Chichele Road Surgery

Updated 21 March 2024

Chichele Road Surgery provides primary care services to around 5,500 patients in the Cricklewood area of Brent in North West London. The service operates from one site in a converted property. Patient facilities are located on the ground and first floors. The first floor is accessible by stairs.

The practice is led by three partners two of whom are GPs and one of whom is the business manager. The practice contracts with regular locum GPs and employs a full-time nurse who is an independent prescriber; a part-time practice nurse, a physician associate and a health care assistant. The practice offers sessions with a mental health therapist for eligible patients and associated professionals including clinical pharmacists and a social prescriber. The practice employs reception and administrative staff.

The practice opens from 8am until 6.30pm Monday to Friday. The practice runs Saturday clinics when demand is especially high and evening and weekend appointments are also available at local extended primary care hubs. Pre-bookable and emergency appointments are available. The practice can offer telephone or face-to-face consultations as appropriate and appointments can be booked through an ‘e-consult’ system, by telephone or in person.

Patients can access an out of hours service through the NHS 111 service if they need urgent advice or treatment when the practice is closed.

The practice population is made up of a higher proportion of adults of working age than average with lower proportions of older patients and children and babies. The population is ethnically and culturally diverse with around half of patients identifying as white. The population experiences slightly lower than average life-expectancy and higher than average levels of unemployment and income deprivation. The practice has a relatively high proportion of transient patients, that is patients who only remain in the area for a short period before moving on. The practice is part of the North West London Clinical Commissioning Group (CCG) and Kilburn Primary Care Network.

Chichele Road Surgery is registered with the Care Quality Commission (CQC) to carry on the following regulated activities: diagnostic and screening procedures; family planning; treatment of disease, disorder or injury; family planning, maternity and midwifery services and surgical procedures.

Updated 21 March 2024

We carried out an announced inspection at Chichele Road Surgery from 28 July - 2 August 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring – not inspected, rating of good carried forward from previous inspection

Responsive – requires improvement

Well-led - good

Following our previous comprehensive inspection which took place on 12 December 2021 the practice was rated requires improvement overall. It was rated good for providing safe, caring and responsive services and requires improvement for providing effective and well-led services. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Chichele Road Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

We carried out this inspection to follow up a breach of regulations from a previous inspection in line with our inspection priorities. This inspection was a focused inspection to follow up on:

• The key questions of safe, effective, responsive and well-led
• A breach of regulation 17 (Good governance)
• Any additional areas identified for improvement.

At our previous inspection we found a lack of good governance in some areas. In particular, we found that the provider did not have a clear strategy in place to achieve stated goals. Governance systems in relation to the oversight of delegated responsibilities, staff performance, competency assessment and clinical supervision were not fully developed or recorded. The provider was not always maintaining accurate, complete and contemporaneous patient records. The provider did not have effective systems in place to ensure the safe management of patients prescribed medicines which required ongoing monitoring. The provider had not effectively used risk assessment to demonstrate that the environment was maintained to a standard to protect patient confidentiality and staff safety. The provider did not have an effective prescription security system in place.

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 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 received effective care and treatment that met their needs. The practice had improved childhood immunisation uptake levels since our previous inspection.
• The practice had focused on improving access to the service and levels of demand remained high at the time of the inspection. Patient survey feedback about access remained below average.
• The practice had improved its governance systems since our previous inspection. The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

• Follow-up patients who have been prescribed a course of rescue steroids for an exacerbation of asthma in line with current guidelines.
• Implement a system to ensure that patients newly prescribed SGLT2 inhibitors (a type of medicine typically used to treat diabetes) are made aware of potential side effects.
• Assure itself that chronic kidney disease is being coded appropriately going forward.
• Take action to improve patient experience in relation to access to the service.
• Take action to improve cervical screening coverage.
• Take action to further improve childhood immunisation uptake rates where these remain below target.

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