Background to this inspection
Updated
23 April 2019
Uxendon Crescent Surgery operates from a converted residential property at 1 Uxendon Crescent, Wembley, Middlesex HA9 9TW. The practice had access to four clinical consulting rooms, two located on the ground floor and two located on the first floor. The first floor was accessible by stairs.
The practice provides NHS primary care services to approximately 5,600 patients. The practice operates under a General Medical Services (GMS) contract (a contract between NHS England and general practices for delivering general medical services and is the commonest form of GP contract). The practice is part of NHS Brent Clinical Commissioning Group (CCG).
The practice is registered as a partnership with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures, treatment of disease, disorder or injury and maternity and midwifery services.
The practice staff comprises of three GP partners, one male and two females, totalling 24 sessions per week, a practice nurse (24 hours per week) and a healthcare assistant (30 hours per week). The clinical team are supported by a full-time practice manager and a team of seven administration and reception staff.
The practice is open between 9am and 6pm, Monday to Friday. Extended hours appointments are offered on Tuesday from 7am to 8am and Thursday from 6.30pm to 7.30pm. The practice offers on-line services, which include appointment booking and repeat prescriptions which can be accessed through the practice website. Appointments are available between 9am to 12 noon and 3.30pm to 5.30pm, Monday and Friday. When the surgery is closed, out-of-hours services are accessed through the local out of hours (OOH) service or NHS 111. Patients can also access GP and practice nurse appointments from 6.30pm-8pm on Monday to Friday and from 8am–8pm on Saturdays and Sundays at five GP hub sites in Brent.
The practice population is in the seventh most deprived decile in England, on a scale of one to 10 with one being the most deprived and 10 being the least deprived. People living in more deprived areas tend to have greater need for health services. Data shows that almost 68% of patients at the practice area were from Black and Minority Ethnic (BME) groups. The highest proportion of the practice population was in the 15 to 44-year-old age category.
Updated
23 April 2019
We carried out an announced comprehensive inspection at the location on 12 April 2018 when the overall rating for the practice was Good with Requires Improvement for providing well-led services because the provider was failing to ensure systems and processes were operated effectively to improve the quality and safety of services. In particular:
- The provider had failed to address risk assessment outcomes in a timely manner.
- The provider had failed to ensure patient risk registers were up-to-date.
- There was no written business plan and strategy in line with health and social priorities to meet the needs of its practice population.
The full comprehensive report on the 12 April 2018 inspection can be found by selecting the ‘all reports’ link for Uxendon Crescent Surgery on our website at www.cqc.org.uk.
This inspection, on 28 March 2019, was an announced comprehensive inspection to confirm that the practice had carried out their plan to meet the requirements that we identified in our previous inspection on 12 April 2018. At this inspection, we found that the provider had satisfactorily addressed these areas.
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 good overall and good for all population groups.
We found that:
- The practice had been proactive and addressed all the findings of our previous inspection.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- 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-centre care.
Whilst we found no breaches of regulations, the provider should:
- Continue to work towards all staff attaining safeguarding children training to a level recommended in updated guidance.
- Consider providing enhanced infection prevention and control training for the lead to support them in the role.
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