- GP practice
Primrose Hill Surgery
All Inspections
2 March 2022
During a routine inspection
We carried out an announced inspection at Primrose Hill Surgery on 2 March 2022. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
How we carried out the inspection/review
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 found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- 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:
- Continue to look at ways to improve patient outcomes from the childhood immunisation and cervical screening programmes.
- Carry out a practice patient feedback exercise.
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
31 Oct 2018
During a routine inspection
This practice is rated as Good overall. (First inspection since re-registration)
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
We carried out an announced comprehensive inspection at Primrose Hill Surgery on 31 October 2018, as part of our inspection programme.
The previously registered and inspected service at this location, Primrose Hill Surgery, was a partnership that de-registered from the Care Quality Commission (CQC) on 6 April 2018. The full comprehensive reports on inspections of the practice under the previous registration in April 2014, June 2016 and January 2018 can be found on our website at .
The current service, also named Primrose Hill Surgery, was registered with CQC with a sole principal GP on 4 April 2018. The principal GP is one of the former partners in the previous service, the other having left the practice.
At this inspection we found:
- Reception staff were unable to describe the symptoms of sepsis nor was the practice displaying a poster in the reception area to assist with identifying the symptoms. Following our inspection, the practice took action to rectify these issues.
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
- Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
- Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
The areas where the provider should make improvements are:
- Ensure that non-clinical staff receive appropriate training and updates to enable them to identify the possible symptoms of sepsis.
- Continue to work to improve uptake, by eligible patients, of its cervical, breast and bowel cancer screening programmes.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.