The Care Quality Commission
  • Doctor
  • GP practice

The Boileau Road Surgery

Overall: Good read more about inspection ratings

104 Boileau Road, Ealing, London, W5 3AJ (020) 8997 6604

Provided and run by:
The Boileau Road Surgery

All Inspections

28 September 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at The Boileau Road Surgery on 28 September 2022. This was a desktop inspection, meaning we did not carry out a site visit to undertake this inspection. Instead we reviewed information we held about the service and asked the provider to send us some information. We also interviewed the provider remotely.

This was a focussed inspection, meaning we only reviewed the areas where the provider had previously been told they should improve. Specifically, we looked at whether the service was providing effective care and treatment.

Overall, the practice is rated as good. This rating has been carried over from the previous inspection in November 2019. The ratings for safe, caring, responsive and well led were also carried forward from previous inspections.

Safe - good

Effective - requires improvement

Caring - good

Responsive - good

Well-led - good

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Boileau Road Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up concerns from a previous inspection in November 2019.

At this inspection we followed up on the areas where we had previously told the provider they should improve. We said they should:

  • Consider ways to improve cervical screening and childhood immunisation uptake. Further develop quality improvement including clinical audit to drive improvement in patient outcomes.
  • Continue to improve Quality and Outcomes Framework performance particularly for long-term conditions and reduce exception reporting.
  • Establish an active patient participation group.

How we carried out the inspection/review

This was a desktop inspection, meaning due to the nature of the concerns we were following up on, a site visit was not necessary. Instead we:

  • Requested evidence from the provider.
  • Spoke with the provider by telephone.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • information from our ongoing monitoring of data about services and
  • information from the provider.

We found that:

  • Patients received effective care and treatment that met their needs. However, the practice’s performance for childhood immunisations and cervical screening remained below national targets.
  • The provider was involved in quality improvement activity, including clinical audit.
  • Quality and Outcomes Framework performance for 202/21 was not available due to modifications made by NHS England and Improvement for 2020/21, due to the impact of the COVID-19 pandemic. However, the provider had taken steps to ensure patients were monitored appropriately.
  • There was a patient participation group in place, however regular meetings were yet to take place. The provider told us the practice had lost several members of their Patient Participation Group in previous years for a variety of reasons. They told us PPG meetings had been suspended during the COVID-19 pandemic in order to focus on clinical priorities. However at the time of this inspection the PPG consisted of four members and they were actively recruiting a new chair.

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

  • Continue taking steps to improve up take of cervical screening and childhood immunisations.
  • Continue to improve Quality and Outcomes Framework performance particularly for long-term conditions.
  • Implement plans to increase and improve the activity of the patient participation group.

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

27/11/2019

During an inspection looking at part of the service

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions: effective and well-led.

Because of the assurance received from our review of information we carried forward the ratings for the following key questions: safe, caring and responsive.

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 with the exception of working age people (including those recently retired and students) and families, children and young people population groups which we rated as requires improvement.

We found that:

  • 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. However, the practice’s performance for childhood immunisations and cervical screening were below national targets.
  • 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:

  • Consider ways to improve cervical screening and childhood immunisation uptake.
  • Further develop quality improvement including clinical audit to drive improvement in patient outcomes.
  • Continue to improve Quality and Outcomes Framework performance particularly for long-term conditions and reduce exception reporting.
  • Establish an active patient participation group.

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

13 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Boileau Road Surgery on 13 September 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.
  • 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 did not find it easy to make an appointment with a preferred GP and continuity of care was an issue. However, the practice was taking steps to address this concern.
  • 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 make improvement are:

  • Continue to improve Quality and Outcomes Framework (QOF) performance and reduce exception reporting.
  • Improve uptake for the cervical screening programme.
  • Identify more patients who are also carers to provide them with appropriate support and information.
  • Keep under review the decision made by the provider not to have access to a defibrillator to deal with cardiac emergencies.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice