This practice is rated as Good overall. (Previous rating 27 July 2017 – Good)

The key questions at this inspection are rated as:

Are services effective? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at the Roehampton Surgery on 14 April 2016. The overall rating for the practice was requires improvement and breaches in regulations were identified.

We carried out an announced focussed follow up inspection visit on 12 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our inspection on 14 April 2016. We found that the practice had made improvements and were meeting requirements in some areas, however the overall rating for the practice remained requires improvement.

We carried out an announced follow up comprehensive inspection on 27 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 12 January 2017. We found that the practice had made a number of improvements and the overall rating was good, however they remained rated as requires improvement for effective services, and a breach in regulations was identified.

The full reports for the April 2016, January 2017 and July 2017 inspections can be found by selecting the ‘all reports’ link for The Roehampton Surgery on our website at .

This inspection was an announced focussed follow up inspection visit on 11 September 2018 under Section 60 of the Health and Social Care Act 2008, to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulation that we identified in our previous inspection on 27 July 2017. This inspection was carried out in line with our next phase inspection programme. This report covers our findings in relation to those requirements and any improvements made since our last inspection. Overall the practice remains rated as good. They remain rated as good for well-led services and the practice are now rated as good for providing effective services.

At this inspection we found:

• Arrangements in respect of identifying, monitoring and managing risks to staff and service users had improved via the use of an overarching action planner, which was used to collate and manage issues identified across the practice’s safety risk assessments.
• 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.
• The practice had implemented a quality improvement programme in response to their performance data. Quality improvement systems included clinical audit, which showed there had been a positive impact on patient care.
• The practice had continued to make improvements in governance arrangements, including a clinical audit programme, systems to manage risk, systems to monitor and improve performance data, improved medicines management systems and improved meeting and communication systems.
• Staff felt supported and valued and demonstrated a commitment to making and sustaining improvements in the service.
• The practice had an operational patient participation group (PPG) however this was not yet fully effective in influencing changes to the service.

The areas where the provider should make improvements are:

• Consider how the responsibilities of staff in leadership and management roles are arranged, to assist with delivering further improvements to the quality of the service.
• Regularly review the central action planner to effectively manage risks.
• Further develop the PPG so it is used to effect and influence improvements in the service.

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 at the Roehampton Surgery on 14 April 2016. The overall rating for the practice was requires improvement.

We carried out an announced focused follow up inspection visit on 12 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our inspection on 14 April 2016. We found that the practice had made improvements and were meeting requirements in some areas however the overall rating for the practice remained requires improvement.

The full comprehensive report on the April 2016 and January 2017 inspections can be found by selecting the ‘all reports’ link for The Roehampton Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused follow up inspection visit on 27 July 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 12 January 2017. This report covers our findings in relation to those requirements and any improvements made since our last inspection. Overall the practice is now rated as good.

Our key findings were as follows:

• The practice had continued to make improvement in implementing formal governance arrangements, including commencing a programme of continuous clinical and internal audit to monitor quality and to make improvements to patient outcomes. We saw that unverified data submitted by the practice in the quality and outcomes framework (QOF) for 2016/17 showed the practice had improved their patient outcomes in line with local and national averages for some areas, whilst other areas remained below average.
• Arrangements in respect of identifying, monitoring and managing risks to staff and service users had improved further to include action plans in place to effectively manage risks and issues identified through risk assessments and implement mitigating actions.
• The practice had made further attempts to reintroduce an effective patient participation group (PPG) however this was not yet operational.
• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had defined systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• 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 sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

There are areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Monitor and effectively manage a programme of quality improvement, including clinical audit, to improve patient outcomes.

In addition the provider should:

• Implement, monitor and review action plans to effectively manage risks, issues and mitigating actions identified through risk assessment.
• Consider, implement, monitor and review ways to engage patients, including continuing with actions to reintroduce the patient participation group.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Roehampton Surgery Health Centre on 14 April 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the April 2016 inspection can be found by selecting the ‘all reports’ link for The Roehampton Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection visit on 12 January 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 14 April 2016. This report covers our findings in relation to those requirements and any improvements made since our last inspection.

Overall the practice is now rated as requires improvement.

Our key findings were as follows:

• The practice had made some improvement in implementing formal governance arrangements; however there was still no programme of continuous clinical and internal audit to monitor quality and to make improvements to patient outcomes. For example, performance in the quality and outcomes framework (QOF) for 2015/16 and unverified data from 2016/17 showed the practice was still below the local and national average for a number of clinical indicators.

• Arrangements in respect of identifying, monitoring and managing risks to staff and service users had improved; however the practice did not have action plans in place to effectively manage risks and issues identified through risk assessments and implement mitigating actions. Staff recruitment records did not demonstrate the provider had carried out the required pre-employment checks that were absent at our last inspection, as the practice had not employed any new staff.

• The practice had made attempts to reintroduce an effective patient participation group (PPG) but this was not yet operational.

• There were effective systems in place for recording, investigating and learning from complaints and significant events.

• The practice had introduced a carer’s register which identified 88 patients as carers who were offered additional support under the CCG led Planning All Care Together (PACT) scheme whereby patients receive a comprehensive health and social care review with a healthcare assistant and a GP.

• The practice had reviewed and improved advertising in the reception area of translation services and the availability of a room for discreet conversation if required by patients.

There are areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Implement monitor and effectively manage a programme of quality improvement, including clinical audit, to improve patient outcomes.

In addition the provider should:

• Implement, monitor and review action plans to effectively manage risks, issues and mitigating actions identified through risk assessment.

• Consider, implement, monitor and review ways to engage patients, including continuing with actions to reintroduce the patient participation group.

• Review the practice complaints policy to ensure the timeline for acknowledging and responding to complaints is in line with guidance and contractual obligations for GPs in England.

At our previous inspection on 14 April 2016, we rated the practice as requires improvement for providing safe, effective, responsive and well led services as staff recruitment records did not demonstrate the provider had carried out required pre-employment checks, performance for patient outcomes was below the local and national average and governance arrangements did not support the delivery of good quality care. At this inspection we found that these arrangements had not improved in all areas. Consequently, the practice is still rated as requires improvement for providing effective and well led services.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Roehampton Surgery on 14 April 2016. Overall the practice is rated as requires improvement.

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

• There was no effective system in place to identify and monitor risks to patients and keep them safe, for instance in regards to fire safety.
• While the practice had systems in place for staff to be trained and for meetings, there were limited or no records to confirm this.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, there was not an effective system in place for identifying, recording and investigating incidents and learning from them.
• Data showed patient outcomes were low compared to the national average for a number of clinical areas such as diabetes care.
• Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.
• The practice did not have an effective system in place for handling complaints and feedback.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

The areas where the provider must make improvements are:

• Introduce effective processes for managing significant events, incidents and near misses.
• Take action to address identified concerns with infection prevention and control practice.
• Implement systems for assessing and monitoring risks to patients including carrying out fire risk assessments and health and safety risk assessments at each site.
• Ensure staff acting as chaperones are suitably trained, with the necessary checks through the Disclosure and Barring Service.
• Ensure recruitment arrangements include all necessary employment checks for all staff.
• Implement formal governance arrangements including systems for assessing and monitoring risks and the quality of the service provision, and the recording of meetings, their outcomes and actions.
• Implement effective arrangements for the identification, recording, investigation, action and learning from complaints and feedback.
• Install an Automatic External Defibrillator (AED) at each site or carry out a risk assessment as to why an AED should not be installed at each site.
• Have a programme of quality improvement, including clinical audit, to improve patient outcomes.

In addition the provider should:

• Re-introduce a patient participation group.
• Maintain a register of, and monitor and improve services for, carers.
• Consider advertising translation services and the availability of a private room so patients are aware of these services.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

We spoke with two people who use the service, three members of the Patient Participation Group, two of the GPs, the nurse and reception staff during this inspection.

"I like it here", "I wouldn't want to move", "you wouldn't find another GP as good as they are here", "the doctors look after you well", "I don't feel rushed", "the doctors give you time", "they take time to explain things" and "my health needs are well met" were just a few of the comments people made about the practice. There was a general consensus that making appointments was not an issue although people said that getting through on the telephone first thing in the morning could be difficult. People said the waiting room and consultation rooms were always clean. The practice had a patient participation group that met three times a year, members of the group felt that it represented the patient population and was "useful" and said "the doctors take our comments on board".

Staff were happy to be working at the practice and had the training and support they needed.

We found that there were appropriate infection control measures in place at the practice. Medicines were adequately managed. Procedures were in place for safeguarding children and vulnerable adults and staff demonstrated that they were aware of their responsibilities.

We saw that improvements could be made to the quality assurance, reviewing and auditing systems in place and more could be done to seek patient's views of the service.