The Care Quality Commission
  • Doctor
  • GP practice

Lady Margaret Road Medical Centre

Overall: Requires improvement read more about inspection ratings

57 Lady Margaret Road, Southall, Middlesex, UB1 2PH (020) 8574 5186

Provided and run by:
Dr Mohammad Alzarrad

All Inspections

18 September 2023

During a routine inspection

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

30 March 2022

During a routine inspection

We carried out an announced inspection at Lady Margaret Road Medical Centre on 30 March 2022. Overall, the practice is rated as Requires Improvement.

The key questions are rated as:

Safe - Requires improvement

Effective - Requires improvement

Caring - Good

Responsive - Requires improvement

Well-led - Requires improvement

Following our previous inspection on 23 September 2019, the practice was rated Good overall and for all key questions.

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

This was a comprehensive inspection. We carried out this inspection in response to concerns we received as part of our regulatory functions. At this inspection we covered all key questions:

  • Are services safe?
  • Are services effective?
  • Are services caring?
  • Are services responsive?
  • Are services well-led?

How we carried out the inspection

Throughout the pandemic, CQC has continued to regulate and respond to risk. At this inspection, we visited the practice which included:

  • Conducting staff interviews
  • 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

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 Requires Improvement overall.

We found:

There was a lack of good governance in some areas.

  • Our clinical records searches showed that the practice did not always have an effective process for monitoring patients’ health in relation to the use of medicines including high risk medicines and potential missed diagnosis/ coding issues with diabetes and over usage of medicines.
  • Risks to patients were not assessed and well managed in relation to fire safety, recruitment checks, infection prevention and control and the national patient safety and medicines alerts.
  • The practice did not have any formal monitoring system in place to assure themselves that blank prescription forms were recorded correctly, and their use was monitored in line with national guidance.
  • The fixed electrical installation checks, portable appliance testing and a gas safety check were not carried out in a timely manner.
  • The practice’s uptake of the national screening programme for cervical and bowel cancer screening was below the national average.
  • Feedback from patients was mixed about the way staff treated people and they said they were not always felt actively involved in decisions about care and treatment.
  • The Patient Participation Group (PPG) was not active.
  • The practice carried out repeated clinical audits.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • The practice could not provide documentary evidence that the prescribing competence of a non-medical prescriber was regularly reviewed and findings were discussed with them.
  • Patient treatment was not always regularly reviewed and updated.
  • Structured medicines reviews for patients with some long term conditions were not always carried out in a timely manner.
  • Patients were not able to access the telephone system in a timely manner.

We found three breaches of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Carry out structured medicines reviews for patients with long-term conditions such as chronic obstructive pulmonary disease (COPD) and dementia.
  • Take steps to install secondary thermometer in a fridge used to store vaccines.
  • Continue to encourage the patient for cervical and bowel cancer screening uptake.
  • Review patients’ feedback regarding involvement in decisions about care and treatment and access to the telephone system.
  • Maintain records when the prescribing competence of a non-medical prescriber is reviewed and discussed with them.
  • Organise sepsis awareness training.
  • Continue to make efforts to re-establish the patient participation group (PPG).

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

23 September 2019

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Lady Margaret Road Medical Centre on 23 September 2019. We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

We also followed up the ratings awarded at the previous inspection on 10 May 2018. At that inspection, we rated the caring key question Requires Improvement. This was due to patient feedback gathered through the National GP Patient Survey which showed the practice results were below average.

Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions:

  • Is the service effective?
  • Is the service caring?
  • Is the service well-led?

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

  • Is the service safe? (Good)
  • Is the service responsive? (Good)

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 found that:

  • Patients received effective care and treatment that met their needs.
  • Patient feedback on the experience at the surgery was mixed. Evidence obtained on the day showed that staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider should make improvements are:

  • Review the practice’s approach to protected time for staff to complete required training.
  • Review the practice’s approach to cervical screening and assess whether further actions are required to improve uptake.
  • Expand and embed quality improvement methods such as clinical audit to drive improvement.
  • Actively monitor and act on patient feedback from a range of sources including the patient participation group.

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

19 December 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 11 December 2015 at Lady Margaret Road Medical Centre. At that inspection the practice was rated good overall. However we rated the safety of the service as requires improvement. This was because staff members were acting as chaperones without having had training and also because the practice was not equipped with a defibrillator for use in an emergency and could not show it had effectively assessed this risk. The full comprehensive report of the 11 December 2015 inspection can be found by selecting the ‘all reports’ link for Lady Margaret Road Medical Centre on our website at www.cqc.org.uk.

This inspection was a desk-based review and commenced on 19 December 2016 to check that the practice had followed their plan to address the findings identified in our previous inspection on 11 December 2015. This report covers our findings in relation to those requirements and also outlines additional improvements made since our previous inspection.

Overall the practice remains rated as good. Following this inspection, we revised the practice’s rating for safe services and the practice’s rating for the care of people of working age to good.

Our key findings were as follows:

  • Administrative staff members who acted as chaperones had completed formal training on how to carry out the role effectively.
  • The practice had purchased a defibrillator with pads since our previous inspection. The practice also provided evidence of staff training and the routine monitoring checks it was carrying out on this equipment.
  • We noted improvements to the practice’s cervical screening uptake rate since our previous inspection.
  • The practice had introduced a telephone reminder system to encourage patients to attend for bowel screening which had been recognised through the clinical commissioning group’s local improvement scheme 2015/16.
  • The practice had identified 46 patients who were carers, that is, 1.5% of the practice list. The practice had also designated one of the staff members as a ‘carer’s champion’ and had an agreement with the local carers centre to refer carers there if they needed advice or additional support.

However, there remained one area of practice where the provider needs to make improvements. The provider should:

  • Continue to focus on ways to improve patient satisfaction. In our previous inspection we reported on the national GP patient survey results for the practice. For example, at that time the most recent survey results showed that 55% of patients said the last GP they saw was good at involving them in decisions about their care (compared to the clinical commissioning group average of 74%). The current survey results show little change as yet with 57% of practice patients responding positively to this question.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

11 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lady Margaret Road Medical Centre on 11 December 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open approach to safety and an effective system in place for reporting and recording significant events. The provider complied with the requirements of the duty of candour.
  • Most risks to patients were assessed and well managed. However some practice staff acting as chaperones had not received training and were unclear about aspects of the role.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients we spoke with said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. However the practice consistently scored below average on the national GP patient survey for these aspects of care.
  • 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 we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care. Urgent appointments were available the same day. The practice opened on weekends on a rota basis to Ealing patients who required access primary care. 
  • The practice developed care plans for patients with complex needs and reviewed cases at locality multidisciplinary meetings.
  • The practice participated in local initiatives to improve access to care, for example providing anticoagulation clinics, phlebotomy, ECG testing, insulin initiation to patients in the locality.
  • 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 areas where the provider must make improvement are:

  • The practice must ensure that all staff undertaking chaperone duties have training on the purpose of the role and how to carry it out.
  • The practice should record its risk assessment showing that a defibrillator is not required.

The areas where the provider should make improvement are:

  • The practice should maintain a stock of emergency medicines that meets with current recommendations for general practice.
  • The practice should continue to review ways to improve cervical and bowel screening uptake and coverage rates.
  • The practice should review the unusually low prevalence of chronic obstructive pulmonary disease within its population.
  • The practice should continue to review ways to improve patient satisfaction, for example, with the timeliness of appointments and involvement in decision making.
  • The practice should review it's systems to identify carers and to provide them with support.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

15 January 2014

During a routine inspection

During our inspection we spoke with three people using the service, the practice manager, two GP's, the receptionist and secretary. We viewed two medical records.

People told us the service they received overall was good. They said that staff were friendly and polite and care and treatment was provided with respect and consideration. People received care and support that met their assessed needs.

We saw that people were involved in making decisions about their care and treatment and where required appropriate referrals were made to the relevant hospital.

Feedback obtained from people using the service had led to some improvements being made, such as appointments and extended surgery hours.

Systems were in place for safeguarding children and adults.

There were enough qualified, skilled and experienced staff to meet people's needs.

People told us they could speak with staff if they had any concerns or worries. The provider had in place an effective complaints management system.