The Care Quality Commission
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  • GP practice

Archived: Cornwall House Surgery

Overall: Good read more about inspection ratings

Cornwall Avenue, London, N3 1LD (020) 8346 1976

Provided and run by:
Cornwall House Surgery

Important: The provider of this service changed. See new profile

All Inspections

7 February 2019

During a routine inspection

This practice is rated as Good overall. (Previous rating 15 June 2016– Good).

At our previous inspection we rated the service as requires improvement for providing effective care (because of a lack of clinical audit) and rated it as good overall and good for providing safe, caring, responsive and well-led services.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced inspection at Cornwall House Surgery on 7 February 2019 as part of our inspection programme.

At this inspection we found:

•Action had been take since our last inspection, such that clinical audit was now being used to drive improvements in patient outcomes.

•When incidents happened, the practice learned from them and improved their processes.

•The practice routinely reviewed the effectiveness and appropriateness of the care it provided.

•The practice’s GP patient survey feedback regarding phone access was lower than the national average but action had been taken action to improve performance.

•The practice did not have a protocol in place to ensure repeat prescriptions were promptly collected although when this was highlighted, prompt action was taken to introduce such a protocol.

•Although Patient Specific Directions documents were kept on file (providing the practice’s Health Care Assistant with dosage and patient assessment information) these were only being reviewed and signed by a doctor after the practice’s Health Care Assistant had administered medication. When this was highlighted, the practice immediately amended its protocol.

•Staff involved and treated patients with compassion, kindness, dignity and respect.

•There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

•Take action to improve cervical screening uptake.

•Monitor recently introduced actions aimed at improving telephone access.

•Further develop patient participation in how the service is delivered.

•Monitor recent actions aimed at improving how uncollected prescriptions are managed.

•Take action to ensure periodic fire drills take place.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

27 July 2016

During a routine inspection

We carried out an announced comprehensive inspection at Cornwall House Surgery on 15th June 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.
  • Risks to patients were assessed and well managed.
  • Although some audits had been carried out, we saw no evidence that a programme of quality improvement was in place. For example clinical audits were not driving improvements to patient outcomes.
  • 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.
  • 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 good facilities and 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:

  • Implement systems for assessing and monitoring risks and the quality of the service provided. For example a programme of quality improvement to improve patient outcomes.

  • Undertake a review of its annual infection control audits to ensure action taken to address any improvements are recorded.

  • Review arrangements for monitoring the consent process.

  • Review accessibility arrangements to the entrance of the premises to ensure those patients less able or those using prams or pushchairs can more easily access the entrance.

  • Consider further ways of meeting the needs of patients with long term conditions given the comparatively high exception reporting rates in some clinical domains.

  • Review the new telephone system to ensure that patients are better able to access the surgery for their specific need.

  • Improve patient awareness of availability of appointments via the North Barnet locality Network (8am-8pm initiative) as a result of patient survey results.

  • Develop a patient participation process which gives patients an opportunity to get involved in service delivery planning.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice