Cholmley Gardens Surgery

Updated 11 August 2022

Cholmley Gardens Surgery (the practice) operates at 1 Cholmley Gardens, London NW6 1AE. Dr Eric Ansell is the registered provider of the service (the provider), registered with CQC to deliver the following Regulated Activities:

• Diagnostic and screening procedures
• Treatment of disease, disorder or injury
• Maternity and midwifery services
• Family planning

The practice operates within the North Central London Clinical Commissioning Group (CCG) and delivers services under a Personal Medical Services (PMS) contract with NHS England to a patient population of 7,934 listed as at 1 July 2022. The practice is part of the Central Hampstead Primary Care Network (PCN), working closely with four other local practices.

Information published by Public Health England shows very low patient deprivation in the practice population group. The practice area has the second highest decile (ninth out of 10); the lower the decile, the more deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is 73% White, 12% Asian, 5% Black, 5% Mixed, and 4% Other.

The clinical team comprises the provider, who is a GP, three salaried GPs and four regular locum GPs. The team includes both female and male GPs, allowing patients a choice of who they see. There are two practice nurses, a physician’s associate, a pharmacist and a healthcare assistant. A paramedic is shared with other practices within the PCN. There is an administrative team comprising the practice manager, five reception / administration staff and a medical summariser.

The practice operates between 8:00 am and 6:30 pm Monday to Friday. Appointments are available throughout the day. Extended access is provided at the practice each weekday morning between 7:30 am and 8:00 am and on Wednesday evenings between 6:30 pm and 8:00 pm. In addition, one of the two local GP federations provides extended access at four hubs in Camden on weekday evenings between 6:30 pm and 8:00 pm, and from 8:00 am to 8:00 pm at weekends. The practice has opted out of operating an out-of-hours service. Patients contacting the practice when it is closed are connected to the local out-of-hours provider. From October 2022, the practice will operate on Saturdays on a regular basis in a rota with other practices within the PCN.

Updated 11 August 2022

We carried out an announced inspection of Cholmley Gardens Surgery (“the practice”) on 28 July 2022.

We had previously carried out an inspection of the practice in October and November 2021. We rated the practice as Requires Improvement for the key questions Safe and Well-led and we served requirement notices citing breaches of Regulation 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, relating to Safe care and treatment and Good governance. The practice was required to take action to:

• 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.

Our previous inspection reports for the practice can be found on our website at –

https://www.cqc.org.uk/location/1-572590221/reports

The practice later sent us a plan of the action it intended to take to address the breaches of regulations.

Why we carried out this inspection

This was a focused inspection looking into the issues we had identified at our inspection of October and November 2021, to review the action taken by the provider. At this inspection we found the practice had taken appropriate and sufficient action to address the matters we had identified previously and to comply with the notices we had served. Accordingly, we have revised the ratings for the key questions Safe and Well-led, resulting in the overall rating now being Good.

We have rated the practice as Good overall.

The key questions are rated as:

• Are services safe? – Good
• Are services well-led? – Good

We did not review the ratings for the key questions Effective, Caring and Responsive, which were rated Good at our previous inspection.

How we carried out the inspection

Throughout the COVID pandemic CQC has continued to regulate and respond to risk. However, having taken account of the circumstances arising from 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:

• A site visit.
• Conducting staff interviews.
• Reviewing health and safety records and governance documentation.

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.
• Information from the practice, patients, the public and other organisations

We found that:

• The practice’s governance policies, protocols and systems had been reviewed and revised, as necessary, and new ones had been introduced.
• Work on reviewing the practice’s patient list to ensure its accuracy had been completed.
• The practice was able to provide evidence that all staff members had received mandatory training appropriate to their roles and responsibilities.
• Health and Safety, Fire and Legionella risk assessments had been conducted, appropriate action had been taken to mitigate risks, and management plans had been introduced.
• The Patient Participation Group had been re-established. Work on revising the practice website was complete and the practice had introduced its own patient survey to obtain feedback to drive improvement.

The practice should:

• Continue with efforts to improve the uptake rates for childhood immunisations and cervical cancer 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