The Care Quality Commission
  • Doctor
  • GP practice

Eltham Palace Surgery

Overall: Requires improvement read more about inspection ratings

30 Passey Place, Eltham, London, SE9 5DQ (020) 8294 8150

Provided and run by:
Eltham Palace PMS

All Inspections

During an assessment under our new approach

Eltham Palace Surgery is an NHS GP practice which provides primary care services to patients in South East London. We carried out an announced assessment on 29 and 30 April 2024. Following this the service is rated as requires improvement overall and the key questions are rated as: Are services safe? – requires improvement Are services effective? - requires improvement Are services caring ?– requires improvement Are services responsive? – requires improvement Are services well-led? – requires improvement Our key findings from this assessment were: • The practice did not have systems for the appropriate and safe use of medicines. • Patients’ needs were not assessed and care and treatment was not delivered in line with current legislation, standards and evidence-based guidance. • Improvements were needed to patient access. • Governance processes did not ensure high quality care.

3 and 4 May 2023

During a routine inspection

We carried out an announced comprehensive inspection at Eltham Palace Surgery on 3 and 4 May 2023. Overall, the practice is rated as Inadequate.

Safe - Inadequate

Effective - Inadequate

Caring - Requires improvement

Responsive - Inadequate

Well-led - Inadequate

Following our previous inspection on 12 July 2017, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Eltham Palace Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up concerns in response to risk reported to us.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • 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 found that:

  • Patient records did not demonstrate those on high-risk medicines or with long-term conditions had sufficient monitoring to ensure their safety.
  • There was evidence that safety alerts were not being monitored or audited to ensure patient safety.
  • Patients were not able to access care and treatment in a timely way.
  • Patients were not satisfied with GP appointment systems.
  • There were insufficient staff.
  • There was a divide between the two GP partners which had created a toxic work environment for staff.
  • Not all patients’ medical records were kept up to date and accurate.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.
  • The overall governance arrangements were inadequate.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice culture did not effectively support high quality sustainable care.
  • Many staff had not completed recommended training such as safeguarding, infection control or equality and diversity.
  • Some staff did not have disclosure and barring checks completed.
  • There was little to no evidence of auditing or quality assurance.
  • Although the complaints process was on the website, it was not easily accessible.
  • We found hundreds of physical medical records which needed to be summarised and added to clinical records.
  • The practice did have an active patient participation group.

We found three 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.
  • Provide sufficient numbers of suitably qualified, competent, skilled and experienced staff to meet the needs of the people using the service at all times.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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 Health Care

12 July 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Eltham Palace Surgery on 12 July 2017. Overall the practice is 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 a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to make an appointment with a named 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 staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

  • Extended hours were provided three times a week 6.30pm to 7.30pm on Tuesdays and Thursdays and 7am to 8am on Tuesdays.

  • The practice employed a community pharmacist to provide support with medicine management, for example medication reviews.

  • The practice had good continuity of care, as they never used locums.

  • The practice was part of the end of year care which was an initiative set up by Greenwich Clinical Commissioning Group (CCG) for patients with long term conditions. Greenwich CCG had withdrawn funding, however the practice continued year of care treatment for patients with diabetes.

The areas where the provider should make improvement are:

  • Continue to review childhood immunisation rates to increase patient uptake, also patients with mental health problems, and to sustain the improvements for patients with diabetes.

  • Review phone access and appointment availability to improve patient satisfaction.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice