Background to this inspection
Updated
1 October 2021
The Pinner Road Surgery is a GP practice located in West Harrow in North West London and is part of the Harrow Clinical Commissioning Group (CCG). The practice is located in converted premises. Services are provided from: 196 Pinner Road, West Harrow, Middlesex, HA1 4JS.
Online services can be accessed from the practice website: www.pinnerroadsurgery.co.uk.
The practice is registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures, treatment of disease, disorder and injury and maternity and midwifery services.
The practice provides primary medical services through a Primary Medical Services (PMS) contract to approximately 4480 patients in the local area (PMS contracts are negotiated locally between GP representatives and the local office of NHS England). There is one principal GP, one salaried GP and one long term locum GP at the practice. Two GPs are female and a male, who work a total of 11 clinical GP sessions per week.
The practice employs a practice nurse, a physician’s associate, a clinical pharmacist and a phlebotomist. Non-clinical services are provided by a practice manager, deputy practice manager and a team of administrative and reception staff.
The practice has opted-out of providing out of hours services which were provided by another organisation.
The practice population of patients aged between 5 to 18 years old and patients aged above 65 years old are slightly lower than the national average. Ethnicity based on demographics shows the patient population is ethnically diverse and around 54% of the population is composed of patients with an Asian, Black, mixed or other non-white backgrounds. Information published by Public Health England, rates the level of deprivation within the practice population group as eight, on a scale of one to ten, ten being the least deprived.
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. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the branch surgery.
Updated
1 October 2021
We carried out an announced inspection at The Pinner Road Surgery on 18 August 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on June 2019. the practice was rated Requires improvement overall and for safe and well-led. It was rated good for being effective, caring and well-led.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Pinner Road Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused inspection to follow up on concerns identified at the previous inspection which included breaches of regulations 12 and 17 in relation to safety and governance. At the inspection in June 2019 we found safety concerns around medicines management, emergency equipment and fire safety. We had also found concerns around governance procedures, specifically those relating to practice policies, staff induction and the practice’s response to patient feedback. At this inspection we found improvements had been made.
For this inspection we covered the safe, effective and well-led key questions only.
At the previous inspection in June 2019 we said the practice should consider how to evacuate patients with mobility problems and consider increasing the frequency of patient participation (PPG) meetings. At this inspection in August 2021 we found the practice had carried out a risk assessment which included evacuation plans and no concerns were found. We spoke to the practice manager and chair of the PPG who told us meetings were planned to take place quarterly.
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
- 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 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:
- Review the coding and wording used by the physician’s associate to ensure the type of review being carried out was clear.
- Review the identification of significant events to ensure staff understood the distinction and were able to prioritise them.
- Review and improve achievement in the care of patients with long-term conditions, childhood immunisations and cervical cancer 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