We carried out an announced comprehensive at Coldharbour surgery and the Hill Surgery branch practice on Tuesday 8 January 2019 as part of our inspection programme.

This practice is rated as Good overall and requires improvement in well led. (Previous rating October 2015 – Good)

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:

• Feedback from patients about the staff, care and treatment was positive.
• Leaders were knowledgeable about issues and priorities relating to the quality and future of services and participated in external groups to ensure they understood the local changes and challenges.
• The practice had recently undergone partnership changes and building refurbishment. Patients and staff said these changes had been positive.
• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice recognised where systems and processes had worked well and improved their processes where appropriate.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Practice patients and those within the locality had access to contraception and/or sexual health testing within a clinic at the practice.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients appreciated the improvements in the appointment system and said it was easy to use. Patients reported that they were able to access care when they needed it.
• Staff had access to learning, improvement and involvement at all levels of the organisation.
• Staff said the practice and branch were good places to work.

The areas where the provider must make improvements are:

Review governance systems to ensure they are fully established and operated effectively to ensure compliance with the assessment, monitoring and mitigation of risks relating to the health and safety of the service. For example, by the,

• Monitoring of immunisation and Quality Outcome framework (QOF) targets
• Maintenance of contemporaneous records and actions in relation of prescription reauthorisation within service user records.
• Maintenance of employment records. For example, to show that conduct in previous employment, checks of professional registers and previous employment history had been sourced.
• Monitoring of quality improvement audits.

The areas where the provider should make improvements are:

• Consider increasing the clinical audit/quality improvement programmes.
• Ensure significant event and complaint records reflect the detail of the action and discussion completed.
• Monitor the two-week referral process to ensure patients had received appropriate and timely follow up.
• Ensure systems are in place to keep all policies up to date.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 2 December 2014. Breaches of legal requirements were found. After the comprehensive inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breaches of regulation 9 and regulation 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010.

We undertook this focussed inspection on 9 October 2015 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Coldharbour Surgery on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services. As the practice was now found to be providing good services for safe, this affected the ratings for the population groups we inspect against. Therefore, it was also good for providing services for older people; people with long-term conditions; families, children and young people; working age people (including those recently retired and students); people whose circumstances make them vulnerable and people experiencing poor mental health (including people with dementia).

Our key findings across all the areas we inspected were as follows:

• the practice had reviewed their recruitment policy which included requesting a Disclosure and Barring Service (DBS) check before new staff started work, they reviewed any DBS checks completed by other employers and they kept checking with the DBS service for progress on the DBS check.
• the practice had purchased oxygen for the branch surgery to enable staff to deal with medical emergencies there if required.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Coldharbour Surgery provides a GP service to just over 4,400 patients in the Eltham area of Greenwich. The provider operates at this location and has a branch surgery The Hill Surgery which is in Bromley and is for the same patient group. We visited both the practice and the branch surgery as part of this inspection.

We carried out an announced comprehensive inspection on 2 December 2014. Overall the practice is rated as good. Specifically, we found the practice to be good at providing well-led, effective, caring and responsive service. It was also good for providing services for all population groups. It required improvement for providing safe services.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns and report issues.
• Risks to patients were assessed and well managed except those relating to recruitment checks in one instance.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff received training appropriate to their roles and future training needs were identified and planned for.
• Patients said they were treated with respect and their privacy and dignity were maintained and they were involved in decisions about their care and treatment. However we found conversations could be overheard at receptions in both surgeries.
• Information about how to complain was accessible, although the process could be made clearer for patients.
• Patients provided us with positive comments about their experience of making an appointment.
• There was a clear leadership structure and staff felt supported by management. The practice sought and acted on feedback from patients and staff.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure all clinical staff have a Disclosure and Barring Service check before they start work.
• Ensure availability of medical oxygen in the branch surgery as well.

In addition the provider should:

• Ensure staff complete updated training in child protection as arranged.
• Staff should record the actions taken if the fridge temperature is recorded outside the required level.
• Improve privacy at reception.
• Ensure patient records are stored securely.
• Update the practice’s complaints policy and improve the information given to patients so they are clear about the procedure.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice