Church Lane Surgery

Updated 4 January 2023

Church Lane Surgery is a GP practice located in the London Borough of Brent in North West London. The practice is located in converted premises. Services are provided from 282 Church Lane, Kingsbury, London. NW9 8LU. The practice is registered with the CQC to provide the regulated activities: diagnostic and screening procedures; family planning; maternity and midwifery services; surgical procedures; and treatment of disease, disorder or injury. Church Lane Surgery is situated within the North West London Clinical Commissioning Group (CCG) and provides services to approximately 9,657 patients under the terms of a Personal Medical Services (PMS) contract. There are three partners and one salaried GP. Two of the GPs are male and two are female. The practice employs a practice nurse, healthcare assistant and a phlebotomist/ healthcare assistant. The practice manager is supported by a deputy practice manager and a team of administrative and reception staff. The practice works with Primary Care Network (PCN) staff, including: a clinical pharmacist; two social prescribing link workers; and a health and wellbeing coach. According to the latest data available, the ethnic make-up of the practice is 44.7% Asian, 33.5% White, 12.3% Black, 5.65 Other ethnic groups and 3.8% Mixed. Information published by the UK Health Security Agency (UKHSA) rates the deprivation within the practice population groups as six, on a scale of one to ten. Level one represents the highest level of deprivation and ten the lowest.

Updated 4 January 2023

We carried out an announced focused inspection at Church Lane Surgery on 26 October 2022, with the remote clinical interview on 24 October 2022. Overall, the practice is rated as good, with the following ratings for each key question:

Safe – Good

Effective – Good

Caring – Not inspected, rating of good carried forward from previous inspection

Responsive – Not inspected, rating of good carried forward from previous inspection

Well-led – Good

Following our previous inspection on 4 August 2021, the practice was rated as requires improvement overall. We rated the practice as inadequate for providing safe services, requires improvement for providing effective and well-led services and good for the caring and responsive key questions. We carried out an announced remote inspection on 23 February 2022, which was an unrated inspection of the service. At this inspection, we found that the practice had addressed the issues identified at out inspection on 4 August 2021, in relation to the safe key question.

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

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulation from our previous inspection in August 2021.

This inspection was a focused inspection focusing on whether:

• Care and treatment was being provided in a safe way to patients.
• There were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.

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.
• Information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall.

We have rated this practice as Good for providing safe, effective and well-led services because:

• The practice had clear systems, practices and processes to keep people safe from abuse. We found that two non-clinical members of staff had not completed safeguarding children training to the appropriate level. The practice informed us that these members had completed this training after our inspection.
• The practice had addressed all concerns identified in our previous inspection in August 2021. At this inspection, we found:
• The practice now had a process in place to effectively monitor patients prescribed high risk medicines.
• The practice now had an effective system in place to implement Medicines and Healthcare Products Regulatory Agency (MHRA) alerts.
• The practice had made improvements to the monitoring of emergency medicines, emergency equipment and vaccinations. We saw that emergency medicines, supplies and vaccinations were all in date and that checking was completed routinely. The emergency medicines held on site were appropriate and risk assessments had been completed for emergency medicines not held on site.
• The practice had made improvements to how it monitored the over usage of medicines, including the over usage of inhalers in patients with asthma. The practice now had safe systems and processes in place and oversight of over usage of medicines.
• The practice now had a learning disabilities protocol and we were satisfied that there was a system in place and oversight to ensure that learning disability reviews were completed appropriately and actions taken where needed.
• We found that the practice was appropriately managing long-term conditions, including diabetes, chronic kidney disease (CKD) and asthma. The practice had made improvements to coding of diabetes and had safe systems and processes in place and oversight of patients with a potential diagnosis of diabetes. We provided feedback to the practice regarding the following up of patients within the timeframe specified by The National Institute for Health and Care Excellence (NICE) guidance. The practice assured us that it was now actively following up patients.
• The practice had processes and oversight in lace for the completion and review of do not attempt cardiopulmonary resuscitation (DNACPR) coding and forms.
• The practice kept accurate and comprehensive clinical records. We saw that medication reviews were completed in detail in the clinical records system, including that all monitoring was up to date or requested and that any relevant safety information of advice had been addressed.
• The practice now had processes in place for discussing the risks of some medicines with patients of childbearing age before prescribing.
• The practice had a process for the review of palliative care patients and completion of personalised care plans in conjunction with the Royal College of General Practitioners guidelines.
• The practice now had an adequate system in place for the evacuation of patients with mobility issues in the event of a fire. The practice now had an evacuation chair in place for use of evacuation of patients from the rear fire exit if required.
• The premises were well managed and there were effective systems for managing staff records.
• The practice’s uptake for cervical screening was below the 80% coverage target for the national programme, however the practice had put in place systems to address barriers to the uptake of screening and was working towards increasing uptake.
• The practice had met the 90% uptake target in three of the childhood immunisation uptake indicators, was very close to meeting this in one of the indicators, and was above 80% in the other indicator. The practice had not met the WHO based national target of 95% (the recommended standard for achieving herd immunity) in all of the childhood indicators, however, it was close to reaching this target in three of the indicators. The practice had put in place systems to address barriers to the uptake of childhood immunisations and was working towards increasing uptake.
• The practice had worked towards providing effective care for patients during the Covid-19 pandemic.
• The practice had made improvements in providing well-led services in relation to good governance. It had implemented systems and processes in response to the findings of our previous inspection.
• The practice strongly encouraged personal and professional development and learning amongst staff and was supportive in staff undertaking appropriate learning for their roles and in their future aspirations.
• The practice had a strong focus on the well-being of its staff and encouraged feedback from staff, which it acted upon. Staff members spoke positively about their employment at the practice and felt supported.
• We received feedback from the Patient Participation Group (PPG) that the practice was responsive in listening to patients.

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

• Continue to take steps to ensure that all non-clinical staff have completed the appropriate level of safeguarding children training.
• Continue to review and monitor patients with acute exacerbation of asthma in line with NICE guidance.
• Continue with plans 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 Sean O’Kelly BSc MB ChB MSc DCH FRCA

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