Barlby Surgery

Updated 4 November 2021

Barlby Surgery is located in West London at:

St Charles Centre for Health & Wellbeing

Exmoor Street

London

W10 6DZ

The practice is situated on the first floor, a wing of the large, modern, purpose-built health centre that provides a range of primary care services. The health centre building is owned and managed by NHS Property Services. Accessible facilities are available throughout the building.

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.

Barlby Surgery is managed by the provider AT Medics Limited. The management contract commenced in 2004. AT Medics Limited is run by six GP directors who are all practising GPs and they manage over 37 GP locations across London.

The practice is situated within the NHS West London (CCG) and delivers Alternative Provider Medical Services (APMS) to a patient population of about 11,050. This is part of a contract held with NHS England.

The practice is part of a local Primary Care Network (PCN).

Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.

There are a higher than the average number of patients under the age of 18 and fewer patients aged over 85 than the national average.

There are five GPs, four male and one female, who collectively work a total of 36 sessions a week. The practice employs a practice nurse, a clinical pharmacist and a health care assistant (also a phlebotomist). The practice also employs a practice manager, an assistant practice manager and a team of administrative and reception staff. The practice manager and assistant practice manager are based at the main location to provide managerial oversight. The administrative team is supported by a central administrative team based remotely.

The practice is a London Deanery accredited training practice. The practices hosts medical students, Foundation Doctors and GP Registrars. There are 2 GP Trainers/supervisors at the practice currently.

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 face-to-face appointment.

Extended access is provided at local hubs, where late evening and weekend appointments are available. Out of hours services are provided by an alternative provider, London Central West (LCW), where phones are diverted after closing hours.

Updated 4 November 2021

We carried out an announced inspection at Barlby Surgery on 5 and 21 October 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Following our previous inspection on 28 February 2019, the practice was rated Good overall and for the key questions effective, caring, responsive and well-led. The practice was rated requires improvement for providing safe services and issued a requirement notice for Regulation 12 Safe care and treatment.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Barlby 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 breaches of Regulation 12 Safe care and treatment.

At this inspection we covered the following key question:

• Are services safe?

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. We rated the practice as Good for providing safe services.

We found that:

• The practice had demonstrated improvements compared to the previous inspection.
• Our clinical records searches showed that the practice had an effective process for monitoring patients’ health in relation to the use of medicines including high-risk medicines.
• We found the prescription box for uncollected prescriptions was monitored effectively.
• We noted the system for checking single-use equipment and the doctors’ bag was operating effectively.
• Sepsis awareness had been discussed in the practice meetings, which included scenario based discussion and training.
• Blind loop cords were secured appropriately.
• We found the practice did not have any formal monitoring system in place to assure themselves that blank prescription forms were recorded correctly, and records were maintained as intended.
• The practice had maintained a complaints log and all complaints were discussed and learning shared during team meetings at the practice and regional level.

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

• Ensure that the newly written protocol for the safe and secure oversight of blank prescription management is embedded and appropriately reviewed to be assured that it is operating effectively.

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