All inspections: Sudbury and Alperton Medical Centre

We carried out an announced comprehensive inspection at Sudbury and Alperton Medical Centre on 21 June 2022. Overall, the practice is rated as Requires improvement.

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Requires improvement

Well-led - Good

Following our inspection on 23 September 2021, the practice was rated inadequate overall and for the safe and well-led key questions and requires improvement for providing effective, caring and responsive services. The practice was placed in special measures and issued with warning notices in respect of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

A follow-up inspection was undertaken in February 2022, to review compliance with the warning notices that were issued following the September 2021 inspection. We found that the provider had taken action to address the breaches identified in the warning notices. The inspection was not rated.

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

Why we carried out this inspection

We carried out this inspection to follow up concerns from the inspection in September 2021. We looked at all five key questions.

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 found that:

The practice had made significant progress to address the concerns identified at our previous inspection.
We identified new concerns in relation to infection prevention and control, and risk assessments of the premises.
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.
People were not always able to access care and treatment in a timely way and this was reflected in the results from the National GP Patient Survey (2022).
The practice had received support from external stakeholders to improve how the practice was managed and promote the delivery of high-quality, person-centred care.

We found a breach of the regulations. The provider must:

Ensure care and treatment is provided in a safe way to patients.

The provider should:

Take steps to ensure fridge temperatures can be measured in the event of electricity loss and in line with National guidance.
Improve uptake rates for cervical cancer screening and childhood immunisations.
Improve patient satisfaction with access to appointments and the service.

I am taking this service out of special measures. This recognises the improvements that have been made to the quality of care provided by this 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 Hospitals and Interim Chief Inspector of Primary Medical Services

We carried out an announced inspection at Sudbury and Alperton Medical Centre on 8 February 2022. This inspection was undertaken to confirm that the practice had carried out their plan to meet the legal requirements regarding the breaches in regulation set out in the warning notices we issued to the provider in relation to Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

At the last inspection in September 2021, the practice was rated inadequate overall and for the key questions safe and well-led. The practice was rated requires improvement for providing effective, caring and responsive services. This will remain unchanged until we undertake a further full comprehensive inspection within six months of the publication date of the September 2021 inspection report.

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

Why we carried out this inspection

This inspection was a focused inspection to follow up on compliance with warning notices in respect of breaches of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance).

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 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

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 not rated this practice as the rating remains unchanged until we have completed a further inspection incorporating all relevant key questions.

However, we found that:

Action had been taken to address the areas of the breaches identified in the warning notices and it was evident that work had taken place and improvements had been made.
The practice had implemented systems and processes to safely manage patients who were diabetic and patients prescribed high-risk medicines.
The practice had reviewed and amended the processes for monitoring and cascading safety alerts.
The practice had carried out work to improve the oversight of clinical and managerial systems along with governance arrangements.

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

We carried out an announced inspection at Sudbury and Alperton Medical Centre on 23 September 2021. Overall, the practice is rated as inadequate.

Safe - Inadequate

Effective - Requires improvement

Caring - Requires improvement

Responsive - Requires improvement

Well-led - Inadequate

Following our previous inspection on 25 February 2020, the practice was rated requires improvement overall and for the key questions safe, effective, responsive and well-led but Good for providing caring services.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on breaches of regulation and areas of concern identified at our previous inspection. We looked at all five key questions.

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 inadequate overall and for the safe and well-led key questions and the People experiencing poor mental health population group. We have rated the practice as requires improvement for the effective, caring and responsive key questions and the remaining five population groups (Older people; People with long-term conditions; Families, children and young people; Working age people and People whose circumstances may make them vulnerable).

We found that:

The practice did not provide care in a way that kept patients safe and protected them from avoidable harm as the practice did not have systems for the appropriate and safe use of medicines.
People with long-term conditions and people experiencing poor mental health did not receive effective care and treatment that met their needs.
Feedback from patients was mixed about the way staff treated people.
The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
Although the practice had reviewed patient feedback and made efforts to improve areas of dissatisfaction, feedback from patients reflected dissatisfaction with telephone access and access to appointments.
The overall governance arrangements were ineffective and had further deteriorated since our last inspection as we identified new concerns which did not promote the delivery of high-quality, person-centred care.

We found two breaches of regulations. The provider must:

Ensure that care and treatment is provided in a safe way.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

In addition to the above, the provider should:

Continue to monitor and address outstanding actions from the fire risk assessment and infection prevention and control audit.
Review the systems for clinical oversight of staff undertaking structured medicines reviews.
Continue work to increase the uptake for cervical cancer screening and improving outcomes for patients experiencing poor mental health.
Continue to monitor and improve patients’ and care home staff’s satisfaction with the service.
Review the arrangements for staff to have access to a Freedom to Speak Up Guardian.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

We carried out an announced comprehensive inspection at Sudbury and Alperton Medical Centre on 25 February 2020 as part of our inspection programme.

At this inspection, we followed up on breaches of regulations identified at a previous inspection on 16 January 2019. We rated the practice as requires improvement overall in January 2019. Previous reports on this practice can be found on our website at: https://www.cqc.org.uk/location/1-538804637.

At this inspection, we found that the practice had demonstrated improvements in some areas, however, we found additional risks and they were required to make further improvements.

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 and requires improvement overall for all population groups.

We rated the practice as r equires improvement for providing safe, effective, responsive and well-led services because:

Patient Group Directions (PGDs) had not been adopted by the practice to allow the locum nurse to administer medicines in line with legislation.
Risks to patients were assessed and well managed in most areas, with the exception of those relating to the monitoring of fridge temperature checks, fire safety procedures, emergency medicines and Disclosure and Barring Service (DBS) checks were not always undertaken appropriately where required in a timely manner.
Recruitment checks were not always carried out in accordance with regulations. Staff vaccination and professional registration were not regularly monitored.
The practice antibacterial prescribing was higher than the local and national averages.
The practice was unable to demonstrate that they had an effective system to monitor and improve patient outcomes for people with long-term conditions and people experiencing poor mental health.
The practice’s uptake of the national screening programme for cervical cancer screening and childhood immunisations rates were below the national averages.
Some health and safety and staff documents were not accessible on the day of the inspection.
The practice was unable to demonstrate that all staff had received annual appraisals and appropriate training relevant to their role.
Feedback from patients reflected that they were not always able to access care and treatment in a timely way.
The practice had not done all that was reasonably practicable to assure systems and processes were established and operated effectively to ensure compliance with requirements to demonstrate good governance.

We rated the practice as good for providing caring services because:

Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated all population groups as requires improvement for providing effective and responsive services because they were all affected by the issues identified.

The areas where the provider must make improvements are:

Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

Improve the monitoring of blank prescription forms in line with national guidance.
Continue to encourage and monitor cervical cancer screening and childhood immunisation uptake.
Take action to ensure information leaflets are available in other languages and in easy read format.
Consider reviewing the practice’s website to see if it meets patients needs and expectations.
Review the patient participation group (PPG) feedback.

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

We carried out an announced comprehensive inspection at Sudbury and Alperton Medical Centre on 16 January 2019 as part of our inspection programme.

At the last inspection in November 2014 we rated the practice as good overall. Previous reports on this practice can be found on our website at: https://www.cqc.org.uk/location/1-538804637.

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 rated the practice as requires improvement for providing safe services because:

Risks to patients were assessed and well managed in some areas, with the exception of those relating to safety alerts, some safeguarding procedures and the management of legionella.
The practice did not have appropriate systems in place for the safe management of medicines, including the monitoring of some high risk medicines.
The practice had not appropriately managed some fire safety procedures.
Electrical installation condition inspection was not carried out at both premises.
Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes. However, we noted significant events were not documented during staff team meetings.
Recruitment checks were carried out in accordance with regulations.

We rated the practice as requires improvement for providing well-led services because:

There was a lack of good governance in some areas.
There was no formal monitoring system for following up patients experiencing poor mental health and patients with dementia who failed to collect their prescriptions in a timely manner; or to identify and monitor who was collecting the repeat prescriptions of controlled drugs from the reception.
There was an ineffective system in place to monitor the use of blank prescription forms for use in printers and handwritten pads. The practice had recently developed a policy and was in the process of implementing changes.
The practice was aware of and complied with the requirements of the Duty of Candour.
Staff we spoke with on the day of inspection informed us there was a clear leadership structure and they felt supported by the management.

We rated the practice as good for providing effective, caring and responsive services because:

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 had the skills, knowledge and experience to deliver effective care and treatment.
Staff dealt with patients with kindness and respect and involved them in decisions about their care.
The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
The practice was encouraging patients to register for online services and 46% of patients were registered to use online Patient Access.
Information about services and how to complain was available and easy to understand.

We have rated this practice as good for all population groups, except requires improvement for Families, children and young people for providing effective services, because of low uptake rates for the national childhood vaccination programme.

The areas where the provider must make improvements are:

Ensure that care and treatment is provided in a safe way.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

Review formal sepsis awareness training needs for non-clinical staff to enable them to identify patients with severe infections.
Continue to improve, monitor and encourage uptake of childhood immunisation and cervical screening.
Continue to monitor and act on patient satisfaction with telephone access to the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

Sudbury and Alperton Medical Centre provides a GP service to approximately 8027 patients in Brent. Sudbury and Alperton Medical Centre is based at two locations (branches), Ealing Road, Brent and Watford Road, Harrow. We visited the Brent location as part of this inspection.

We carried out an announced comprehensive inspection of Sudbury and Alperton Medical Centre on 29 October 2014 and 19 November 2014 (PM). Overall the practice is rated as good. Specifically, we found the practice to be good at providing well-led, safe, effective, caring and responsive services.

Our key findings were as follows:

Patients were overall satisfied with the service. They said the staff were able to get an appointment within a reasonable time, staff involved them in decision making about their care and were kind and respectful.
Medicines were managed safely and infection control measures were in place.
Staff were suitably qualified and received sufficient training to meet patients needs.
The practice sought feedback form patients and staff and acted on it to improve the services provided.

However, there was one area where the provider needed to make am improvement.

An automated external defibrillator should be available for medical emergencies.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

Sudbury and Alperton Medical Centre

All Inspections

21 June 2022

During a routine inspection

08 February 2022

During an inspection looking at part of the service

23 September 2021

During a routine inspection

25 February 2020

During a routine inspection

16 January 2019

During a routine inspection

29 October 2014 19 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)