Archived: Sydenham Group Practice

We carried out an announced inspection at Sydenham Group Practice on 6-8 April 2022. Overall, the practice is rated as Requires Improvement.

The ratings for the key questions are as follows:

Safe - Requires Improvement

Effective - Requires Improvement

Caring - Good

Responsive - Good

Well-led - Requires Improvement

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Sydenham Group Practice on our website at www.cqc.org.uk. However, this was a first inspection.

Why we carried out this inspection

This inspection was a comprehensive inspection due to the provider being a new provider. They had not been inspected previously.

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 inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• 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 have rated this practice as Requires Improvement overall.

We found that:

• leaders did not always have assurance of sustainability and stable systems in place to ensure a full and comprehensive oversight of the practice;
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• The practice could not demonstrate they had completed an up to date infection prevention control audit.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• the practice did not have assurance of the overall learning and improvements from reviews of significant events
• staff recruitment documentation was not always fully completed
• There were some gaps in staff training and staff had not received an appraisal

We found breaches of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties.

The provider should:

• Continue to monitor and take actions to improve the uptake for childhood immunisations and cervical cancer screening for women at the practice.
• Continue to monitor and take action for patients identified as having potential diabetes on the clinical system.
• Continue to monitor safety alerts in a way that give assurance that alert tasks are acted on.
• Continue to explore ways at implementing formal multi-disciplinary, palliative care and staff team meetings.
• Continue to explore ways of re-establishing the Patient Participation Group.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care