The Care Quality Commission
  • Doctor
  • GP practice

Wells Park Practice

Overall: Good read more about inspection ratings

1 Wells Park Road, Sydenham, London, SE26 6JQ (020) 8699 2840

Provided and run by:
Wells Park Practice

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Wells Park Practice on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Wells Park Practice, you can give feedback on this service.

29 September 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Wells Park Practice on 29 September 2022. Overall, the practice is rated as good. At this inspection we looked at the responsive key question and have rated it ‘good’. The remaining key ratings were carried forward from the previous inspection.

At our previous inspection in October 2019, the practice was rated good overall and for providing safe, effective and well-led services. We rated the provider as requires improvement for providing responsive services.

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

Why we carried out this review

This was a focused review to follow up on the responsive services. At the last inspection we found;

  • The practice scored below the national average in the National GP Patient Survey in relation to how easy it was to get through to someone at the GP practice on the phone.

We also followed up on several ‘should’ actions identified at the last inspection. Specifically;

  • Continue to implement a programme to improve uptake of childhood immunisations and national cancer screening programmes.
  • Continue to ensure policies and procedures are followed; for example, the emergency medicines protocol.

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 review was carried out without visiting the location by requesting documentary evidence from the provider and speaking to a staff member and members of the Patient Participation Group (PPG) on the phone.

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:

  • Efforts had been made to improve telephone access to the GP; the practice updated their call system, conducted their own patient survey, increased staff members and engaged with their patients.

In addition;

  • The practice had taken steps to improve childhood immunisation uptake. They had recruited a nurse designated to carry out childhood immunisations. The practice continuously followed up on patients who declined appointments for their children and made referrals to health visitors if necessary. Other methods to increase uptake included highlighting the importance of childhood immunisations in monthly newsletters, speaking about childhood immunisations during Patient Participation Group meetings and opening dedicated Saturday clinics.
  • The practice had taken steps to encourage cancer screening uptake. The practice sent weekly text reminders to patients, offered opportunistic cervical screening and opened dedicated Saturday clinics.
  • The practice ensured policies and procedures, such as the emergency medicines protocol, were followed. We were assured that the practice followed their protocols in monitoring and recording their emergency medicines.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

30 October 2019

During a routine inspection

This practice is rated as good overall. (Previous rating September 2018 – requires improvement)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? - Good

We carried out an announced comprehensive inspection of Wells Park Practice on 30 October 2019. The practice was previously inspected on 11 September 2018 where they were rated as requires improvement for providing Safe, Effective, Responsive and Well led services and requires improvement overall. The practice was rated good for providing caring services. As a result of the findings on the day of the September 2018 inspection, the practice was issued with two requirement notices for breach of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). The full comprehensive report of the 11 September 2018 inspection can be found by selecting the ‘all reports’ link for Wells Park Practice on our website.

This inspection was an announced comprehensive inspection on 30 October 2019. We carried out this inspection to check if the practice had made and sustained improvements identified at previous inspections. This report includes our findings in relation to the actions we told the practice they should take to improve.

At this inspection we inspected all six population groups. We rated all population groups as requires improvement overall.

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 good overall.

At this inspection we found:

  • The practice had clear systems and processes to keep patients safe.
  • At our last inspection not all risks to patient safety were managed well. At this inspection we found arrangements for identifying, monitoring and managing risks to patient safety had improved.
  • At the time of inspection, the practice did not have appropriate medicines for the safe management of medical emergencies. We found one emergency medicine used for treating seizures was not in stock. During our inspection, the provider obtained this emergency medicine.
  • The practice still scored below the national average in the National GP Patient Survey in relation to how easy it was to get through to someone at their GP practice on the phone. The practice had acted effectively on issues with telephone access and delays after appointment time. Feedback from patients showed evidence of a little improvement.
  • Practice leaders had established policies, procedures and activities, and had assured themselves that they were operating as intended.
  • Some performance data was below local and national averages. Uptake rates in 2018/2019 for the vaccines given were below the World Health Organisation (WHO) target of 95% in the four areas where childhood immunisations are measured.
  • The practice’s systems for managing staff recruitment and training had improved.
  • We found evidence of quality improvement measures including clinical audits and reviews. There was evidence of action taken to change practice.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • We received 29 patient comment cards and most were positive about the practice although 5 patients said they had experienced problems accessing appointments. Patients consistently described the staff as kind and helpful.

We rated Effective as good except Families, Children and Young People which we rated as requires improvement because of the low childhood immunisation rates and failure to take adequate action to improve them.

The areas where the provider should make improvements are:

  • Continue to implement a programme to improve uptake of childhood immunisations and national cancer screening programmes.
  • Continue to monitor patient satisfaction with telephone access, and take further action if necessary.
  • Continue to ensure policies and procedures are followed; for example the emergency medicines protocol.

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

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

11 September 2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous rating May 2017 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Requires improvement

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at Wells Park Practice on 11 September 2018. We carried out this inspection to check if the practice had made and sustained improvements identified at previous inspections.

At this inspection we found:

  • Systems to ensure that patients and others in the practice were kept safe were not consistently implemented.
  • The practice had succeeded in making improvements to some aspects of performance, but there were other areas that had not been addressed effectively.
  • Staff treated patients with kindness, respect and compassion.
  • Staff helped patients to be involved in decisions about care and treatment, although this was not systemic.
  • The practice had failed to act effectively on issues with telephone access and delays after appointment time.
  • The practice was not consistently following its own policies and procedures.
  • Clinical audit had had some positive impact on quality of care and outcomes for patients, but had not demonstrated improvement such that care in the areas reviewed were consistently good.

The areas where the provider must make improvements as they are in breach of regulations are:

  • 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.

The areas where the provider should make improvements are:

  • Take action to improve the uptake of cancer screening.
  • Take action to implement the Accessible Information Standard.

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

11 April 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wells Park Practice on 17 March 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Wells Park Practice on our website at www.cqc.org.uk.

At our previous inspection on 17 March 2016, we rated the practice as requires improvement for providing responsive services as patient satisfaction with access to the service was below average.

This inspection was a desk-based review carried out on 11 April 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 17 March 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

  • The provider has taken action on all of the areas we identified for improvement.

  • When we inspected in March 2016, patient outcomes, as measured by the Quality and Outcomes Framework (QOF), were below average. Although the data is unverified, the 2016/17 QOF scores showed significant improvement, particularly for people with long-term conditions and poor mental health.

  • Survey results published in July 2016 showed that patient satisfaction with access to the service remained below average, despite action from the practice.

Consequently, the practice is still rated as requires improvement for providing responsive services.

The provider should:

  • Continue to monitor and take action to improve patient satisfaction with making appointments.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

17 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Wells Park Practice on 17 March 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 generally well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had 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.
  • The practice took action to make it easier for patients to make appointments. Patients told us that access to the practice and appointment availability had improved, 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 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.

The areas where the provider should make improvement are:

  • Continue to take action to improve the care of people with long-term conditions and poor mental health.
  • Continue to monitor and take action to improve patient satisfaction with making appointments.
  • Review care plans to ensure that they meet patients needs fully.
  • Ensure systematic monitoring of all samples taken for the cervical screening programme.
  • Ensure all staff undertaking chaperoning understand what is required while performing the role.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice