Dr D Cowen & Partners Also known as Northfields Surgery

We carried out an announced inspection at Dr D Cowen & Partners (Northfields Surgery) on 7, 8 and 9 December 2021. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Requires improvement

Well-led - Requires improvement

Following our previous inspection on 9 February 2016, the practice was rated Good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr D Cowen & Partners (Northfields Surgery) on our website at www.cqc.org.uk.

Why we carried out this inspection

This was a comprehensive inspection. At this inspection we covered all key questions:

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

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 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 found that:

• There was a lack of good governance in some areas.
• Recruitment checks including Disclosure and Barring Service (DBS) were not always carried out in accordance with regulations or records were not kept in staff files.
• The practice did not have any formal monitoring system in place to assure themselves that blank prescription forms were recorded correctly, and their use was monitored in line with national guidance.
• Risks to patients were not assessed and well managed in relation to some safety alerts and the monitoring of the prescription box for uncollected prescriptions.
• Some staff had not received safeguarding adults, infection control, basic life support, legionella, sepsis awareness, equality & diversity, chaperone and fire safety training relevant to their role.
• People were not able to access the telephone system in a timely manner.
• Complaints were not responded to in writing and the register was not maintained appropriately.
• Policies and procedures were not always updated or followed appropriately.
• Our clinical records searches showed that the practice had an effective process for monitoring patients’ health in relation to the use of medicines including high-risk medicines.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• The Care Quality Commission (CQC) rating poster was not displayed on the premises.

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 areas where the provider should make improvements are:

• Continue to monitor, encourage and improve cervical cancer screening and childhood immunisation uptake.
• Take steps to collect patient feedback and review Patient Participation Group (PPG) feedback.
• Document when significant events have occurred.
• Take necessary steps to ensure staff are clear about their responsibilities to report cases of Female Genital Mutilation (FGM).

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