The Care Quality Commission
  • Doctor
  • GP practice

Tudor Lodge Health Centre

Overall: Good read more about inspection ratings

8c, Victoria Drive, London, SW19 6AE

Provided and run by:
A,P & S Thurairatnam

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Tudor Lodge Health Centre 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 Tudor Lodge Health Centre, you can give feedback on this service.

30 September 2022 - off site review

During an inspection looking at part of the service

We carried out an announced review of Tudor Lodge Health Centre on 30 September 2022.

Following our previous inspection on 5 August 2021, there were areas we said the provider should improve. The practice was rated as good overall and for all key questions, except for safe which was rated as requires improvement.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for of Tudor Lodge Health Centre on our website at www.cqc.org.uk.

This was a focused review of information, without undertaking a site visit, to follow up on the safe key question and areas we recommended the practice should improve at our previous (5 August 2021) inspection.

We based our judgement of the quality of care at this service on a combination of:

  • What we found when we carried out our review;
  • information from our ongoing monitoring of data about services; and
  • information from the provider, patients, the public and other organisations.

We have rated the practice as good overall.

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

  • Where required, staff who administered prescription only medicines had Patient Group Directions authorisations in place.
  • Systems and processes for the storage of emergency medicines were appropriate and regularly reviewed.
  • There were appropriate arrangements for the safe management of clinical waste.
  • Changes made within the practice were reflected in the practices policies that were regularly updated.
  • There was a system of oversight and management to ensure staff completed required training relevant to their roles, and to consider the learning and development needs of staff.
  • The provider had continued to consider ways to improve uptake for cervical screening and childhood immunisations.

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

05 August 2021

During an inspection looking at part of the service

We carried out an announced focused inspection at Tudor Lodge Health Centre on 5 August 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Requires Improvement

Effective - Good

Well-led - Good

Following our previous inspection on 11 December 2019, the practice was rated Requires Improvement overall and requires improvement for providing safe and effective services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Tudor Lodge Health Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on breaches of Regulation 12 Safe care and treatment and Regulation 19 Fit and proper persons employed.

At the previous inspection we found:

  • Arrangements to keep people safeguarded from abuse, manage medicines and ensure staff had completed necessary training were not consistently implemented.
  • The practice had failed to carry out, seek and retain evidence of satisfactory evidence of conduct in previous employment concerned with the provision of services relating to (a) health or social care, (b) children or vulnerable adults.

We also followed up on areas we identified the practice should improve at the last inspection. Specifically:

  • Continue to improve outcomes for patients with diabetes and uptake of learning disability health checks, immunisations and screening.
  • Develop governance processes to ensure training is completed and documented, complaints management is fully documented, and that governance documentation is complete and clear, including arrangements for whistleblowing.

How we carried out the inspection/review

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
  • 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 have rated this practice as Good overall and good for all population groups except Families, children and young people, which we have rated as requires improvement.

We found that:

  • 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 practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Patients could access care and treatment in a timely way.
  • There was a clear leadership structure and staff felt supported by management.
  • The practice proactively sought feedback from patients, which it acted on.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.
  • There was evidence of quality improvement activity.

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

  • Ensure that all staff who administer and/or supply prescription only medicines have appropriate authorisation, and this is correctly documented in the form of Patient Group Directions.
  • Ensure that systems and processes for the storage of emergency medicines are regularly reviewed and clinical waste is properly disposed of in line with guidance.
  • Ensure that changes made within the practice are reflected in the practices policies and updated regularly.
  • Continue to ensure that staff complete required training relevant to their roles and consider the learning and development needs of staff.
  • Continue to consider ways to improve uptake for cervical screening and childhood immunisations.

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

10 October 2019

During a routine inspection

We carried out an announced comprehensive inspection at Tudor Lodge Health Centre on 11 December 2019 as part of our inspection programme, because the practice had changed from being run by a single GP to being run as a partnership.

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 requires improvement overall and requires improvement for all population groups.

  • We have rated the practice as requires improvement for Safe because arrangements to keep people safe were not consistently implemented, including for recruitment checks, medicines management and for staff training.
  • We rated the practice as requires improvement for Effective because data showed that the practice was below average/target for several measures of care in 2018/19. Although action plans were in place unverified data did not show improvement to in line with target/2018/19 averages. The practice had a programme of learning and development to provide staff with the skills, knowledge and experience to carry out their roles, but was unable to demonstrate that this was fully completed.
  • We have rated Caring as good because staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • We have rated Responsive as good because the practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • We have rated Well-led as good because although there were areas for development, in general, the way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We have rated all of the population groups as requires improvement for Effective, because some of the issues impact all patients. A rating of requires improvement for this key question means that the population groups are all rated as requires improvement.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Continue to improve outcomes for patients with diabetes and uptake of learning disability health checks, immunisations and screening.
  • Develop governance processes to ensure training is completed and documented, complaints management is fully documented, and that governance documentation is complete and clear, including arrangements for whistleblowing.

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