The Care Quality Commission
  • Doctor
  • GP practice

East Croydon Medical Centre

Overall: Good read more about inspection ratings

59 Addiscombe Road, Croydon, Surrey, CR0 6SD (020) 3657 4170

Provided and run by:
East Croydon Medical Centre

Important: We are carrying out a review of quality at East Croydon Medical Centre. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

Site visit 23 November 2022, Records review 1 December 2022, Interviews 30 November – 23 December 2022

During a routine inspection

We carried out an announced comprehensive inspection at East Croydon Medical Centre, with a site visit 23 November 2022, records review 1 December 2022 and interviews 30 November – 23 December 2022. Overall, the practice is rated as good.

Safe - requires improvement

Effective - good

Caring - good

Responsive - good

Well-led - good

Following our previous inspection in 2021, the practice was rated requires improvement overall and for providing safe services, being effective and being well-led but was rated as good for the other key questions.

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection.

We inspected all of the key questions.

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:

  • Conducting staff interviews using video conferencing.
  • 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:

  • The provider had recently strengthened the operational management of the practice with new staff to support safety systems and processes. There were still weaknesses in some areas, but there were action plans in place to address these and we saw clear evidence of progress.
  • Patients received effective care and treatment that met their needs.
  • There was positive feedback from patients about how staff treated people. There was also some mixed and negative feedback, including from the national GP patient survey.

The practice had an action plan in place to improve patient satisfaction.

  • At the time of the inspection it was challenging for the practice to deliver care in way that suited all patients because there were two GP services operating from one premises space so there was limited space for face-to-face GP appointments. There was mixed feedback from patients about access. There was positive feedback, but also negative feedback, including from the national GP patient survey. The practice had an action plan in place to improve patient access and we saw evidence of actions taken to date and of active monitoring.
  • There was a new management team. Some systems were quite newly-implemented or were being implemented during the inspection, and some weaknesses that had been identified were still being addressed, but action plans were in place and risks were being formally monitored.

We found one breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

Whilst we found no breaches of regulations, the provider should:

  • Continue with work to increase the number of patients identified as having caring responsibilities so that they can be offered support.
  • Continue with work to improve uptake of childhood immunisations and cervical screening, and of learning disability annual reviews.

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

Clinical record review 12 October 2021, site visit 11 October 2021, staff interviews 27, 29 September and 13 October 2021

During a routine inspection

We carried out an announced inspection at East Croydon Medical Centre. A remote clinical records review was undertaken on 12 October 2021, a short site visit was completed on 11 October 2021 and interviews with staff were held remotely on 27, 29 September and 13 October 2021. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective - Requires Improvement

Caring – Good

Responsive - Good

Well-led - Requires Improvement

Following our previous comprehensive rated inspection on 6 November 2019, the practice was rated Requires Improvement overall; requires improvement for safe, effective and responsive and well led and good for caring.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on concerns identified at our last inspection. Specifically:

  • There was not a robust system in place for the management of recruitment checks and medicines.
  • Staff had not completed safeguarding training relevant to their role.
  • The provider did not have an effective system to ensure exception reporting for people with long-term conditions were appropriate.
  • The uptake for cervical screening and childhood immunisations were below average.
  • Some of the patients we spoke to indicated it was difficult to get appointments.
  • Some of the national GP patient survey indicators were below average.
  • Governance systems required improvement.

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.
  • Requesting staff feedback using surveys.
  • 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 and Requires Improvement for the following population groups; working age people, families children and young people and vulnerable people.

We found:

  • The vaccine cold chain had not been monitored in accordance with the practice’s policy.
  • Staff vaccination records were not completed in line with the practice’s own policy.
  • Expired equipment was found with the practice’s emergency equipment.
  • The practice was not undertaking the required monitoring for patients prescribed one medicine that required regular review. However we found that there were robust systems in place to ensure monitoring was completed for high risk medicines.
  • Systems for medication management created a risk that patients on multiple medicines would not have reviews/monitoring undertaken for each of the medicines they were prescribed.
  • One staff member was not able to outline the guidelines in respect of obtaining consent and assessing the capacity of minors.
  • Some risks identified with infection control had not been acted upon; though we found that the practice was trying to engage with the building manager to try and get these issues addressed.
  • Complaint responses did not contain information about organisations that patients could escalate complaints to.
  • There had been little engagement with patients in respect of below average national patient survey scores related to care and treatment and access; though the practice had made some efforts to improve patient satisfaction in these areas.
  • Reviews for patients with learning disabilities did not contain sufficient detail to make them meaningful.
  • There was not an effective system in place to identify patients who were prescribed a large number of asthma inhalers and take steps provide these patients with appropriate support.
  • Rates of cervical screening were below target. However, this service was suspended during the early part of the pandemic and the practice had hired additional nursing staff and could refer patients to the local access hub where this service was available. Additionally, the practice told us they had an annual turnover of approximately 30% of their patients which impacted on the practice’s ability to meet this and other targets.
  • Some staff reported that members of the leadership team were not approachable.

However, we also found that:

  • The practice had worked with the primary care network to provide both the first round of covid 19 vaccinations and booster jabs. The practice had reached out and offered support to those they had identified as having caring responsibilities.
  • The was an extensive programme of quality improvement activity.
  • There was a system to manage significant events.

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

The provider should:

  • Take action to improve approachability of leadership.
  • Have staff refamiliarise themselves with requirements around capacity and consent.
  • Review the patient list size with a view to increasing the number of patients identified as having caring responsibilities.
  • Seek feedback from a broad range of practice patients.
  • Include information about organisations the practice can escalate concerns to if their unhappy with the practice’s complaint responses.
  • Continue to engage with building managers to address issues related to infection control and legionella.
  • Continue with work to improve uptake of childhood immunisations and cervical screening.

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

06 Nov 2019

During a routine inspection

We carried out an announced comprehensive inspection at East Croydon Medical Centre on 06 November 2019 to follow up on the breaches of regulations identified in the last inspection (September 2018).

At the last inspection in September 2018 we rated the practice as requires improvement overall with requires improvement in effective and well-led because:

  • The provider had not considered some incidents as significant events.
  • There was no system in place to monitor the implementation of medicines and safety alerts.
  • Some of the staff had not received training relevant to their role.
  • Some of the staff has not received appraisals on a regular basis.
  • The outcomes for patients with long-term conditions including asthma and mental health were below average and clinical exception reporting for patients with long-term conditions were significantly above average.
  • The provider failed to undertake health checks for patients with learning disability to improve outcomes for these patients.
  • Some performance data was below the local and national averages and national targets.

At this inspection, we found that the provider had addressed most of these areas; however, we identified some new issues.

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 and requires improvement for the all population groups.

We found that:

  • The systems and processes in place to keep patients safe required improvement. For example, the provider did not have a robust system in place for the management of recruitment checks and medicines. Staff had not completed safeguarding training relevant to their role.
  • The provider did not have an effective system to ensure exception reporting for people with long-term conditions were appropriate. The uptake for cervical screening and childhood immunisations were below average.
  • Staff dealt with patients with kindness and respect and patients we spoke to indicated that they were involved in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. However, some of the patients we spoke to indicated it was difficult to get appointments. Some of the national GP patient survey indicators were below average.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care; however, governance systems in place required improvement.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review procedures in place for appropriate coding of medicines reviews.
  • Consider ways to improve uptake for childhood immunisations and cervical screening.
  • Review procedures to improve organisation of recruitment and training records to enable monitoring.
  • Review service procedures to improve low scoring areas in the national GP patient survey to improve patient satisfaction.

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

05 Sep 2018

During a routine inspection

This practice is rated as Requires Improvement overall. (Previous rating 5 June 2017 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at East Croydon Medical Centre on 5 September 2018 as part our inspection programme.

At this inspection we found:

  • The practice had systems to manage risk so that safety incidents were less likely to happen; however, we found that the provider had not considered some incidents as significant events. When incidents did happen, the practice learned from them and improved their processes.
  • We found that some staff had not received training relevant to their role.
  • The practice reviewed the effectiveness and appropriateness of the care it provided. However, the outcomes for patients with long-term conditions including asthma and mental health were below average and clinical exception reporting for patients with long-term conditions were significantly above average.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a focus on learning and improvement.

The areas where the provider must make improvements are:

  • Ensure care and treatment of the service users met their needs.
  • Ensure staff receive appropriate support, training, professional development, supervision and appraisal as is necessary to enable them to carry out the duties they are employed to perform.

The areas where the provider should make improvements are:

  • Improve identification of significant events.
  • Review procedures in place to ensure equipment’s are tested and calibrated appropriately; risk assessments are carried out; there is a system in place to monitor the implementation of medicines and safety alerts.
  • Improve uptake for childhood immunisations and cervical screening.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

To Be Confirmed

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of East Croydon Medical Centre on 8 June 2016. The overall rating for the practice was Good. However breaches of legal requirements were found relating to the Well Led domain. The provider failed to maintain systems and processes to assess, monitor and improve the quality and safety of the services provided. After the comprehensive inspection, the practice submitted an action plan, outlining what they would do to meet the legal requirements in relation to the breach of regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The full comprehensive report can be found by selecting the ‘all reports’ link for East Croydon Medical Centre on our website at www.cqc.org.uk.

This inspection was a focused desk-based review carried out on 19 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 8 June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Following the focussed inspection, we found the practice to be good for providing well led services.

Our key findings were as follows:

  • The practice had effective governance arrangements in place; they had policies and procedures that met the requirements to manage risk. We saw evidence of new and updated policies regarding infection control, safeguarding children and adults, significant events, chaperone policy and a smartcard policy. We saw a comprehensive policy index spread sheet detailing all practice policies. We also saw a range of detailed practice minutes with action points and learning outcomes.

  • The practice had an effective infection control policy in place. We saw evidence of monthly meeting minutes where infection control was discussed. We also saw a checklist the practice used on a daily/monthly basis to ensure infection control was addressed regularly.

  • Since the initial inspection the practice had reviewed their accessibility to patients including those with mobility problems and those with young children. We saw, minutes confirming planning permission had been granted for a first floor extension which would incorporate a lift and a pram park. We saw architect plans for a lift extension which was commencing in April 2017. We saw photographs of a lowered reception counter, and new hand rails on the fire exit/disabled ramp.

We also reviewed the areas we identified where the provider should make improvement:

  • The practice confirmed they discussed their exception reporting rate; however, had no formal minutes.

Importantly, the provider should:

Ensure minutes are kept of discussions in relation to the level of exception reporting, which was higher than the national average.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

8 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of East Croydon Medical Centre on 8 June 2016. 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, however there was no policy and not all significant events were recorded.
  • Risks to patients were assessed and well managed.
  • 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 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 was not ideally suited to patients with mobility problems or parents with pushchairs, as patients had to use steps to make their way up to the first floor and there was no lift to help facilitate this.
  • 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 and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Ensure that governance arrangements are robust, and that policies and procedures meet the requirements of the practice and managing risk.

  • Ensure that the infection control policy is adhered to.

In addition the provider should:

  • Ensure services provided on site are available and accessible to all patients, including those with mobility problems and those with young children.

  • The practice should consider reviewing the level of exception reporting, which was higher than the national average.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice