The Care Quality Commission
  • Doctor
  • GP practice

Dr Evans & Partners

Overall: Good read more about inspection ratings

Florence Road Surgery, 26 Florence Road, Ealing, London, W5 3TX (020) 8567 2111

Provided and run by:
Florence Road Surgery

All Inspections

19 & 20 July 2023

During an inspection looking at part of the service

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

29 February 2016

During a routine inspection

We carried out an announced comprehensive inspection at Dr Evans & Partners which provides clinical services from two sites; Florence Road the main surgery and the branch surgery at Bramley Road, which are both situated in the London Borough of Ealing. We visited both of these locations as part of the inspection on 29 February 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.

  • The practice had a dedicated clinical pharmacy team that ensured robust processes in place for repeat prescription management.

  • 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 staff were caring, supportive, and friendly and treated them with dignity and respect.

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

We saw areas of outstanding practice:

  • Clinical pharmacist expertise to support GPs in the management of patients with chronic disease and elderly patient care. Attendance by the clinical pharmacist at local nursing home ward rounds had contributed to a 91% reduction of medication errors.

The areas where the provider should make improvement are:

  • Ensure that DBS checks are completed for all staff who may be required to undertake chaperone duties.

  • Ensure that fridge temperature monitoring records are complete.

  • Complete annual staff appraisals for administration staff.

  • Ensure administrative staff attend basic life support training in accordance with national guidance.

  • Improve vaccine stock records with inclusion of expiry dates and running stock totals.

  • Implement proposed procedures to identify carers to ensure they are provided with support.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

During this review we did not speak with people who used the service. We carried out a desk top review to follow up on a compliance action we issued on 9 January 2014 as the provider could not demonstrate that they had undertaken the appropriate recruitment checks, including criminal record checks and references for staff employed at the practice.

Following our visit of 9 January 2014 the provider sent us an action plan and told us that they would review the employment records of all staff employed at the practice.

As part of this review the provider sent us a copy of the current staff recruitment document check list and Disclosure and Barring Services (DBS) protocol. The documents demonstrated that two reference checks had been received for the majority of staff and that criminal record checks had been undertaken for staff in accordance with risk assessment analysis of individual staff roles and responsibilities.

This meant that the practice had effective recruitment processes in place to ensure that staff employed at the practice had the qualifications, skills and experience necessary for the work to be performed.

9 January 2014

During a routine inspection

We spoke with six people using the service, three GP's, the practice manager, nurses and administrative staff working in the practice. The people we spoke with all told us they were very happy with the services they received. One person told us 'I've always had a good experience. They take time to listen and really care about getting it right.' A second person said 'they always ask about what I want and what's important to me.'

We saw people were given the information they needed to make decisions about their care and treatment.

Staff working in the practice understood the local arrangements for safeguarding children and adults using the service and had been trained to recognise possible abuse.

The provider carried out checks to make sure staff were suitable to work with people using the service. However, there was a need to make sure that checks were completed for all staff.

The provider had procedures for monitoring the standards of care and treatment provided. A Patient Participation Group worked with the partners to monitor and improve services.