Background to this inspection
Updated
28 June 2019
The Surgery, also known as 102 The Avenue Surgery, is located in the London Borough of Ealing.
The Surgery is situated in Ealing Clinical Commissioning Group (CCG) and provides services to approximately 3,700 patients under the terms of a general medical services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community.
The provider is registered with the CQC as an individual entity to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning, and treatment of disease, disorder or injury. At the time of inspection, the practice was formalising a new partnership agreement between the GP principal and a sessional GP.
Staff at the practice consisted of two GP partners (female and male), a practice nurse (female), a health care assistant (female), a practice manager, a deputy practice, practice manager, six receptionists and a secretary.
The age range of patients is predominantly 15 to 64 years. The practice has a lower percentage of patients over 65 years when compared to the national average. The National General Practice Profile states that 16% of the practice population is from an Asian background with a further 18% of the population originating from black, mixed or other non-white ethnic groups. Information published by Public Health England rates the level of deprivation within the practice population group as six, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.
Updated
28 June 2019
We decided to undertake an announced focused inspection of this service on 14 May 2019 following our annual review of the information available to us. This inspection looked at the following key questions: Safe, Effective and Well-led.
At the last inspection in August 2018 we rated the practice as good overall, and requires improvement for providing safe services because:
- There were shortfalls in the systems for monitoring patients on some high-risk medicines.
- The system to manage uncollected repeat prescriptions was not effective.
- There were no records to confirm the action taken in response to safety alerts.
- Some non-clinical staff were unclear about their responsibilities when acting as chaperones.
- Reception staff had not been provided with training to assist them in identifying a deteriorating or acutely unwell patient.
- Improvements were needed in the auditing of infection prevention and control.
At this inspection, we found that the provider had satisfactorily addressed these areas.
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 good overall and good for all population groups.
We found that:
- 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.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Complete the outstanding actions identified in the latest infection prevention and control audit.
- Improve the monitoring and security of blank prescriptions stored in consulting rooms.
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
Working age people (including those recently retired and students)
Updated
28 June 2019
People experiencing poor mental health (including people with dementia)
Updated
28 June 2019