The Care Quality Commission
  • Doctor
  • GP practice

Dr Jerome Kaine Ikwueke Also known as Grove Road Surgery

Overall: Good read more about inspection ratings

1 Grove Road, Tottenham, London, N15 5HJ (020) 8800 9781

Provided and run by:
Dr Jerome Kaine Ikwueke

All Inspections

During an assessment under our new approach

We carried out an announced assessment of one quality statement, equity of access, under the key question Responsive at Dr Jerome Kaine Ikwueke on the 25 January 2024. Overall, the practice is rated as good overall and the key question responsive continues to be rated as providing a good service. We carried out the assessment as part of our work to understand how practices are working to try to meet peoples demands for access and to better understand the experiences of people who use services and providers. We recognise the work that GP practices have been engaged in to continue to provide safe, quality care to the people they serve. We know staff are carrying this out whilst the demand for general practice remains exceptionally high, with more appointments being provided than ever. However, in this challenging context, access to general practice remains a concern for people. Our strategy makes a commitment to deliver regulation driven by people’s needs and experiences of care. The assessment of the quality statement equity of access includes looking at what practices are doing innovatively to improve patient access to primary care and sharing this information to drive improvement. At this assessment we found: People can access services when they need to, without physical or digital barriers, including out of normal hours and in an emergency. Physical premises and equipment are accessible. People are given support to overcome barriers to ensure equal access. The leaders understood the challenges to patient access and responded to patient needs.

5 September 2022

During a routine inspection

We carried out an announced comprehensive inspection at Dr Jerome Kaine Ikwueke on 5 September 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on 24 July 2021, the practice was rated inadequate overall and for providing safe and well led services. The practice was rated as requires improvement for providing effective and responsive services and rated as good for providing caring services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Jerome Kaine Ikwueke on our website at www.cqc.org.uk

Why we carried out this inspection

When we inspected in July 2021, we rated the practice as inadequate for providing safe and well led services because arrangements for monitoring high risk medicines placed patients at risk and because the practice lacked effective safety alerts systems. We also saw limited evidence of learning from significant incidents and identified concerns regarding staff recruitment processes.

We served a Warning Notice for breach of Regulation 17 and a Requirement Notice for breach of Regulation 16 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The practice was placed into special measures and we asked the provider to take improvement action to achieve compliance with the relevant Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We conducted an unrated, focussed, follow up inspection on 14 March 2022 which confirmed the provider had addressed our most serious concerns (as detailed in the Regulation 17 Warning Notice).

The inspection which took place on 5 September 2022 was a comprehensive, rated inspection to assess whether wider improvements had taken place since July 2021; sufficient for the practice to be taken out of special measures.

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:

  • Leaders had robustly responded to the concerns identified at our July 2021 inspection and had achieved compliance with the relevant Regulations of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.
  • Action had been taken since our last inspection, such that the practice’s monitoring systems now kept patients safe in relation to the use of high-risk medicines.
  • We noted there were now adequate systems in place to manage risks associated with emergency situations.
  • We noted that when things went wrong, there were now systems in place to review, investigate and learn.
  • We noted the practice now had appropriate systems in place to act on safety alerts.
  • Clinical searches confirmed that the practice’s management of long-term conditions now reflected current evidence-based guidance, standards and best practice.
  • We noted that complaints were now handled appropriately - including timely acknowledgment, response and appropriate systems for learning from complaints.
  • Clinical audits were carried out and all relevant staff were involved. There was also participation in relevant local audits (such as prescribing audits).
  • Patient feedback was generally above local and national averages regarding phone and appointments access. Patients fed back that they could access the right care at the right time.
  • Governance arrangements now supported the delivery of high-quality and patient centred care (for example regarding staff induction arrangements , significant incident reporting, safety alerts and complaints management). We noted systems were in place to ensure these governance improvements were sustained.

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

  • Continue to monitor and take action to improve cervical screening and child immunisation uptake rates.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

As a result of the above findings the provider has been taken out of special measures.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

14 March 2022

During an inspection looking at part of the service

We carried out a focussed, unrated inspection at Dr Jerome Kaine Ikwueke (also known as Grove Road Surgery) on 14 March 2022.

Following our previous inspection on 22 July 2021, the practice was rated as Inadequate for the Safe question, the Well led question and overall. The practice was rated as Good for the Caring question and rated as Requires Improvement for the Responsive question.

We identified concerns in regard to whether the service was Safe, Effective, Responsive And Well-Led. We served a Requirement Notice under Regulation 16 (Receiving and acting on complaints) and also served a Warning Notice under Regulation 17 (Good governance) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The practice was placed into special measures and required to address the Warning Notice concerns by 15 October 2021.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Jerome Kaine Ikwueke on our website at www.cqc.org.uk

Why we carried out this inspection

Following the publication of our July 2021 announced comprehensive inspection report, the practice sent us a plan of action to ensure the service was compliant with the requirements of the regulations.

We carried out this focussed inspection on 14 March 2022: looking at the identified breaches set out in the Warning Notice, under the key questions of Safe, Responsive and Well-led.

We found the practice had made improvements sufficient for us to consider the Warning Notice had been met.

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 not reviewed the ratings for the key questions or for the practice overall as this is a focussed follow-up inspection to look at whether the Warning Notices served under the Safe and Well-led key questions have been met. We will consider the practice’s ratings in all key questions and overall when we carry out a full comprehensive inspection at the end of the period of special measures.

We found that:

  • Action had been taken since our last inspection such that there were now adequate systems in place to manage risks associated with emergency situations.
  • Action had been taken since our last inspection such that when things went wrong, there were now systems in place to review, investigate and learn.
  • Action had been taken since our last inspection such that the practice’s monitoring systems now kept patients safe in relation to the use of high-risk medicines.
  • Action had been taken since our last inspection such that complaints were now handled appropriately - including timely acknowledgment, response and appropriate systems for learning from complaints.
  • Action had been taken since our last inspection such that governance arrangements now supported the delivery of high-quality care (for example regarding arrangements for staff induction, significant incident reporting, safety alerts and complaints management).

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

22 July 2021

During an inspection looking at part of the service

We carried out an announced inspection at Dr Jerome Kaine Ikwueke on 22 July 2021. Overall, the practice is rated as Inadequate.

We had previously carried out an announced comprehensive inspection at Dr Jerome Kaine Ikwueke on 9 January 2017. At that time, the practice was rated as Good overall and Good for providing safe, effective, caring, responsive and well led services. The practice was also rated as Good for all six population groups.

Ratings for each key question (22 July 2021)

Safe - Inadequate

Effective -Requires Improvement

Caring – Good

Responsive - Requires Improvement

Well-led - Inadequate

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Jerome Kaine Ikwueke on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on information of concern we hold about the location.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering 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 Inadequate overall and requires improvement for all population groups.

We found that:

  • There were inadequate systems in place to manage risks associated with emergency situations.
  • When things went wrong, the approach to reviewing and investigating causes was insufficient.
  • We saw instances of where care and treatment were not delivered in line with evidence-based guidance (for example regarding gaps in monitoring high risk medicines).
  • Complaints were handled inappropriately and we did not see evidence of discussion, shared learning or how complaints led to improvements in the quality of care.
  • Governance arrangements hindered the delivery of high-quality care (for example regarding staff induction arrangements and arrangements for acting on safety alerts).
  • Patient feedback was above local and national averages regarding phone and appointments access. Patients fed back that they could access the right care at the right time.

We found two breaches of regulations. The provider must:

  • Establish an effective and accessible system for identifying, receiving, recording, handling and responding to complaints.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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 population group, 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.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

09 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Jerome Kaine Ikwueke on 9 January 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 an effective system in place for reporting and recording significant events.
  • 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 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 and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Improve the identification of carers to ensure their needs are known and can be met.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

11 March 2014

During an inspection looking at part of the service

This inspection was a follow up to our visits to the practice on the 16 and 22 October 2013.

At that time we found that the service was failing to comply with the requirements of Regulations 15, 16 and 21 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. Specifically, we found that there had been no recent fire safety risk assessment of the premises, that there had been no recent testing of the fire alarm and fire drills were not routinely carried out. We saw that some disposable medical instruments and supplies were out of date. Finally, there was not sufficient evidence that the provider operated effective employment procedures.

After our inspection in October, the provider sent us a plan of the actions the practice intended to take to meet the requirements of the regulations. We made this follow up inspection to check that the actions planned had been implemented.

We found that the provider had taken sufficient steps to comply with the requirements of the regulations.

16, 22 October 2013

During a routine inspection

We inspected the service on the 16 and 22 October 2013. We spoke with the provider, practice manager, health care assistant and administrative staff. We spoke with people who used the service and reviewed health care records and other records regarding the service. We reviewed other records provided after the inspection. The provider worked with two other doctors, one of whom was on maternity leave. Cover was being provided by locums.

People we spoke with were generally happy with the service provided, although two said that making convenient appointments was occasionally difficult. People told us that the doctors explained matters well and that they had been able to ask questions about their treatment and to make choices.

Many people using the service had English as a second language. There was a very limited amount of information regarding the service, and general health care issues, available in languages other than English at the practice. However, a telephone translation service was available for people attending appointments.

The premises and furniture were clean and tidy. However, we found that there had been no recent fire safety risk assessment. There had been no recent testing of the fire alarm and fire drills were not routinely carried out. Some disposable medical instruments and supplies were out of date.

There was not sufficient evidence that the provider operated effective employment procedures.

We have set compliance actions accordingly.