The Care Quality Commission
  • Doctor
  • GP practice

The Stanmore Medical Centre

Overall: Good read more about inspection ratings

85 Crowshott Avenue, Stanmore, Middlesex, HA7 1HS (020) 8951 3888

Provided and run by:
The Stanmore Medical Centre

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Stanmore Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Stanmore Medical Centre, you can give feedback on this service.

13 October 2022

During an inspection looking at part of the service

We previous carried out an announced comprehensive inspection at The Stanmore Medical Centre on 03 August 2021. The overall rating for the practice was good, with the exception of key question of responsive which was rated requires improvement. The full report on the 03 August 2021 inspection can be found by selecting the ‘all reports’ link for The Stanmore Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced focused follow-up inspection carried out on 13 October 2022 to confirm that the practice continued to make improvements on areas that we had identified the August 2021 inspection.

Why we carried out this inspection

We carried out this inspection to follow up on the areas from the last inspection that we identified the practice should improve on.

At the last inspection in August 2021, we rated the practice requires improvement for providing responsive services because:

  • The practice National GP Survey data continued to be lower than local and national averages in relation to patient access to services at the practice.

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:

  • Requesting evidence from the provider in advance of the site visit.
  • Conducting staff interviews using telephone calls

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 had systems in place to review and act on complaints, however evidence to show learning gained from complaints was not always apparent.
  • The practice had increased the use of text messaging to send a range of information to patients.
  • The National Patient Survey achievement scores for the provider continued to be lower than local and national averages for the second year running.
  • The practice responded to the needs of its patients. This was evidenced by the introduction of “in-school clinics”, where appointments were available for pre-school aged children during the afternoon.

Whilst we found no breach of regulations. The provider should:

  • Continue to identify effective systems to act upon the low achievement scores attributed to the practice from the most recent published National GP Survey.

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

3 August 2021

During a routine inspection

We previously carried out an announced comprehensive inspection at The Stanmore Medical Centre on 25 April 2019. The overall rating for the practice was requires improvement, with the exception of key question Effective which was rated good. The full report on the 25 April 2019 inspection can be found by selecting the ‘all reports’ link for The Stanmore Medical Centre on our website at www.cqc.org.uk.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring – Good

Responsive – Requires improvement

Well-led - Good

This inspection was an announced comprehensive follow-up inspection carried out on 3 August 2021 to confirm that the practice continued to make improvements on areas that we had identified at our previous inspection held on 25 April 2019. This report covers our findings in relation to those improvements and also additional improvements made since our last inspection. 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.

Why we carried out this inspection

This inspection was a comprehensive follow-up inspection to review progress against previous breaches of regulation

  • The practice did not have clear systems and processes to keep patients safe. This included recruitment checks, staff immunisations, equipment checks, fire and health and safety, infection control and mandatory staff training.
  • The processes in place to protect patients from avoidable harm required improvement. This was in relation to the timely review of pathology results, significant events and near misses.
  • Not all staff had received training on identifying deteriorating or acutely unwell patients. They were not aware of actions to take in respect of such patients.
  • The practice did not have appropriate systems in place for the safe management of medical gases, medicines and prescriptions.
  • The practice was unable to demonstrate what action had been taken to improve patient experience in relation to listening to patients and treating them with care and concern.
  • Patients did not always receive timely access to the practice.
  • There was limited evidence to show what learning took as a result of complaints.
  • Leaders could not always demonstrate that they had the capacity and skills to deliver high quality, sustainable care.
  • The overall governance arrangements were ineffective.
  • The systems for continuous learning and improvement were not always implemented effectively.

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.

At this inspection we found there had been sufficient improvement to rate the safe, effective, caring and well-led key questions good, however responsive would remain as requires improvement as the practice had not improved patient experience in relation to accessing appointments and services. The ratings for the practice is now good overall.

We found that:

  • The practice had developed systems and processes to keep patients safe. This included recruitment checks, staff immunisations, equipment checks, fire and health and safety, infection control and mandatory staff training.
  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • All staff had received training on identifying deteriorating or acutely unwell patients and had had Sepsis training, there were posters in reception and clinical rooms.
  • The systems and arrangements for managing medicines, including vaccines, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • The practice was able to demonstrate what action had been taken to improve patient experience in relation to listening to patients and treating them with care and concern.
  • Patient survey results however were still lower than local and national averages for access to services..
  • Privacy screens were available in all clinical rooms.
  • Due to patient feedback the service had installed a new telephone system, increased the amount of administration and reception staff and introduced an online triage system to augment the existing telephone triage.
  • Leaders could demonstrate that they had the capacity and skills to deliver high quality, sustainable care.
  • The practice had a clear vision, that vision was supported by a credible strategy. The service had made several improvements to improve patient care in the last 12 months.
  • The provider conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. They outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate, we reviewed the recruitment and training files for five members of staff and found that all of the recommended checks and training had been completed.
  • All staff received up-to-date safeguarding and safety training appropriate to their role.
  • The service used information about care and treatment to make improvements. The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients.

Whilst we found no breaches of regulations, the provider should:

  • Continue to review and improve the uptake of cervical screening and the childhood immunisation programme.
  • Continue to improve and review the management of complaints.
  • Continue to review the National GP Patient Survey results and make improvements with patient satisfaction with accessing services.

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

25 April 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Stanmore Medical Centre on 25 April 2019 as part of our inspection programme.

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 for all population groups.

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

  • The practice did not have clear systems and processes to keep patients safe. This included recruitment checks, staff immunisations, equipment checks, fire and health and safety, infection control and mandatory staff training.
  • The processes in place to protect patients from avoidable harm required improvement. This was in relation to the timely review of pathology results, significant events and near misses.
  • Not all staff had received training on identifying deteriorating or acutely unwell patients. They were not aware of actions to take in respect of such patients.
  • The practice did not have appropriate systems in place for the safe management of medical gases, medicines and prescriptions.

We rated the practice as requires improvement for providing caring services because:

  • The practice was unable to demonstrate what action had been taken to improve patient experience in relation to listening to patients and treating them with care and concern.
  • Privacy screens were not provided in all clinical rooms.

We rated the practice as requires improvement for providing responsive services because:

  • Patients did not always receive timely access to the practice.
  • There was limited evidence to show what learning took as a result of complaints.

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

  • Leaders could not always demonstrate that they had the capacity and skills to deliver high quality, sustainable care.
  • While the practice had a clear vision, that vision was not supported by a credible strategy.
  • The practice culture did not effectively support high quality sustainable care.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • The systems for continuous learning and improvement were not always implemented effectively.

These areas affected all population groups so we rated all population groups as requires improvement

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

  • Patients’ needs were assessed, and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • The practice had taken steps to improve their cervical cancer screening uptake.
  • The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.
  • The practice was able to demonstrate that staff had the skills, knowledge and experience to carry out their roles, although some monitoring was required.

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.
  • Ensure recruitment procedures are established and operated effectively.

(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 display of chaperone notices around the practice.
  • Continue to monitor and improve the cervical screening uptake rates.
  • Take action to install a hearing loop.

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

6 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

Following a comprehensive inspection of the Stanmore Medical Centre in February 2015, the practice was given an overall inadequate rating and a decision was made to place the practice in special measures. Specifically, we found the practice to be inadequate for providing safe and well led services, requires improvement for providing effective services and good for providing caring and responsive services. It was also rated as inadequate for all the population groups.

We carried out a second comprehensive inspection at the Stanmore Medical Centre on 29 September 2015, to consider whether sufficient improvements had been made to bring the practice out of special measures. At the inspection we found sufficient improvements had been made, however the systems in place for mitigating risks in relation to the health and safety of service users were still not sufficiently robust. Overall the practice was rated as requires improvement.

We then carried out a third comprehensive inspection on 6 December 2016 to assess if the necessary improvements had been made since our previous inspection. At this inspection we found that the necessary improvements had been made and overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • 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 did not always find it easy to make an appointment with a named GP however continuity of care had improved since our last inspection, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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 provider was aware of and complied with the requirements of the duty of candour.
  • The practice demonstrated a strong ethos of advocating for their patients which was exemplified by over 30 case reviews presented to us at our inspection. The case reviews were examples of exceptional care provided in managing and supporting vulnerable patients. These included patients experiencing poor mental health, patients with learning disabilities and those receiving treatment for substance misuse.

The areas where the provider should make improvement are:

  • Continue to improve childhood immunisation and cervical screening uptake to bring in line with national averages.
  • Continue to improve patient satisfaction with access to care and treatment.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

29 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

Following a comprehensive inspection of the Stanmore Medical Centre in February 2015, the practice was given an overall inadequate rating and a decision was made to place the practice in special measures.

We carried out an announced comprehensive inspection at the Stanmore Medical Centre on 29 September 2015, to consider whether sufficient improvements had been made. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe, responsive and well led services and good for providing effective and caring services. It was also rated as requires improvement for all the population groups.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, however reviews and investigations were not always thorough enough to support improvement.
  • Risks to patients were assessed and well managed, with the exception of those relating to vaccine fridge temperature monitoring and health and safety.
  • Data showed patient outcomes were comparable to others in the locality. Clinical audit had been carried out, and we saw evidence that audits were driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment although national GP survey data showed the practice was below average in this regard.
  • Information about services and how to complain was available and easy to understand.
  • Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments and found it difficult to get through on the phone.
  • The practice had a number of policies and procedures to govern activity. Most of these had been reviewed annually however the practice’s policy for the management of significant events was in need of review.
  • The practice had proactively sought feedback from staff or patients.

The areas where the provider must make improvements are:

  • Ensure more effective arrangements are in place for managing risks and implementing mitigating actions; including those for monitoring risks associated with legionella bacteria, infection control, inappropriate vaccine storage and general health and safety.
  • Review policy and procedures for managing incidents / significant events.

In addition the provider should:

  • Improve patient satisfaction in relation to those areas identified by the national GP survey to be below local / national averages such as access to the service.

I am pleased that this practice has made significant improvements to the care that it is providing for its patients but there is still more work to be done. I am therefore taking this practice out of special measures and we will return to re-inspect within a year to ensure that the good progress has been maintained and that care has hopefully improved further.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

04 February 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of The Stanmore Medical Centre on 4 February 2015. We rated the practice as ‘inadequate’ for the service being safe, ‘requires improvement’ for the service being effective, ‘good’ for the service being caring and responsive to people’s needs and ‘inadequate’ for the service being well-led. We rated the practice as ‘inadequate’ for the care provided to older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia).

We gave the practice an overall rating of ‘inadequate’

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

  • Patients said staff were caring, considerate and helpful. They said staff treated them with dignity and respect.
  • Patients said the GPs and nurses were good at explaining tests and treatment and involved them in decisions about their care and treatment.
  • The needs of the local population were understood and the practice provided services to meet them.
  • We found inadequate systems and processes to identify, assess and manage risk in relation to medicine management, infection control, security of medical records, recruitment and general health and safety.
  • We found inadequate maintenance of the premises and equipment.

The areas where the provider needs to make improvements are;

Importantly, the provider must:

  • Ensure the necessary pre-employment checks are completed on all staff.
  • Ensure emergency medicines are obtained appropriately.
  • Introduce effective systems to assess the risk of and to prevent, detect and control the spread of health care associated infections.
  • Maintain appropriate standards of cleanliness and hygiene in relation to the premises.
  • Introduce adequate systems and processes to manage and monitor risks to patients, staff and visitors to the practice in relation to health and safety.
  • Ensure patients, staff and visitors are protected against the risks associated with unsafe or unsuitable premises by means of adequate maintenance of the premises and equipment.
  • Ensure paper medical records are stored securely.
  • Ensure systems are in place to provide reassurance that all safety alerts are acted on and in a timely manner.
  • Share learning from incidents with all staff where appropriate.
  • Provide staff with accredited training in safeguarding children and vulnerable adults.
  • Update the business continuity plan and ensure it is accessible to staff.
  • Ensure audit cycles are completed to demonstrate improved outcomes for patients

In addition the provider should:

  • Ensure the oxygen cylinder is refilled and in working order.
  • Carry out cervical screening audits in line with the Royal College of Nursing (RCN) guidance.
  • Provide staff with training in mandatory topics and ensure training is monitored and records kept on site.
  • Introduce job descriptions for staff which outline their roles and responsibilities.
  • Provide staff with training in consent and the Mental Capacity Act 2005.
  • Formulate a clear vision for the practice and a strategy to deliver it. Ensure staff know their responsibilities in relation to it.
  • Ensure all key policies are in place to govern activity in the practice and accessible to staff.
  • Formalise a clear leadership structure and ensure staff are aware of their level of responsibility.
  • Introduce meetings to include the whole practice team.

On the basis of the ratings given to this practice at this inspection. I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

 

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice