Lady Margaret Road Medical Centre

Updated 13 March 2024

Lady Margaret Road Medical Centre is located in the borough of Ealing in North West London at:

57 Lady Margaret Road

Southall

Middlesex

UB1 2PH

The practice is run from a single site, in a converted property. The practice is located within the North West London Integrated Commissioning Board (ICB) area and delivers General Medical Services to a patient population of about 3,300 through a contract held with NHS England. The practice is part of the local Primary Care Network (PCN) and Ealing GP Federation.

Information published by Public Health England shows that deprivation within the practice population group is in the fourth lowest decile (four of 10). The lower the decile, the more deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is 65% Asian, 13% White, 9% Black, 2% Mixed, and 10% Other. The working age practice population is slightly higher and the older people practice population is slightly lower than the national average.

The lead GP is supported by 3 regular locum GPs and a recently recruited GP assistant. The practice employs a practice nurse, a locum advanced nurse practitioner ,a health care assistant, a practice manager and a team of administrative and reception staff. Patients have the choice of a male or female GP. The practice also uses ‘associated professionals’ including clinical pharmacists and a social prescriber who are provided through the PCN.

The practice is open between 8am to 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments. Extended access (in the evening and at the weekend) is provided at other practices locally and can be booked through the Lady Margaret Road Medical Centre reception team. Out of hours services are accessed through the 111 telephone/online service.

The lead GP operates a separate general practice at Brunswick Medical Centre which is also in Ealing. The lead GP and practice manager split their time between the 2 practices but are accessible to staff by telephone/online when not present on the premises.

The provider is registered with CQC to deliver the regulated activities: diagnostic and screening procedures; surgical procedures; maternity and midwifery services; treatment of disease, disorder or injury; and family planning.

Updated 13 March 2024

We carried out an announced comprehensive inspection at Lady Margaret Road Medical Centre on 18 September 2023. Overall, the practice is rated as requires improvement.

Safe - good

Effective – requires improvement

Caring - requires improvement

Responsive - requires improvement

Well-led - good

Following our previous inspection on 30 March 2022, the practice was rated requires improvement overall and for all key questions with the exception of caring which was rated good.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Lady Margaret Road Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection in line with our inspection priorities.

At our previous inspection we found a lack of good governance in some areas. The practice had not carried out all necessary environmental risk assessments and checks (including fire safety); there were gaps in recruitment checks and disclosure and barring service checks and our clinical records searches showed that the practice was not always monitoring its prescribing of ‘higher risk’ medicines. There were also coding issues in relation to the usage of medicines and diagnoses of diabetes. In addition, we found that national patient safety alerts had not been consistently actioned and the practice did not have a systematic process for monitoring prescription stationery.

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 and in person.
• Completing clinical searches on the practice’s patient records system (this was in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• A 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:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients generally received effective care and treatment that met their needs. However, the quality of documentation of medicines and asthma reviews was variable and it was sometimes unclear whether patients with poorly controlled diabetes had been offered timely specialist input.
• We observed that staff dealt with patients with kindness and respect but patient feedback about the experience at the practice was mixed and patient survey scores were consistently below average.
• The practice had improved access to the service. It was increasing the proportion of face-to-face appointments and was offering a relatively high number of appointments for the number of registered patients. However, patient survey feedback about access remained below average.
• The way the practice was led and managed promoted the delivery of safe and effective care. The practice had acted on the findings of our previous inspection and could demonstrate how it had improved.

We found a breach of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Audit the management of gabapentin prescribing to ensure this is consistently carried out in line with guidelines. (Gabapentin is a type of medicine typically used to treat epilepsy or nerve pain.)
• Ensure staff and locum staff views are reflected in discussions and decisions about the service.

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 Health Care