The Queens Road Partnership

Updated 17 May 2022

The Queens Road Partnership is located in Lewisham, South East London at;

387 Queens Road

New Cross Gate

London

SE14 5HD

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning and treatment of disease, disorder or injury. The practice is situated within the South East London Clinical Commissioning Group (CCG) and delivers Personal Medical Services (PMS) to a patient population of about 9,100. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices North Lewisham PCN.

Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (two 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 Asian 8.7%, White 47.8%, Black 32.4%, Mixed 7.4% and 3.7% Other. The age distribution of the practice population shows the number of people between 20 and 39 and children under ten is significantly higher than the England average. Census data shows an increasing population and a higher than average proportion of BAME residents in Lewisham. The practice had the highest number of registered patients between the ages of 15 and 64 and relatively low numbers of patients aged over 75 years old.

The practice has four GP partners and they are supported by two salaried GPs, a nurse and a nurse trainee two nurses and an administrative team led by the practice manager. The practice is a GP training practice. There are 34 GP sessions each week. (1600 patients per WTE).

Updated 17 May 2022

We carried out an announced focused inspection at The Queens Road Partnership.

Interviews were held remotely with staff on 14 and 19 April 2022 a short site visit was completed on 12 April 2022 and a clinical records review was undertaken remotely on 14 April 2022. Overall, the practice is rated as Good.

Safe – Requires Improvement

Effective - Good

Well-led - Good

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

Why we carried out this inspection

This inspection was a focused inspection to follow up on concerns identified at our previous inspection which was completed on 10 September 2021.

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 aimed to enable 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.
• Requesting staff feedback using surveys.
• Reviewing patient records remotely 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.

Our previous inspection was a comprehensive inspection. The provider was rated inadequate for providing safe services, requires improvement for providing a service that was effective and well led and good for caring and responsive. We rated the practice as requires improvement overall as:

• The practice did not have clear and effective processes for managing risks, issues and performance. For example, medicines management processes related to the monitoring of patients taking high-risk medicines.
• The provider did not have effective systems to manage safety alerts.
• The systems to identify patients with undiagnosed long-term conditions was not effective.
• Performance was below target for cervical screening and childhood immunisations and the practice did not have effective systems for improvement in this area

At this inspection we have rated this practice as Good overall.

We found the following improvements had been made:

• Systems to monitor patients on high risk medicines and act on patient safety alerts had improved.
• The practice was running regular searches to find patients with undiagnosed health conditions.
• Reviews of clinical records showed that the standard of care was good, and people were receiving the treatment and care that they needed though the coding of patients with certain long term conditions needed to be improved.
• The practice had systems to respond to identify and act on significant events.
• There were arrangements to safeguard vulnerable patients and we were told of systems to proactively contact these patients on a regular basis the check on their wellbeing
• Risks associated with the premises were assessed and action taken to mitigate any concerns identified.
• There was an active patient participation group.

However, we also found:

• Some gaps in initial recruitment checks.
• The system for dealing with medical emergencies needed refinement.
• All staff reported that there was not sufficient staff in the reception and administrative team; though the practice were actively recruiting for this role and for a healthcare assistant.
• There was limited quality improvement activity.
• The practice had not met targets for cervical screening and childhood immunisations. However, there were robust recall systems and performance against these targets was continually reviewed and monitored.

We found breaches of regulations. The provider must:

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

The provider should:

• Continue to work to improve the uptake of cervical screening and childhood immunisations.
• Increase the volume of quality improvement activity
• Continue plans to recruit additional staff.
• Review systems to code patients with long term conditions.

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