Central Surgery

Updated 12 August 2022

Central Surgery is located in Surbiton at:

Surbiton Health Centre, Ewell Road, KT6 6EZ

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within South West London Clinical Commissioning Group and delivers Personal Medical Services (PMS) to a patient population of about 13,000. This is part of a contract held with NHS England. The practice team is made up of 12 GPs (three Partners), four nurses, one senior pharmacist, two Primary Care Network (PCN) pharmacists, one paramedic, three healthcare assistants, one PCN physiotherapist and two PCN social prescribers. The practice manager and assistant are supported by 17 administration and reception staff.

The practice is open Monday to Friday from 7.30am to 6.30pm. Extended hours surgeries are offered between 8am and 8pm most days and there is an out of hours service available 24 hours a day. The practice operates from a 3-storey purpose built premises, which also houses three other practices and a range of community services. Car parking is available on-site. The reception desk, waiting area and consultation rooms are situated on the ground floor. The practice manager’s office and administrative office are situated on the second floor. The practice has access to 13 doctors’ consultation rooms and three treatment rooms.

Updated 12 August 2022

We carried out an announced inspection at Central Surgery on 21 April 2022. Clinical records reviews were carried out remotely on 20 April 2022. Overall, the practice is rated as requires improvement.

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 Central Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection
We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.

How we carried out this 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:

• The practice had not completed monitoring for all patients on high risk medicines.
• The practice had not completed monitoring for all patients with long-term conditions.
• The practice had not acted in response to all MHRA alerts.
• There was no patient participation group or patient feedback process.
• Some staff had not completed recommended training.
• There was no clear governance or quality assurance process in place for patient monitoring, significant events, complaints, safeguarding or patient feedback.
• Patients had given positive feedback about the levels of access at the practice and the care provided by clinicians.
• The premises were clean and well organised.
• The practice responded to and engaged well with complaints and feedback from patients.

We found breaches of regulations. The provider must:
• 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.

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