The Care Quality Commission
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  • GP practice

Devonshire Lodge Practice

Overall: Requires improvement read more about inspection ratings

The Devonshire Lodge Health Centre, 2a Abbotsbury Gardens, Eastcote, Pinner, Middlesex, HA5 1TG (020) 8866 0075

Provided and run by:
Devonshire Lodge Practice

All Inspections

09 and 10 January 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at Devonshire Lodge Practice on 09 and 10 January 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 - not inspected, rating of Good carried forward from the previous inspection.

Well-led - Requires improvement

Following our previous inspection in November 2021, the practice was rated requires improvement overall and for the key questions safe and well-led. The practice was rated good for providing effective, caring and responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Devonshire Lodge Practice 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 three key questions:

  • Are services safe?
  • Are services effective?
  • Are services well-led?
  • Breaches of regulations 17 and 19 and ‘shoulds’ identified in the previous inspection.

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 demonstrated improvement in some areas, however, we found additional concerns and the practice was required to make further improvements.
  • 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 high risk medicines and patients with long term conditions.
  • The practice had a system in place to manage safety alerts but it did not always work effectively.
  • We noted the monitoring of blank prescription forms was not working as intended and the blank prescription forms were not recorded correctly.
  • Patient Group Directions (PGDs) were not signed by all the practice nurses.
  • Some staff documents were not kept in staff files.
  • Annual appraisals were carried out in a timely manner.
  • Staff had received training relevant to their role.
  • There was evidence of quality improvement activity. Clinical audits were carried out.
  • The Patient Participation Group (PPG) was active.

We found two breaches of regulation. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

  • Continue to encourage and monitor cervical cancer screening and childhood immunisation uptake rates.
  • Consider the Patient Participation Group (PPG) feedback regarding improving access to the service.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

2, 3 and 4 November 2021

During a routine inspection

We carried out an announced inspection at Devonshire Lodge Practice on 2, 3 and 4 November 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 - Good

Well-led - Requires improvement

Following our previous inspection on 1 March 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 Devonshire Lodge Practice 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 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 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 emergency medicines and staff vaccinations.
  • Some clinical and non-clinical staff had not received safeguarding children, safeguarding adults, infection control and fire safety training relevant to their role.
  • The practice was unable to provide documentary evidence of a legionella risk assessment and electrical installation condition inspection.
  • 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, with the exception of patients being prescribed medicine used to treat thyroid hormone deficiency.
  • 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. Patients could access care and treatment in a timely way.

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.

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

  • Improve the monitoring of patients’ medicines, in particular medicines prescribed to treat thyroid hormone deficiency.
  • Improve the monitoring of infection control procedures.

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

01/03/2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Devonshire Lodge Practice, Pinner, Middlesex, HA5 1TG on 1 March 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.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients when interviewed 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.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from patients and staff, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The area where the provider should make an improvement is to:

  • Implement a programme of continuous quality improvement to improve outcomes for patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

15 April 2014

During an inspection looking at part of the service

We carried out this inspection following shortfalls we identified during our previous inspection on 26 November 2013. During our previous inspection we found inadequacies in the complaints system for the service. We asked the provider to make improvements and they wrote to us and told us the action they would take to address the shortfalls identified. At this inspection we found that improvements had been made.

26 November 2013

During an inspection in response to concerns

This inspection was carried out as a result of concerns raised with the Care Quality Commission about the quality of care and treatment provided by the practice.

During our inspection we spoke with nine people using the service and eight staff including the practice manager, two GP's and a practice nurse. People told us they were happy with the care and treatment they received. One person said "the staff are good." Another said "I can usually get an appointment in a reasonable time, I am never waiting too long."

People were protected from the risk of abuse. Safeguarding procedures were in place for children and adults and staff were aware of them. They had also received adequate support and training to meet the needs of people using the service, including induction training for new staff, training to deal with foreseeable emergencies and training specific to their role. Appraisals had been completed to assess staff performance and identify any development needs.

Effective systems were in place to monitor the quality of service provided including satisfaction surveys, audits and risk assessments. The results of surveys and audits had been analysed and action taken to make improvements to the service where necessary. There was a complaints procedure in place and people were made aware of it. However, people's complaints were not always acknowledged until received in writing. Responses did not always fully address the complainants concerns and where complaints were substantiated the responses did not identify the remedial action that had been taken as a result to reduce the likelihood of reoccurrence. We also noted a lack of clinical input in complaints handling which meant that some responses did not always fully address people's complaints.