Bishopsford Road Medical Centre

Updated 30 August 2023

Bishopsford Road Medical Centre serves approximately 4649 patients in the London Borough of Sutton, in south-west London.

The practice operates under a Personal Medical Services (PMS) contract, and is signed up to a number of local and national enhanced services (enhanced services require an enhanced level of service provision above what is normally required under the core GP contract). These are: Meningitis provision, Childhood Vaccination and Immunisation Scheme, Extended Hours Access, Facilitating Timely Diagnosis and Support for People with Dementia, Influenza and Pneumococcal Immunisations, Learning Disabilities, Rotavirus and Shingles Immunisation and Unplanned Admissions.

The practice is part of an organised group of GP practices in Sutton CCG that aim to work together to improve primary care delivery for patients in the local area.

The provider is registered with CQC to deliver the following Regulated Activities: diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury.

Information published by Public Health England shows that deprivation within the practice population group is in the fourth lowest decile (four of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 15% Asian, 71% White, 8% Black, 4% Mixed, and 1% Other.

Compared to the national average, there are slightly more young people registered at the practice, and slightly fewer older people. There are more male patients registered at the practice compared to females.

The prevalence of chronic medical conditions (including depression) is in line with or higher than local and national averages.

There is a team of 5 GPs (two of whom are long-term locums). There is a practice nurse, a healthcare support worker and a healthcare assistant. There is also a Clinical Pharmacist who is able to prescribe medicines. The practice is supported by a practice manager, a deputy practice manager and a team of reception/administration staff.

The practice is open between 8 am and 6.30 pm Monday to Friday. Appointments are available during these times. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Patients also have access to evening and weekend appointments at two other local surgeries. Practice staff can book appointments for patients on weekdays between 6.30pm and 8pm. On weekends appointments are available between 8am and 8pm, and patients can book these directly (by phone).

Updated 30 August 2023

We carried out an announced focused inspection at Bishopsford Road Medical Centre on 10 August 2023. Overall, the practice is rated as good.

Safe - not inspected, rating of good carried forward from previous inspection

Effective - not inspected, rating of good carried forward from previous inspection

Caring - not inspected, rating of good carried forward from previous inspection

Responsive - not inspected, rating of good carried forward from previous inspection

Well-led - good

Following our previous inspection in June 2022 the practice was rated good overall and for all key questions apart from well-led, which was rated as requires improvement.

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection.

Following the last inspection we rated well-led as requires improvement because:

• Some aspects of below average patient satisfaction had not been effectively assessed. Where the practice had taken action to improve the patient experience, there was no active monitoring to ensure that this had been successful and had not had any unintended consequences.
• There were systems and processes to identify, manage and mitigate risks, but these were not all consistently effective.
• There was not, at the time of the inspection, any documented overview of incomplete actions arising from risk assessments/other safety mechanisms, to allow governance oversight of risk management.

As well as requiring the practice to establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care, we said that they should:

• take further steps to assess and improve patient perception of healthcare professionals.
• continue to monitor and take action on areas of below average/below target performance in hypnotics prescribing, childhood immunisation and cervical screening.

Following this inspection we rated the practice as good for providing well-led services because of improvements that the practice had made.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Reviewing available data
• 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 found that:

• The practice had taken action on all of the areas identified for improvement. Actions to address risk were complete and changes were working well. In some more challenging areas, the practice had made improvements and were continuing to implement changes to try to improve further.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• continue to monitor and take action on areas of below average/below target performance in patient satisfaction, hypnotics prescribing, childhood immunisation and cervical screening.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care