Background to this inspection
Updated
13 October 2021
The Fryent Way Surgery provides NHS primary care services to approximately 8,482 patients with an additional 50 patients in a local care home.
The practice is situated within the NHS Brent Clinical Commissioning Group (CCG) area. The service is provided through a general medical services (GMS) contract with NHS England. The practice is a member of Kingsbury & Willesden Healthcare GP Federation made up of 28 GP practices across Brent. The practice is situated in a residential area, on a main road which is well served by public transport. Parking is available on the premises and on surrounding streets.
The provider is registered with CQC to deliver the Regulated Activities; surgical procedures, maternity and midwifery services, family planning and treatment of disease, disorder or injury.
Information published by Public Health England shows that deprivation within the practice population group is in the sixth lowest decile (six 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 27.4% White, 56.5% Asian, 8.2% Black, 2.9% Mixed, and 4.9% Other.
The provider is a single-handed male GP who is currently absent from the practice. To ensure effective leadership and continuity of care for patients a caretaking management team is in place provided by Kingsbury & Willesden Healthcare. The clinical team consists of two lead GPs, six sessional GPs, one practice nurse, one advanced nurse practitioner, one healthcare assistant / phlebotomist, one phlebotomist and one clinical pharmacist. The clinical team is supported by a practice manager and a large team of reception and administration staff.
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 or video consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment to be seen onsite.
The practice reception is open Monday to Thursday 8.45am to 6.30pm and Friday 8.45 to 6pm. When the practice is closed in the evenings and weekends patients have access to several GP Hubs.
Updated
13 October 2021
We carried out an announced inspection at The Fryent Way Surgery on 09 September 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Requires Improvement
Effective - Good
Well-led - Good
Following our previous inspection on 01 August 2019 the practice was rated Requires improvement overall and for the key questions safe and well-led. The key questions effective, caring and responsive were rated good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Fryent Way Surgery on our website at www.cqc.org.uk
This inspection was a focused inspection on the key questions safe, effective and well-led. It was also carried out to follow-up on breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance.
Why we carried out the inspection
We carried out this focused inspection to follow up on the breaches of Regulation identified at the previous inspection.
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 and good for all population groups.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm. However, some areas of clinical risk management needed improving.
- Patients received effective care and treatment that met their needs.
- 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-centred care.
We found one breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way.
In addition, the provider should:
- Continue to improve cervical screening and childhood immunisation performance to bring in line with national targets.
- Continue to develop the patient participation group to gain feedback from patients and improve the service provided.
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