Medical Centre is situated within the London Borough of Hammersmith and Fulham. The practice is part of the Hammersmith and Fulham Clinical Commissioning Group (CCG) and is a member of the GP locality group, Network One. The practice is located at 134 Askew Road, Shepherds Bush W12 9BP. Website:
The practice operates from a converted three storeys building owned and managed by the lead GP partner. There are four consultation rooms and a reception and waiting area on the ground floor of the premises and administration offices on the upper floors. There is wheelchair access to the entrance of the building and toilet facilities for people with disabilities.
The practice provides primary medical services to approximately 4,987 patients and holds a General Medical Services Contract and Directed Enhanced Services Contracts. The enhanced services provided include chronic disease management, maternity care and health checks for patients 45 years plus. Health promotion services include, cervical screening, childhood immunisations, contraception and family planning.
The practice population is ethnically diverse and has a lower than the national average number of male and female patients between 5 and 19 years of age and higher than the national average number of patients 25 to 54 years of age. There is a higher than the national average number of patients 65 years of age plus. The practice area is rated in the fourth more deprived decile of the national Index of Multiple Deprivation (IMD). People living in more deprived areas tend to have greater need for health services.
The practice team comprises of two GP partners; one male and one female, one female salaried GP and one male long-term locum GP, who collectively work a total of 22 clinical sessions a week. They are supported by a practice nurse who works three days a week, a practice manager and four administration/reception staff.
The opening hours in the morning are 8.30am to 1pm Monday, Tuesday, Thursday and Friday and 8.30am to 1.30pm Wednesday and in the afternoon from 3pm to 6:30pm Monday, Tuesday and Friday and 1.30pm to 6.30pm on Wednesday. Appointments in the morning are from 8.30am to 11.40am Monday to Friday and in the afternoon from 3:20pm to 5:50pm Monday, Tuesday and Friday and 1:30pm-5:50pm on Wednesday. Telephone consultations are offered daily and bookable appointments can be booked two weeks in advance. Urgent appointments are available for patients who need them. Patients can access extended hours pre-bookable appointments Monday to Friday and on Saturday and Sunday at other GP practices within NHS Hammersmith & Fulham CCG.
The practice is registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury.
Updated
7 December 2018
This practice is rated as requires improvement overall.
The practice was previously inspected on 10 October 2017. At that inspection the rating for the practice was good overall. This rating applied to the safe, caring, responsive and well led domains. Effective was rated as requires improvement.
The 2017 report stated where the service must make improvements:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
In addition, there were areas identified where the provider should make improvement:
- Review the storage arrangements of environment cleaning equipment and consider an independent external led Infection and prevention control review.
- Consider installing an independent thermometer to confirm accuracy of the vaccine fridge temperature.
- Implement a tracking system to monitor the use of blank prescription pads.
- Continue to monitor and improve Quality and Outcomes Framework performance.
- Continue to encourage the uptake of childhood immunisations.
- Continue to encourage the uptake of the cervical screening programme to eligible women.
We carried out an announced comprehensive inspection at Ashchurch Medical Centre on 10 October 2018 to follow up on breaches of regulations.
At this inspection the key questions are rated as:
Are services safe? – Requires improvement
Are services effective? – Requires improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? – Requires improvement
At this inspection we found:
- The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, there was no system in place to ensure that all staff were aware of the learning outcomes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
The areas where the provider
must
make improvements as they are in breach of regulations are:
- Ensure care and treatment is provided in a safe way for patients.
- Ensure that learning from incidents, safeguarding and complaints is shared with all staff within the team.
The areas where the provider
should
make improvements are:
- Review staff training system to ensure staff are up-to-date with training requirements.
- Continue to monitor prescription stationary to ensure they are maintained securely.
- Provide all members of staff with a copy of team meeting minutes to ensure they are aware of developments within the service.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice