Background to this inspection
Updated
15 November 2019
Ellis Practice is a GP practice located at The Welford Centre, Chalkhill Primary Centre, 113 Chalkhill Road, Wembley. The practice lies within the administrative boundaries of Brent Clinical Commissioning Group (CCG) and provides primary medical services to approximately 9018 patients. The practice holds a General Medical Services (GMS) contract.
The surgery is situated on the first floor, a wing of the large, modern, purpose-built health centre. It consists of seven clinical rooms, a dedicated reception, a back office and a range of offices in the premises. The centre comprises of another GP practice, a café located on the ground floor and other community health services. The health centre is owned and managed by Metropolitan Housing, who lease the practice building to NHS Property Services. The practice premises are sublet from NHS Property Services. Accessible facilities are available throughout the building and this includes lift access and disabled toilets. There is ramp access from the premises to a large supermarket with parking facilities. There is limited underground parking for staff only. The practice website can be found at ellispractice.co.uk
The practice area is rated in the fourth most deprived decile of the national Index of Multiple Deprivation (IMD). People living in more deprived areas tend to have a greater need for health services. The practice has a high ethnically diverse population and includes a higher than average proportion of working age and young people and a lower proportion of patients aged over 65.
The practice is open between 8am and 6.30pm on Monday to Friday. Extended hours are offered between Tuesday and Thursday between 7am and 8am. Outside of these hours, patients are redirected to their out of hours provider, Care UK.
The practice team comprises three female GP partners and five salaried GPs (four female and one male), one nurse practitioner and one practice nurse who provide a combination of 31 sessions. The practice also employs a clinical pharmacist, a healthcare assistant, a newly employed practice manager, a secretary and 13 reception and administration staff. The practice is an accredited training practice supporting Foundation Year two doctors from Imperial College School of Medicine and University College London (UCL).
The practice is registered with the Care Quality Commission to provide the regulated activities of diagnostic and screening procedures, treatment of disease, disorder or injury, surgical procedures; family planning and maternity and midwifery services. Services provided include chronic disease management, insulin initiation, 24-hour blood pressure monitoring, ECG monitoring, child health surveillance and immunisation, cervical screening, phlebotomy, family planning, joint injections and cryotherapy and smoking cessation.
Updated
15 November 2019
We carried out an announced comprehensive inspection at Ellis Practice on 10 July 2018 as part of our inspection programme. The overall rating for the practice was good and requires improvement for providing safe services. The full comprehensive report on the July 2018 inspection can be found by selecting the ‘all reports’ link for Ellis Practice on our website at: cqc.org.uk
At the last inspection in July 2018, we rated the practice as requires improvement for providing safe services because:
- There were gaps in appropriate recruitment checks for all new staff.
- Patient Specific Directions (PSDs) had not been completed for two patients.
- Significant events were not shared with all staff and outcomes were not completed for all significant events.
We also found areas where the provider should make improvements:
- Take action to ensure all completed induction records are stored in staff files.
- Consider adding safety alerts and significant events as standing agendas in clinical meetings.
- Provide Gillick competency training to junior clinicians.
- Continue to improve and monitor cancer screening uptake.
- Continue to monitor and improve exception reporting.
- Continue to monitor and improve access to the service.
- Continue to monitor and improve on patient satisfaction scores on nurse consultations.
This inspection was an announced focused follow up inspection carried out on 18 September 2019, to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified in our previous inspection on 10 July 2018. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.
Overall the practice is now rated as Good overall and Good for providing safe services.
Our key findings were as follows:
- The practice could not demonstrate they addressed the findings of significant events; however, a clear documented process was still required.
- There was no evidence to show that Gillick competency training had been completed by junior clinicians.
- Completed induction records were now in place.
- Safety alerts and significant events were consistent standing agenda items in practice meetings.
- The practice took part in cancer screening campaigns to improve uptake.
- An exception reporting audit showed improvement in overall exception reporting over the last year.
- The practice offered e-consults to improve access to the service.
- Action was required to demonstrate improvement on patient satisfaction with nurse consultations.
While there were no breaches of regulation, the areas where the provider should make improvements are:
- Implement a clear documented process for sharing significant event learning.
- Ensure completed interview summaries are available for new staff.
- Provide Gillick competency training to junior clinicians.
- Continue to improve and monitor cancer screening uptake.
- Improve patient satisfaction scores on nurse consultations.
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