The Care Quality Commission
  • Doctor
  • GP practice

The Bacon Lane Surgery

Overall: Requires improvement read more about inspection ratings

11 Bacon Lane, Edgware, Middlesex, HA8 5AT (020) 8952 5073

Provided and run by:
The Bacon Lane Surgery

All Inspections

4 & 5 July 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at The Bacon Lane Surgery on 4 and 5 July 2023. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question:

Safe - Requires improvement.

Effective - Requires improvement.

Caring - not inspected, rating of Good carried forward from the previous inspection.

Responsive - Requires improvement.

Well-led - Requires improvement.

Following our previous inspection in April 2022, the practice was rated requires improvement overall and for the safe, effective and well-led key questions. It was rated good for caring and the responsive key questions.

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

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulations from a previous inspection.

This was a focused inspection. At this inspection, we covered the following key questions:

  • Are services safe?
  • Are services effective?
  • Are services responsive?
  • Are services well-led?

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 had demonstrated some improvements in areas of concern identified during the previous inspection. However, we found additional concerns during this inspection.
  • There was a lack of good governance in some areas.
  • Our clinical records searches showed that the practice did not always have an effective process for monitoring patients’ health in relation to the use of medicines including medicines that require ongoing monitoring.
  • Risks to patients were not assessed and well managed in relation to some medication reviews, some emergency medicines, the fire evacuation plan and the implementation of national patient safety and medicines alerts.
  • Recruitment checks including Disclosure and Barring Service (DBS) were not always carried out in accordance with regulations and some records were not kept in staff files.
  • There was a system in place to monitor the use of blank prescription forms and pads. However, it did not work as intended.
  • There was a system for recording and acting on significant events.
  • There was an infection prevention and control policy and procedures were in place to reduce the risk and spread of infection.
  • There was evidence of quality improvement activity. Clinical audits were carried out.
  • Patients were not able to access care and treatment in a timely way.
  • Staff had received training relevant to their role.
  • Annual appraisals were carried out in a timely manner.
  • Feedback from patients was positive about the way staff treated people.
  • The practice had systems to manage and learn from complaints.
  • The Patient Participation Group (PPG) was active.

We found two breaches of regulations. The provider must:

  • 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 to ensure only fit and proper persons are employed.

The provider should:

  • Continue to encourage the patient for cervical cancer screening and childhood immunisation uptake.

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

7 April 2022

During a routine inspection

We carried out an announced inspection at The Bacon Lane Surgery, with the remote clinical review on 4 April 2022 and site visit on 7 April 2022. Overall, the practice is rated as requires improvement.

Set out the ratings for each key question

Safe - Requires improvement

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led – Requires improvement

Following our previous inspection on 29 September 2016, the practice was rated as good overall and for all key questions apart from safe, which was rated as requires improvement. We inspected the safe key question on 5 October 2017 and rated the practice as safe on this occasion.

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

Why we carried out this inspection

This inspection was a comprehensive inspection focusing on:

  • Ensuring care and treatment was being provided in a safe way to patients.
  • Establishing if there were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.

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 Requires Improvement overall.

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

  • We found that some members of staff, both clinical and non-clinical, had not completed the appropriate level of safeguarding training.
  • We found gaps in the training records we reviewed, in particular in relation to sepsis awareness and information governance training. The practice told us that this had been completed by all staff, however, we did not see evidence of this in all cases.
  • We identified some issues with the monitoring of patients on some high risk medicines.
  • We found that the system for managing and acting on Medicines and Healthcare Products Regulatory Agency (MHRA) alerts was not always effective.
  • The premises were well managed and there were effective system for managing infection prevention and control.
  • We found that emergency medicines and equipment on site were organised, in date and effectively managed.

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

  • We identified some issues with the monitoring and management of long-term conditions.
  • The practice’s uptake for cervical screening was below the 80% coverage target for the national screening programme. We did not see sufficient action by the practice to understand this low update to address any barriers to the uptake of screening.
  • The practice had not met the minimum 90% uptake for all five of the childhood immunisation uptake indicators and was below 80% in four of the indicators. The practice had not met the WHO based national target of 95% (the recommended standards for achieving herd immunity) for all of the childhood uptake indicators.
  • The practice had worked towards providing effective care for patients during the Covid-19 pandemic.

We rated this practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice had arrangements for providing interpreters for patients who did not have English as a first language and made adjustments for patients to ensure access.
  • The practice offered longer appointments for patients where appropriate.

We rated this practice as good for providing responsive services because:

  • We found that people’s needs were met through the way services were organised and delivered.
  • The practice offered extended hours in the early morning and late evening to accommodate patients.
  • The practice had an increasing practice population and it had diversified services to assist with demand. The practice had a first contact physiotherapist, in-house phlebotomy service and a pharmacist which assisted with providing integrated and holistic care to patients.

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

  • We identified some shortfalls in the overall governance and risk management systems. These included the risks associated with the required monitoring of patients on some high risk medicines, systems for acting on MHRA alerts, management of long-term conditions and uptake of childhood immunisations and cervical screening.
  • The system for oversight of staff training was not sufficient.
  • Action were taken to support the maintenance of the service during the Covid-19 pandemic.
  • We received feedback from the patient participation group (PPG) that the practice was not collaborating effectively with it currently.
  • Staff spoke positively about their employment at the practice and felt supported.
  • The practice had reflected on challenges faced and had put in place plans for improvements to services.

We found breaches of regulations. The provider must:

  • 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.

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

In addition to the above, the practice should:

  • Review the oversight of staff training and records kept.
  • Continue to conduct routine fire risk assessments.
  • Demonstrate an understanding of why childhood immunisations uptake is low and what barriers there are to uptake in the patient population, and take action to address such barriers as appropriate.
  • Improve the relationship and engagement with the PPG.

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

5 October 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 29 September 2016 at The Bacon Lane Surgery. At that inspection the practice was rated good overall. However, we rated the practice as requires improvement for providing a safe service. This was because the practice could not demonstrate it assessed and managed risks safely.

The full comprehensive report of the 29 September 2016 inspection can be found by selecting the ‘all reports’ link for The Bacon Lane Surgery on our website at www.cqc.org.uk.

This inspection was a focused inspection undertaken on 5 October 2017 to check that the practice had addressed the requirements identified in our previous inspection. This report covers our findings in relation to those requirements.

Overall the practice remains rated as good. Following this inspection, we have revised our rating for whether the practice is providing a safe service. The practice is now rated as good for providing a safe service.

Our key findings were as follows:

  • The practice had effective systems in place to assess and manage risks to patients and staff. The practice had developed a tailored health and safety policy. Fire safety and legionella risk assessments had been carried out by suitably qualified persons with clear recommendations for further action and monitoring.
  • The practice had implemented the recommendations arising from relevant risk assessments. The practice was document the health and safety related monitoring checks it routinely carried out.

At our previous inspection, we also noted that:

  • Consent was not always documented in patient notes for example when carrying out procedures such as joint injections. At this inspection, the practice showed us the patient consent form and information leaflet provided to patients undergoing joint injections. We reviewed a number of records and found that consent had been recorded in the patient notes.
  • GPs were not always familiar with the Deprivation of Liberty Safeguards (DoLS). At this inspection, we reviewed staff training records. Staff had received update training on the Mental Capacity Act and Deprivation of Liberty Safeguards within the last 12 months. Staff we spoke with understood their roles and responsibilities under this legislation.

However, there were areas where the practice should make improvements:

  • The practice should ensure that all staff can access practice policy and procedures relating to the storage and management of liquid nitrogen (a hazardous substance).
  • The practice should ensure that treatment rooms are kept uncluttered to avoid impeding fire exits; to reduce the risk of accidents and as part of effective infection prevention and control.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

29 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Bacon Lane Surgery on 29 September 2016. 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. However, the recording of significant event analysis (SEA) required improvement as we noted changes to practice as a result of SEAs were not documented in all cases .
  • Risks to patients were assessed however they were not in all cases well managed. For example, those relating to general health and safety.
  • 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.
  • The practice had a triage-led appointment system and some patients commented that they did not find it easy to get an appointment particularly with their preferred GP.
  • The practice had adequate facilities and was equipped to treat patients and meet their needs however the practice was in need of an upgrade. The provider had applied for funding from the CCG to improve the premises and they were awaiting the decision.
  • 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 areas where the provider must make improvement are:

  • Ensure the recommendations from the fire risk assessment, health and safety audit, legionella risk assessment and the boiler inspection are implemented to mitigate risk to patients and staff.

In addition the provider should:

  • Improve the documentation of significant event analysis (SEA) in particular changes to practice as a result of SEAs.
  • Ensure fire drills are rehearsed and documented and fire alarms are checked regularly.
  • Develop a health and safety policy specific to the practice.
  • Ensure consent is documented in patient notes when carrying out joint injections.
  • Ensure all the GPs are familiar with the Deprivation of Liberty Safeguards (DoLS).
  • Continue to improve patient satisfaction with access to appointments, getting through to the practice by phone, access to a preferred GP and with the handling of repeat prescription requests.

Professor Steve Field CBE FRCP FFPH FRCGP 

​ Chief Inspector of General Practice

29 May 2014

During an inspection looking at part of the service

On our inspection of 22 January 2014 we found that the provider had not made arrangements for all staff to attend training in Basic Life Support (BSL) and there was no evidence that all staff had undertaken training in safeguarding children and adults. We also found that there was no evidence of a cleaning schedule and infection control audit. The appropriate recruitment checks had not taken place prior to some staff commencing their employment.

The provider wrote to us on 14 March 2014 to inform us they would arrange training for staff in BLS and safeguarding children and adults. They informed us they would ensure the required staff recruitment documentation was sought and records in relation to cleaning and infection control would be improved.

During this inspection we reviewed the progress the provider had made to meet requirements relating to the care and welfare of people who used the service, safeguarding people who used services from abuse, cleanliness and infection control and requirements relating to workers. We found that the provider had made arrangements to ensure that staff had received training in BSL and safeguarding children and adults. We saw that a formal system was in place for planning and recording cleaning tasks. The provider had carried out the relevant recruitment checks for staff who worked at the surgery.

22 January 2014

During a routine inspection

During our inspection, we spoke with seven people who used the service and four members of the Patient Participation Group (PPG). We also spoke with six members of staff which included two GPs, the practice manager and three receptionist/administrative staff.

One person we spoke with told us "the doctors are very good' and people were positive about the clinical care provided by the practice. However, people told us that they were not satisfied with the triage appointment system, experienced difficulties getting an appointment and were not happy with the waiting times at the surgery. One person told us that the triage and appointment system was 'dreadful'. Another person said 'waiting times are getting worse'.

We found that patients were informed and involved in the care provided to them.

We observed that the provider had a safeguarding adults' policy and a separate policy for safeguarding children. We noted that staff who had started employment at the practice after 2011 had not yet received safeguarding training. However, we noted that all staff had been booked to attend a safeguarding training course.

We found that the practice was not following government guidelines in relation to the safe management of clinical waste.

We observed that there was a lack of evidence available to confirm that appropriate recruitment checks had been carried out for all staff.

We saw evidence that the provider had a system in place to monitor quality and safety.