The Care Quality Commission
  • Doctor
  • GP practice

Central Surgery

Overall: Requires improvement read more about inspection ratings

Surbiton Health Centre, Ewell Road, Surbiton, Surrey, KT6 6EZ (020) 8399 6622

Provided and run by:
Central Surgery

Important: This service was previously registered at a different address - see old profile

All Inspections

21 April 2022

During a routine inspection

We carried out an announced inspection at Central Surgery on 21 April 2022. Clinical records reviews were carried out remotely on 20 April 2022. Overall, the practice is rated as requires improvement.

Safe - Requires Improvement
Effective - Requires Improvement
Caring - Good
Responsive - Good
Well-led - Requires Improvement

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

Why we carried out this inspection
We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

How we carried out this 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.

We have rated this practice as requires improvement overall

We found that:

  • The practice had not completed monitoring for all patients on high risk medicines.
  • The practice had not completed monitoring for all patients with long-term conditions.
  • The practice had not acted in response to all MHRA alerts.
  • There was no patient participation group or patient feedback process.
  • Some staff had not completed recommended training.
  • There was no clear governance or quality assurance process in place for patient monitoring, significant events, complaints, safeguarding or patient feedback.
  • Patients had given positive feedback about the levels of access at the practice and the care provided by clinicians.
  • The premises were clean and well organised.
  • The practice responded to and engaged well with complaints and feedback from patients.

We found breaches of regulations. The provider 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.

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

31 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Central Surgery on 31 August 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.
  • The practice had policies in place to cover its activities; however, these were not always sufficiently prescriptive. For example, their recruitment policy did not provide details of when Disclosure and Barring Service (DBS) checks would be required, and the chaperone policy did not detail whether DBS checks should be carried-out on staff who acted as chaperones (however, all staff who acted as chaperones had received a DBS check).
  • 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 services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Feedback from patients about access to appointments was mixed, with some patients reporting that there was a lack of pre-bookable appointments. On the day of the inspection we saw evidence that there were sufficient appointments available; however, we did observe that in some cases patients had to wait a long time after their appointment time before they were seen. The practice had done some analysis of this and had identified the average waiting times for each member of clinical staff, and was addressing the issue with individuals.
  • 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 practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw one area of outstanding practice:

  • The Advance Nurse Practitioner (ANP) was the lead nurse for the Kingston CCG Clinical Education Network and led on the professional development of nursing staff at the practice. She had researched and introduced the HeART online revalidation and appraisal tool for nurses, which allowed nursing staff to keep track of the training and education they had completed, complete a training needs analysis, and gather the necessary evidence for their appraisal and revalidation. This tool was piloted at the practice, and having found it a success, the ANP had presented this to the CCG and helped to roll-out the system to other practices across several neighbouring CCGs. She had also worked with a local further education college to introduce a Healthcare Assistant Diploma award.

The areas where the provider should make improvement are:

  • Consider reviewing the appointment system to ensure that patients are not waiting too long to be seen once they arrive for their appointment.
  • Ensure that the Patient Participation group is re-established in order to gather feedback and ideas from patients to improve patient experience.
  • Review policies to ensure that they are practice-specific and contain sufficient detail.
  • Consider establishing a failsafe process to check that results of cervical screening tests are received.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice