The Care Quality Commission
  • Doctor
  • GP practice

Arcadian Gardens Surgery

Overall: Good read more about inspection ratings

The Surgery, 1 Arcadian Gardens, Bowes Park, London, N22 5AB (020) 8888 4142

Provided and run by:
Arcadian Gardens Surgery

All Inspections

19 December 2023

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Arcadian Gardens Surgery on 19 December 2023. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring – Not inspected (rating of Good carried forward from previous inspection)

Responsive - Not inspected (rating of Good carried forward from previous inspection)

Well-led - Good

Following our previous inspection on 10 October 2022, the practice was rated Requires improvement overall and for the providing safe and well-led services. 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 Arcadian Gardens Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up concerns and breaches of regulation from a 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:

  • Completing remote 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 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:

  • Following our inspection in October 2022, we found the practice did not have effective systems in place to monitor cancer referrals and the recording of cervical smear results. At this inspection, we found the practice had implemented systems to monitor these and had established protocols to ensure these were reviewed in a timely manner.
  • Following our inspection in October 2022, we found that the practice had failed to act on previous risks identified through risk assessments and infection, prevention and control audits. At this inspection, we found that the practice had completed the necessary risk assessments we would expect to see, and devised action plans in response to any concerns identified. We saw evidence that the practice had acted on issues identified through such risk assessments and audits and had a clear plan in place for addressing all concerns noted.
  • An appropriate range of in-date emergency medicines were available, although their co-location across two clinical rooms would present access issues if items needed to be sourced in the event of an emergency and both clinical rooms were in use.
  • Not all staff had completed the correct level of safeguarding training applicable to their roles.
  • We saw evidence of comprehensive meeting minutes, with safeguarding and significant events / complaints discussed as a standard agenda item. However, on the complaints log submitted, it was not always clear what learning needs had arisen as a result.
  • An informal arrangement was in place to provide clinical oversight of non-medical prescribers. However, there was no formalised process in place for the management of such prescribing.
  • Staff interviewed were all able to describe in detail how significant events are recorded and managed, and how learning is cascaded and shared.
  • All staff spoken with spoke positively about the work environment and stated they felt supported in their day-to-day duties. Staff were aware of their additional roles and could clearly state what their responsibilities were.
  • The practice had implemented an allotment initiative to promote social inclusion and mental well-being. The practice had taken account of patients’ holistic needs and recognised the importance of how patients’ mental well-being can positively impact their physical state.
  • Patients report that the practice is caring and go above and beyond for patients. This was further supported by observing both clinical and non-clinical staff interacting positively with patients throughout the day.

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

  • Continue to monitor and take action to improve cervical screening and child immunisation uptake rates.
  • Take action so that all staff have up-to-date training applicable to their role.
  • Introduce a formalised process for managing non-medical prescribing.
  • Continue to action items in response to risk assessments and audits.
  • Explicitly record and detail the learning needs which arise from complaints and significant events.
  • Risk assess the placement and accessibility of their emergency medicines supplies.

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

10 October 2022

During a routine inspection

We carried out an announced comprehensive at Arcadian Gardens Surgery on 10 October 2022. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive - Good

Well-led - Requires Improvement

Following our previous inspection on 18 January 2017, 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 Arcadian Gardens Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in response to risks specifically regarding child immunisation rates and cervical screening uptake rates.

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 and on site.
  • 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:

  • Governance arrangements did not work effectively. For example, systems for monitoring cancer referrals and recording cervical smear test results generated inaccurate monitoring data.
  • The practice did not have effective processes for managing risks. For example, we noted a failure to act on previously identified risks regarding the absence of calibration of medical devices and periodic infection prevention and control audits.
  • Leaders were aware of the practice’s child immunisations and cervical screening uptake rates. We noted a range of interventions aimed at improving performance. Unverified practice data indicated a resulting improvement in cervical screening uptake.
  • We noted the practice had set up a local community allotment project, aimed at promoting patients’ physical and mental wellbeing. Leaders spoke positively about how the project tackled social isolation and offered patients an opportunity to grow their own foods and plants. A local faith-based organisation spoke positively about how the project had brought local communities together. We also noted the initiative had recently received a Royal College of General Practitioners “Healthier Places” award.
  • The practice’s management of long-term conditions reflected current evidence-based guidance, standards and best practice.
  • We saw extensive evidence of how clinical audit had been used to improve patient outcomes.
  • When things went wrong, there were systems in place to review, investigate and learn.
  • Patient feedback was above local and national averages regarding phone and appointments access. Patients fed back that they could access the right care at the right time.
  • Practice management arrangements did not support the delivery of high-quality and person-centred care.

We found one breach of regulation. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Continue to monitor and take action to improve cervical screening and child immunisation uptake rates.
  • Take action to actively engage staff and improve staff satisfaction levels.
  • Take action to introduce a structured programme of clinical audit.

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

18 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Arcadian Gardens Surgery on 18 January 2017. 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.
  • Risks to patients were assessed and well managed.
  • 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.
  • Telephone consultations were available to patients who were unable to attend the surgery during normal opening hours and for those who could not attend the practice
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had a dignity champion whose focus was to ensure that individuals at the practice were treated with dignity, care and respect.
  • The practice was well equipped to treat patients and meet their needs.
  • 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 should make improvement are:

  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is available to them.
  • Ensure that a programme of regular fire drills is devised and implemented

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

26 September 2014

During an inspection looking at part of the service

When we inspected on 11 December 2013, we noted that the practice had not implemented some of the actions recommended in a February 2013 infection control audit. For example, treatment rooms were still carpeted and a legionella risk assessment had not yet taken place. This meant that the provider was failing to comply with the requirements of Regulation 12 Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. We asked the provider to take action.

At this inspection, we saw that carpeting in treatment rooms had been replaced with non permeable flooring. A legionella risk assessment had also taken place and the subsequent recommended removal of a water storage tank had taken place. We found that the actions taken by the provider was sufficient to comply with the requirements of the regulation.

11 December 2013

During a routine inspection

We visited Arcadian Gardens surgery and spoke with five patients, two GPs, the practice manager, a receptionist and an administrator. People told us they were satisfied with the service they received from the surgery. One person said "both doctors are good", and another person said "they treat me with respect". People told us that they did not have difficulties making appointments.

We spoke with the two doctors who told us how they involved people in their treatment plans and how they ensured that they explain to people about their treatment and conditions. We saw that information was available in written form (via leaflets and print outs) so people were informed about their treatments and conditions.

The surgery was clean and hygienic. However some of the recommendations which had been highlighted in a premises audit had not been actioned. This meant that there were some areas relating to infection control which could present risks.

Both clinical and non-clinical staff at the practice told us they felt supported and we saw that training took place in relevant areas such as safeguarding adults and children. The practice had regular meetings to ensure that up to date information was shared.

We saw that the practice conducted internal surveys and audits and acted on the results of these to make improvements in clinical care. We saw that they responded appropriately to complaints in line with their own complaints policy.