• Doctor
  • GP practice

The Upstairs Surgery

Overall: Good read more about inspection ratings

Chadwell Heath Health Centre, Ashton Gardens, Chadwell Heath, Romford, Essex, RM6 6RT 0844 387 8044

Provided and run by:
The Upstairs Surgery

Latest inspection summary

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Background to this inspection

Updated 31 August 2021

The Upstairs Surgery is situated in East London, within NHS Havering Clinical Commissioning Group (CCG). The practice provides services to approximately 6,381 patients under a General Medical Services contract (an agreement between NHS England and general practices for delivering primary care services).

The practice is located on the first floor of a purpose-built health centre, with access via the communal lift and stairs. The building accommodates two other GP practices as well as other local healthcare services, such as phlebotomy.

The provider is registered as a partnership with the CQC to carry on the following regulated activities: Diagnostic and screening procedures; Family planning; Maternity and midwifery services; and Treatment of disease, disorder or injury.

The clinical team at the practice consists of two male GP partners, one female locum GP, and one full-time and two part-time female practice nurses. They are supported by a practice manager, a senior administrator, and a team of reception and administrative staff.

The practice is open on Monday and Tuesday from 8am to 7.30pm, and on Wednesday, Thursday and Friday from 8am to 6.30pm. Appointments include home visits, telephone consultations and online consultations. Patients telephoning when the practice is closed are directed to the local out-of-hours service provider.

Information published by Public Health England rates the level of deprivation within the practice population group as five, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest; in England, people living in the least deprived areas of the country live around 20 years longer in good health than people in the most deprived areas. National General Practice Profile describes the practice ethnicity as being 57.4% White, 21.7% Asian, 14.7% Black, 4.2% mixed race, and 2% other ethnicities.

Overall inspection

Good

Updated 31 August 2021

We carried out an announced review of The Upstairs Surgery on 23 August 2021.

Following our previous comprehensive inspection on 22 July 2019, the practice was rated as good overall and for all key questions, except for the safe key question which was rated as requires improvement.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Upstairs Surgery 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.

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:

  • The practice had systems in place to safeguard vulnerable patients at risk of abuse.
  • We reviewed information on the clinical system which demonstrated that the practice had accurate and appropriately coded information in relation to vulnerable patients.
  • Safeguarding was a standing agenda item for discussion in clinical meetings.
  • There was a process in place to document and follow-up on patients who failed to attend appointments.
  • The practice had implemented an audit system to maintain clinical oversight of the nurse prescriber.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care