31 October and 1 November 2023
During a routine inspection
We carried out an announced comprehensive inspection at Churchill Medical Centre on the 31 October and 1 November 2023. Overall, the practice is rated as good.
Safe – good.
Effective – good.
Caring – good.
Responsive – good.
Well-led – good.
Following our previous inspection on 2 June 2015, the practice was rated good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Churchill medical centre on our website at www.cqc.org.uk
Why we carried out this inspection.
We carried out this comprehensive inspection because the practice has not been inspected since 2015.
How we carried out the inspection/review
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 clear systems, practices, and processes to keep people safe and safeguarded from abuse.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- 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 the delivery of high-quality, person-centre care.
- As part of the practices work to offer healthcare to the vulnerable and disadvantaged in society, and as part of the commitment to safe surgeries a project was started in early 2022 to try to improve the access to primary care amongst local asylum seekers and refugees.
- Staff had access to a broad range of Wellness resources within a dedicated Wellness Hub.
- The practice encouraged a culture which drove quality sustainable care.
- There was compassionate, inclusive, and effective leadership at all levels.
- There were responsibilities, roles and systems of accountability to support good governance and management.
Whilst we found no breaches of regulations, the provider should:
- Take steps to check all equipment has been calibrated.
- Take action to attach the blind cords safely in the Surbiton branch.
- Continue to improve the uptake of childhood immunisations.
- Continue to improve patient access to the practice.
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 Health Care