We carried out an announced comprehensive inspection at Colliers Wood Surgery on 28 November 2018.
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 and good for all population groups
.
We rated the practice as inadequate for providing safe services because:
- The practice did not have clear systems and processes to keep patients safe.
- The practice did not have appropriate systems in place for the safe management of medicines.
We rated the practice as requires improvement for providing well-led services because:
- The overall governance arrangements were ineffective.
- The practice did not have clear and effective processes for managing risks, issues and performance.
We rated the practice as good for providing effective, caring and responsive services because:
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
The areas where the provider must make improvements are:
- Ensure that care and treatment is provided in a safe way.
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
(Please see the specific details on action required at the end of this report).
The areas where the provider should make improvements are:
- Continue to address the below-target uptake for childhood immunisations.
- Complete appraisals for all staff.
- Continue to embed the new prescription security arrangements at the branch practice site.
- Put in place a locum information pack.
- Continue the monitoring of care outcomes for patients with hypertension, and (where necessary) take any necessary action to address below average achievement.
- Consider whether patients would find it helpful if leaflets in languages other than English and in easy read format were available in the waiting area.
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