The Care Quality Commission
  • Doctor
  • GP practice

Archived: South Fulham Heatlh Clinic

Overall: Good read more about inspection ratings

Bridge House Centre for Health, London, SW6 2FE (020) 7731 3498

Provided and run by:
South Fulham Health Clinic

All Inspections

23 March 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Surgery – Dr Das and Partners on 23 March 2016. This was to follow up a comprehensive inspection we carried out on 9 October 2014 where we found the practice was not meeting the essential standards of quality and safety. There were deficiencies with regard to pre-employment recruitment checks and accurate record keeping about staff training and appraisal, and overall we rated the practice as requires improvement. At our recent inspection the practice had made improvements in all of the areas identified previously and overall the practice is now 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 well managed, with the exception of those relating to security of prescriptions and the management of emergency medicines.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they were able to make an appointment with their preferred 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 the majority of 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 improvements are:

  • Review the arrangements for ensuring the security of prescriptions and complete a documented risk assessment of emergency medicines where it is decided not to stock medicines recommended in national guidance.
  • Risk assess the co-location of administrative staff in the same office as staff from another practice occupying the premises with regard to confidentiality of patient information.
  • Review the lone worker policy to ensure it reflects current arrangements for staff working alone.
  • Ensure all clinical staff are up to date in relation to their duties under the Mental Capacity Act 2005 by arranging further training where appropriate.
  • Review systems to improve the identification of carers and provide support.

Professor Steve Field ( CBE FRCP FFPH FRCGP ) 

Chief Inspector of General Practice

9 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

The Surgery – Dr Das and Partners provides primary medical services to approximately 2900 patients in the Fulham area of West London. This is the only location operated by this provider.

We visited the practice on 9 October 2014 and carried out a comprehensive inspection of the services provided.

We rated the practice as ‘Good’ for the caring, responsive and well-led domains; and as ‘Requiring Improvement’ under the safe, and effective domains and for all six population groups: older people; people with long-term conditions; families, children and young people; working age people (including those recently retired and students); people whose circumstances may make them vulnerable; and people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

  • The practice worked in collaboration with other health and social care professionals to support patients’ needs and provided a multidisciplinary approach to their care and treatment.
  • The practice promoted good health and prevention and provided patients with suitable advice and guidance.
  • The practice provided a caring service. Patients indicated that staff were caring and treated them with dignity and respect. Patients were involved in decisions about their care.
  • The practice provided appropriate support for end of life care and patients and their carers received good emotional support.
  • The practice understood the needs of its patients and was responsive to these. It recognised the needs of different groups in the planning of its services.
  • The practice learned from patient experiences, concerns and complaints to improve the quality of care.

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

Importantly, the provider must:

  • Take steps to ensure patients are fully protected from the risks of unsafe or inappropriate care and treatment by the accurate maintenance of records about staff employed to carry out the regulated activities.
  • Ensure patients are fully protected against the risks associated with the recruitment of staff, in particular in the recording of recruitment information and in ensuring all appropriate pre-employment checks are carried out or recorded prior to a staff member taking up post.

In addition the provider should:

  • Put in place a formal protocol for sharing information with staff and a documented process to show the practice has discussed, reviewed and agreed any action from patient safety alerts and guidance issued by the National Institute for Health and Care Excellence (NICE).
  • Include in the procedure for reporting, recording and monitoring significant events a process for communicating the outcome and learning to relevant staff and document evidence of the dissemination of findings and follow up action within the practice.
  • Put in place a policy for safeguarding vulnerable adults and ensure all staff receive relevant training.
  • Ensure the practice’s chaperone policy is prominently displayed and clearly communicated to patients.
  • Display signs to indicate a CCTV system is in use and ensure with the landlords of the premises that it is registered with the Information Commissioners Office (ICO).
  • Ensure the prescription collection box at the reception desk is not left unattended. Staff should double check the patient’s address and date of birth when handing them their prescription.
  • As there was only one thermometer for the vaccines fridge, consider carrying out a monthly check of the thermometer to confirm that the calibration is accurate, in line with Public Health England guidance ‘Protocol for ordering, storing and handling vaccines (March 2014)’.
  • Ensure the vaccine fridge was not overstocked, to avoid inhibiting air flow and circulation.
  • Undertake more effective monitoring and review of the outcome of clinical audits, by further audit to test their effectiveness, to ensure the completion of the full audit cycle.
  • Ensure there is documented evidence to confirm that the lessons learned from complaints have been communicated throughout the practice.
  • Review practice policies and procedures in a systematic way to ensure they remain up to date and relevant.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice