Background to this inspection
Updated
14 October 2021
Hammersmith Surgery is located at 1 Hammersmith Bridge Road, London, W6 9DU. The provider is the owner of the premises. The building is set over two floors with lift and stair access. There are several clinical consultation rooms and a practice nurse and a health care assistant’s room on the ground floor and offices on the first floor. The building is a base for community services including Health Visitors for the area. The reception and waiting area are on the ground floor with wheelchair access to the entrance of the building. There are toilet facilities on the ground floor. There is pre-payable off street parking in the surrounding area. There are good transport links with bus and tube stations nearby.
The practice provides NHS services through a General Medical Services (GMS) contract to patients’ and is part of a primary care network of GP practices called the Central Network.
We previously inspected the provider in September 2019 when the provider was rated as Requires improvement over all and in safe, effective and well-led good in caring and responsive, and requires improvement in the Families, children and young people and working age people
patient population groups.
The full comprehensive reports of the previous inspections can be found by selecting the ‘all reports’ link for Hammersmith Surgery on our website at www.cqc.org.uk.
The practice provides NHS primary care services to approximately 10 889 patients and operates under a General Medical Services (GMS) contract. In addition, the practice holds a Directed Enhanced Services Contract. This is a contract between general practices and NHS England for delivering services to the local community. The practice is part of the Hammersmith and Fulham GP Federation and the NHS North West London Clinical Commissioning Group (CCG).
The practice is registered with the CQC to carry out the following regulated activities - diagnostic and screening procedures, treatment of disease, disorder or injury, surgical procedures, family planning, and maternity and midwifery services.
The practice was registered with the Care Quality Commission in April 2013 to carry out the following regulated activities: diagnostic and screening procedures, treatment of disease, disorder or injury, surgical procedures, family planning, and maternity and midwifery services.
There are three GP partners who lead the clinical service at the practice. There are four salaried GPs’, a clinical pharmacist, a practice nurse and a pharmacy assistant and two GP Registrars in training. A practice manager leads the administration team of a reception manager and seven receptionists/administration staff.
The practice population is in the fourth most deprived decile in England. The practice population is ethnically diverse with 69% of patients from a white Caucasian background and 31% from black, middle eastern and south-east Asian ethnicities. There is a higher than the national average number of patients between 20 and 44 years of age. There is a lower than the national average number of patients 60 years plus. Information published by Public Health England, rates the level of deprivation within the practice population group as three, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.
The practice is open Monday to Friday between the core hours of 8am-6.30pm. Extended hours are offered 6.30pm-7.30pm on Tuesday and Wednesdays and on Saturday mornings between 8.00am-11.00am. Patients may book appointments by telephone, online or in person.
When the practice is closed, patients are directed to contact the local out of hours service and NHS 111. Out of hours services are provided by London Central and West and contact details are communicated in a recorded message accessed by calling the practice when it is closed, or by accessing the information on the practice website.
During the practice’s opening hours, patients may request to book an appointment at one of these sites for an evening or weekend appointment. On Saturdays, at all sites, pre-bookable practice nurse appointments are available which can be booked through the practice.
Information is available on the practice website regarding GP extended hours services open to all patients in the borough running 7 days a week in Hammersmith and Fulham
Updated
14 October 2021
We previously carried out an announced comprehensive inspection at Hammersmith Surgery on 25 September 2019. The overall rating for the practice was requires improvement, with the exception of key question Effective which was rated good. The full report on the 25 September 2019 inspection can be found by selecting the ‘all reports’ link for Hammersmith Surgery on our website at www.cqc.org.uk.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led – Good
This inspection was an announced comprehensive follow-up inspection carried out on 1 September 2021 to confirm that the practice continued to make improvements on areas that we had identified at our previous inspection held on 25 September 2019. This report covers our findings in relation to those improvements and also additional improvements made since our last inspection. This review of information was undertaken without carrying out a site visit.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hammersmith Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a comprehensive follow-up inspection to review progress against previous breaches of regulation
- The practice did not have reliable systems in place to manage the practice premises safely. This included fire safety systems, infection prevention and control (IPC) practices.
- The provider could not demonstrate they operated safe recruitment systems within the practice. This included ensuring that all staff had the skills, knowledge and experience to carry out their roles safely and effectively. The provider could not demonstrate that all staff had formal appraisals undertaken on a regular basis, and that all staff had completed safeguarding training relevant to their role.
- The provider could not demonstrate they have an effective system in place to safely manage patients who had been referred via the urgent two week-wait system and that they have an effective system in place to safely manage regarding patient safety alerts. The provider could not demonstrate they have a fail-safe system in place to safely manage and monitor cervical smear screening.
- The provider could not demonstrate they had a fail-safe process in place regarding significant events.
How we carried out the inspection
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.
At this inspection we found there had been sufficient improvement to rate the safe, effective and well-led key questions good. The ratings for the practice is now good overall.
We found that:
- The practice had developed systems and processes to keep patients safe. This included recruitment checks, staff immunisations, equipment checks, fire and health and safety, infection control and mandatory staff training.
- There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
- The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
- The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate, we reviewed the recruitment and training files for two members of staff and found that all of the recommended checks and training had been completed.
- All staff received up-to-date safeguarding and safety training appropriate to their role.
- The service used information about care and treatment to make improvements. The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients.
Whilst we found no breaches of regulations, the provider should:
- Continue to review and improve the uptake of cervical screening and the childhood immunisation programme.
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