Dr Evans & Partners

Updated 29 November 2023

Dr Evans & Partners (Florence Road Surgery) is located in the Ealing area in West London at:

Florence Road Surgery

26 Florence Road

Ealing

London

W5 3TX

We visited this location as part of this inspection activity. The practice is in converted premises.

The provider is registered with CQC to deliver the Regulated Activities: diagnostic and screening procedures; maternity and midwifery services; surgical procedures; family planning; and treatment of disease, disorder or injury. The practice’s CQC registration was not up-to-date. There are 5 partners, however, the CQC registration certificate only included 2 partners.

The practice is situated within the North West London Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 14,500. This is part of a contract held with NHS England.

The practice is part of the South Central Ealing Primary Care Network (PCN) and Ealing GP Federation.

Information published by the Office for Health Improvement and Disparities rates the deprivation within the practice population groups as 7, on a scale of 1 to 10. Level 1 represents the highest level of deprivation and 10 the lowest.

According to the latest available data, the ethnic make-up of the practice area is 70% White, 15% Asian, 6% Black, 5% Mixed, and 4% Other.

The majority of patients within the practice are of working age. The working age practice population is higher and the older people practice population is lower than the national average.

There are 4 GP partners and a managing partner. There are 7 salaried GPs and 3 trainee GPs. 10 GPs are female and 4 are male. The practice employs 1 practice nurse, 2 clinical pharmacists, 2 advanced nurse practitioners, 1 health care assistant, 1 phlebotomist, 2 pharmacy technicians and 1 trainee pharmacy technician. The partners are supported by a practice administration manager and a team of administrative and reception staff.

This is a GP training practice.

The practice is open from 8am to 6.30pm Monday to Friday. The practice offers a range of appointment types.

Extended access is provided locally by the PCN, where late evening and weekend appointments are available. Out of hours services are provided by Practice Plus.

Updated 29 November 2023

We carried out an announced focused inspection at Dr Evans & Partners (Florence Road Surgery) on 19 & 20 July 2023. Overall, the practice is rated as Good.

Safe - Good.

Effective - Good.

Caring - not inspected, rating of Good carried forward from the previous inspection.

Responsive - Good.

Well-led - Good.

Following our previous inspection on 29 February 2016, 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 Dr Evans & Partners on our website at www.cqc.org.uk.

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

At this inspection, we covered these key questions:

• Are services safe?
• Are services effective?
• Are services responsive?
• Are services well-led?

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.
• 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:

• Our clinical records searches showed that the practice had a process for monitoring patients’ health in relation to the use of medicines including medicines that require ongoing monitoring. However, some improvements were required.
• Most of the recruitment checks including Disclosure and Barring Service (DBS) were carried out in accordance with regulations. However, some improvements were required.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Blank prescription forms were recorded correctly, and their use was monitored in line with national guidance.
• There was an infection prevention and control policy and procedures were in place to reduce the risk and spread of infection.
• There was a system for recording and acting on significant events.
• There was a system for recording and acting on safety alerts.
• Patients could access care and treatment in a timely way.
• The practice had systems to manage and learn from complaints.
• The Patient Participation Group (PPG) was active. Feedback from PPG was positive about the way staff treated people.

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

• Take further steps to improve processes for monitoring patients’ health in relation to the use of some medicines that require ongoing monitoring.
• Continue to encourage the patient for cervical, breast and bowel cancer screening and childhood immunisation uptake.
• Carry out appropriate health checks during the recruitment process and keep interview notes in staff files.
• Take necessary actions to address the Care Quality Commission registration issues.

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