South Norwood Hill Medical Centre

Updated 27 February 2023

South Norwood Hill Medical Centre provides primary medical services in 103 South Norwood Hill, London SE25 6BY to approximately 7000 registered patients and is one of the 49 practices in Croydon Local Area Team and part of the South West London Integrated Care System.

The clinical team at the surgery is made up of a full-time male lead GP partner, a full-time female managing partner, one full-time female salaried GP, one part-time male salaried GP providing 25 GP sessions. The practice also employs a female practice nurse, a female healthcare assistant and a physicians associate.

The non-clinical practice team consists of a reception manager and administrative or reception staff members.

The practice population is in the fourth more deprived decile in England. The practice population of children is below the local and national averages and the practice population of working age people is above the local average and significantly above the national average. The practice population of older people is similar to the local and significantly below the national average.

The practice is registered as a partnership with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.

Updated 27 February 2023

We carried out an announced inspection at South Norwood Hill Medical Centre.

A remote clinical records review was undertaken on 15 November 2022, remote interviews on 16 November 2022, a site visit on 17 November 2022 and a discussion following the clinical records review on 5 December 2022. Overall, the practice is rated as Requires Improvement.

Safe – Requires Improvement

Effective – Requires Improvement

Caring – Good

Responsive - Requires Improvement

Well-led - Requires Improvement

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

Why we carried out this inspection

This was a comprehensive inspection as part of our risk-based approach to reviewing and inspecting services and to follow up concerns identified at our previous inspection completed on 14 & 16 March 2022. At that inspection we rated the provider as inadequate overall and in each question as:

• There were gaps in recruitment checks and one staff member had not complete basic life support training.
• One significant event raised in a clinical meeting was not dealt with under the practice’s significant event process.
• The practice’s legionella risk assessment required action in a number of areas and there was not documented evidence that these actions had been completed.
• Childhood immunisations and cervical screening were below target although the practice outlined actions undertaken to improve uptake.
• Reviews of patient records indicated that: medicines safety alerts were not actioned in a timely manner and patients on certain medicines that required regular monitoring were not having this completed.
• The systems for identifying and following up patients who had undiagnosed health conditions; specifically, chronic kidney disease and diabetes were not effective.
• Feedback from patients raised telephone access and access generally as a concern.
• Governance processes and systems related to risk management did not operate effectively.

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 aimed to enable 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.
• Requesting staff feedback using surveys.
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit where we undertook clinical searches on the practice’s patient records system and discussed our findings with the provider..

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.

Our key findings were

• Concerns from our last inspection related to recruitment, training, significant events and premises had been addressed.
• Systems for identifying and following up patients with undiagnosed long-term conditions appeared to have improved as these were not flagged for follow up when we undertook searches of patient records.
• Reviews of clinical records showed that systems for actioning safety alerts needed further refinement, medication reviews were not sufficiently detailed and follow up for a very small proportion of patients with some long-term conditions needed to be improved.
• Childhood immunisations and cervical screening were still below target although the practice outlined further actions undertaken to improve uptake and there had been a slight improvement in the uptake of cervical screening.
• Feedback from patients raised telephone access and access generally as a concern. However, patients said they were treated with respect by staff and they felt that the quality of clinical care was of a good standard.
• It was evident that staff at the practice had undertaken a significant amount of work to rectify the concerns identified at our last inspection. However, this had resulted in additional work for the lead clinician at the service which did not appear to be sustainable. The clinical lead told us of plans to delegate work to other staff after our visit had been completed but these plans were yet to be implemented.
• Some staff told us that they did not feel encouraged to report concerns.

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.

The provider should:

• Continue to work to improve the uptake of screening and immunisations.
• Continue to work to address patient feedback related to access to appointments.
• Develop a process to oversee the work of pharmacists and physicians’ associates.
• Work to improve the systems for recalling patients with long term conditions.
• Take action to ensure the sustainability of the practice’s operating model.

This service was placed into special measures following the last inspection in March 2022. The service made sufficient improvements so that it will now be taken out of special measures.

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