Custom House Surgery

Updated 29 July 2022

Custom House Surgery is partnership located in the London Borough of Newham at Custom House at 16 Freemasons Road, London, E16 3NA.

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 the NHS Newham Clinical Commissioning Group (CCG) and provides primary care to around 9,800 patients under a Personal Medical Services (PMS) contract. This is part of a contract held with NHS England. The practice is part of a wider Primary Care Network (PCN) of GP practices – South One Primary Care Network (PCN).

The clinical staff team are two male partner GPs both working eight sessions per week, a female salaried GP working four sessions, two regular locum GPs (one male and one female) collectively working eight sessions. Two female advanced nurse practitioners collectively working 11 sessions, a female Practice Nurse working four sessions, a full time clinical pharmacist, and three female healthcare assistants (two full time and one part time) that also undertake phlebotomy (blood tests) on site.

The clinical team are supported by a full time practice manager and a team of reception and administrative staff. Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations.

GP appointments are available Monday to Friday 8am to 6.30pm.

Extended hours appointments are provided via the PCN 6.30pm to 10pm on weekdays, Saturday 9am to 5pm and Sunday 9am to 1pm. Patients telephoning when the practice is closed are directed to the local out-of-hours service provider, the Newham GP Co-operative.

Updated 29 July 2022

We carried out an announced inspection at Custom House Surgery on 20 June 2022.

Overall, the practice is rated as Requires Improvement.

The ratings for each key question are:-

Safe - Good

Effective – Requires Improvement

Caring - Good

Responsive – Requires Improvement

Well-led - Good

Following our previous inspection on 20 October 2021, the practice was rated Requires Improvement overall. The key questions were rated Inadequate for providing a Safe service, Requires Improvement for providing an, Effective, Responsive and Well-led services and Good for providing a Caring service.

At the inspection we issued a breach of Regulation 17 (Good Governance) and 12 (Safe Care and Treatment) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

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

Why we carried out this inspection

This comprehensive inspection was to review the improvements made by the provider in response to the breaches of regulation.

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: 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 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.
• 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 made significant improvements since the last inspection and had developed a good strategy to continue drive improvements.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs. However, child immunisations and cervical screening remained below the national target.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way. However, further action was required to improve the practice performance regarding patient satisfaction.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We found one breach of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

• Improve whole practice communication to allow all staff member sto be aware of what is happening within the practice.
• Conduct annual apprasials for all staff within the appropriate timeline.

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