The Care Quality Commission
  • Doctor
  • GP practice

Eastmead Avenue Surgery Also known as Eastmead Surgery

Overall: Good read more about inspection ratings

The Surgery, 20 Eastmead Avenue, Greenford, Middlesex, UB6 9RB (020) 8578 1244

Provided and run by:
Eastmead Avenue Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Eastmead Avenue Surgery 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 Eastmead Avenue Surgery, you can give feedback on this service.

23 June 2021

During an inspection looking at part of the service

We carried out an announced review at Eastmead Avenue Surgery on 23 June 2021. Overall, the practice is rated as good.

We reviewed whether the practice was providing effective services:

Effective - Good

Following our previous inspection on 15 October 2019, the practice was rated good overall and for the key questions of Safe, Caring, Responsive and Well-led. The practice was rated as requires improvement for providing Effective services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Eastmead Avenue Surgery on our website at www.cqc.org.uk

Why we carried out this review

This review was a focused review of information without undertaking a site visit to follow up on a breach of Regulation17 Good governance. At the last inspection we found:

  • The practice performance for its management of some long-term conditions, including aspects of mental health, was below average as measured by the Quality and Outcomes Framework. The practice’s uptake rates for childhood immunisations and cervical screening were also below target.

We also followed up on ‘should do’ actions identified at the last inspection. Specifically, the practice should:

  • Document actions arising from clinical meetings in a timely way.
  • Implement a version control system for policies and processes.
  • Implement consistent criteria for incident reporting.

How we carried out the 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 reviews differently. This review was carried out without visiting the location by reviewing information supplied by the provider and the most recently published performance data for the practice. The inspector also carried out a telephone interview with the GP partners and practice manager.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • 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 had taken action to make the required improvements since our previous inspection:

  • Patients received effective care and treatment that met their needs.

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

  • Continue to work on cervical screening and childhood immunisation uptake rates with the goal of achieving the national targets.

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

15 October 2019

During an inspection looking at part of the service

We decided to undertake a focused inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Are services effective?
  • Are services responsive to people’s needs?
  • Are services well-led?

We based our judgement of the quality of care at this service is 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.

Because of the assurance received from our review of information we carried forward the rating for the following key questions: Is the service safe? and Is the service caring? The practice is rated as Good for both of these key questions.

We have rated this practice as good overall.

We rated the practice as good for providing responsive and well-led services. This was because:

  • The practice organised and delivered services to meet patients’ needs. 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.

The practice was also rated as good for the following population groups: older people and, people whose circumstances may make them vulnerable.

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

  • The practice’s published performance for the management of some longer-term conditions such as asthma was below average.
  • The practice was also below target for childhood immunisations and cervical screening.
  • The practice had taken some actions to improve in these areas but could not yet demonstrate a positive impact.

These findings were particularly related to the following population groups: people with long-term conditions; families, children and young people; working age people; and people experiencing poor mental health. These population groups were also rated as requires improvement.

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.

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

The areas where the provider should make improvements are:

  • Document, share and review actions arising from clinical meetings in a timely way.
  • Implement an effective version control system for all policies and processes.
  • Implement consistent criteria for incident reporting and ensure all relevant incidents are captured for review.
  • Take action to improve childhood immunisation and cervical screening uptake rates.

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

8 January 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Eastmead Avenue Surgery on 08 January 2015. We rated the practice as ‘Good’ for the service being safe, effective, caring, responsive to people’s needs and well-led. We rated the practice as ‘Good’ for the care provided to older people and people with long term conditions and ‘Good’ for the care provided to, 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 ‘Good’

Our key findings were as follows:

  • Patients were overall satisfied with opening times and access to appointments.
  • The practice was managed well from a health & safety perspective. Where risks were identified, control measures were in place to minimise them.
  • The practice was clean & hygienic, infection control audits were regularly completed and action taken where risks had been identified.
  • Staff were trained to respond to emergency situations and the welfare of patients was prioritised.
  • Patients said they were treated with compassion, dignity & respect and this was reflected in patient surveys we reviewed.
  • Clinical staff followed recognised guidance to deliver effective care & treatment to patients.
  • Clinical audit cycles were completed resulting in improved outcomes for patients.
  • The practice was well-led. There were clear leadership and governance arrangements in place and staff were supported to deliver effective care.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

  • Provide staff with access to and training in the use of an automated external defibrillator (used to attempt to restart a person’s heart in an emergency) in line with the Resuscitation Council (UK) recommendations for primary care.
  • Introduce a whistleblowing policy to ensure staff are aware of the procedures to follow if they had concerns about suspected wrong doing at work relating to other staff members.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice