The Care Quality Commission
  • Doctor
  • GP practice

Cholmley Gardens Surgery

Overall: Good read more about inspection ratings

1 Cholmley Gardens, London, NW6 1AE (020) 7794 6256

Provided and run by:
Dr Eric Ansell

All Inspections

6 July 2023

During a monthly review of our data

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

28 July 2022

During an inspection looking at part of the service

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

19 October 2021 and 9 November 2021

During a routine inspection

We carried out an unannounced inspection visit at Cholmley Gardens Surgery (the practice) on 19 October 2021 and a further announced visit on 9 November 2021.

Overall, the practice is rated as Requires improvement

Safe – Requires improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led – Requires improvement

Following our previous inspection on 17 November 2016, the practice was rated Good overall and for all key questions. The full reports for previous inspections can be found on our website at –

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

Why we carried out this inspection

This was a comprehensive inspection carried out in response to us receiving information of concern. This was principally relating to patients’ access to the service and the availability of clinical staff, which we established to be unfounded.

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:

  • An initial site visit
  • 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 practice
  • Requesting evidence from the practice
  • A further 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 practice, patients, the public and other organisations

We found that:

  • Leaders had identified where improvements were needed and had taken action to address concerns. However, the process was continuing, and the changes made need to be sustained and embedded and the improvement needs to be maintained.
  • The practice’s governance policies and protocols were in the process of review.
  • Work on revising the practice’s patient list to ensure its accuracy was ongoing.
  • The practice could not provide sufficient 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 carried out, but there was limited evidence of action being taken to address all the issues identified.
  • The practice worked well with other agencies to provide patients with co-ordinated and effective care, which met their needs.
  • Feedback from the national GP Patient Survey was generally positive regarding caring and responsive aspects of the service, above or on par with local averages.
  • Patients could access care and treatment in a timely way.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

We found two breaches of regulations. The practice 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

In addition, the practice should:

  • Provide further training and guidance on the patient records system to ensure care reviews were clearly noted.
  • Continue with efforts to improve the uptake rates for childhood immunisations and cervical cancer screening.
  • Continue with action to review and update the practice website.
  • Continue with plans to reinstate its own patient survey activities, such as the Friends and Family Test, and reactivate the Patient Participation Group.

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

17 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 17 November 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.
  • 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 how to complain was available and easy to understand. Comments and complaints were analysed and improvements were made to the quality of care as a result of complaints and concerns.
  • 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 provider was aware of and complied with the requirements of the duty of candour.

Professor Steve Field

CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

4 November 2013

During an inspection looking at part of the service

This report is a follow up to our report published in August 2013. We had inspected this provider on the 18 and 20 June 2013.

We noted some issues which had minor or moderate impacts on people using the service. These related to the safety and suitability of the premises, cleanliness and infection control, requirements relating to workers and record keeping. We set various compliance actions requiring the provider to take steps to comply with Regulations 12, 15, 20 and 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

Following our inspection in June, we had asked the provider to send us an action plan setting out what would be done to meet the requirements of the regulations. The action plan was received in August. We carried out this inspection to check on the action the provider had taken to meet the requirements of the regulations.

We found that improvements had been made and that the provider had taken appropriate and sufficient action to comply with the Regulations.

18, 20 June 2013

During a routine inspection

We inspected the practice on the 18th and 20th June 2013. We spoke with the provider, practice manager, the practice's two nurses and staff members. We also spoke with a number of people attending appointments and with the chair of the newly established patients' participation group. We looked at a number of treatment records and other records relating to the service. We also looked at comments about the service which people had added to the NHS Choices website and saw the results of the practice's own 2012 / 13 patient survey.

People who use the service were very complimentary about the practice. One person said, 'They are marvellous to me.' Another said, 'The treatment is good and the staff here are excellent. They often go that extra mile.'

The practice regularly sought the views of people using the service to monitor performance. The patients' participation group had been set up to improve service user involvement.

We had some concerns regarding the cleaning procedures at the premises and noted that the practice had failed to carry out necessary fire safety checks. People's healthcare records were well-maintained, but the standard of record keeping relating to policies and procedures and staff members' personnel records was not sufficient. We have set compliance actions accordingly.

The staff team worked well together and were appropriately supported to undertake training and gain experience.