Background to this inspection
Updated
4 November 2021
Lanark Medical Centre Ground Floor (Dr Aseem Kashif), operates from 165 Lanark Road, London, W9 1NZ. The practice operated on the ground floor and first floor which was accessible by lift and stairs. The property is shared with another GP practice.
The practice holds a Personal Medical Services (PMS) contract with NHS Central London (Westminster) Clinical Commissioning Group (CCG) and provides services to approximately 3,700 patients.
The practice is registered as an individual with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures, treatment of disease, disorder or injury, surgical procedures and maternity and midwifery services which is required as part of their service portfolio.
The practice includes one male lead GP, two female salaried GPs and one male salaried GP, a part-time practice nurse and phlebotomist. They are supported by a practice manager and administration and reception team.
The practice core hours are between 8am and 6.30pm Monday to Friday. Extended hours appointments are available on Monday from 6.30pm to 8pm for GP and practice nurse appointments. In addition, patients can also access GP and practice nurse appointments from local GP in the evenings and at the weekend.
Information published by Public Health England rates the level of deprivation within the practice population group as three on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest. Data shows that almost 47% of patients at the practice area were from Black and Minority Ethnic (BME) groups.
Updated
4 November 2021
We previously carried out an announced comprehensive inspection at Lanark Medical Centre
Ground Floor on 30 January 2020. The overall rating for the practice was requires improvement, with the exception of the key question Effective which was rated good. The full report on the 30 January 2020 inspection can be found by selecting the ‘all reports’ link for Lanark Medical Centre Ground Floor on our website at www.cqc.org.uk.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
This inspection was an announced comprehensive follow-up inspection carried out on 15 & 17 September 2021 to confirm that the practice continued to make improvements on areas that we had identified at our previous inspection held on 30 January 2020. This report covers our findings in relation to those improvements and also additional improvements made since our last inspection. This review of information was undertaken without carrying out a site visit.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Lanark Medical Centre Ground Floor on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was a focused follow-up inspection to follow up on:
- There was no programme of clinical audit.
- There were gaps in relation to safety-netting of urgent two-week wait referrals and monitoring cervical cytology.
- There was no formal system to review and document clinical notes and prescribing of clinical staff.
- There was no clear system to receive, disseminate and discuss new and updated evidence-based guidance.
- Induction processes had failed to appropriately assess the skills competency and training needs of a newly recruited clinical staff member.
- Policies and procedures contained out-of-date and insufficient information.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- 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.
At this inspection we found there had been sufficient improvement to rate the effective and well-led key questions good, however the population group working age is still requires improvement due to the low cancer screening rates. The ratings for the practice is now rated good overall.
We found that:
- The practice used information about care and treatment to make improvements. The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients.
- The practice had implemented fail safes in relation to safety-netting of urgent two-week wait referrals and monitoring cervical cytology to ensure that patients received effective care and treatment that met their needs in a way that as safe and effective.
- The practice ensured the safety of prescribing and consultations by to reviewing clinical notes and the prescribing of all clinical staff.
- There was now a clear system to receive, disseminate and discuss new and updated evidence-based guidance. The Practice received updates to the latest guidelines via the NICE newsletter, CCG bulletin, and CLH bulletin, as well as from other sources such as the Practice Index newsletter. There is a standard agenda item on the Practice meeting agenda that is used to disseminate and discuss new and updated guidelines.
- The practice recruitment policy now outlines the skills competency and training needs of newly recruited clinical staff members.
- The practice had ensured that all current policies and procedures did not contain out-of-date information or data. They had a log sheet for all policies and procedures when they have been reviewed and when the date for review is due.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
Whilst we found no breaches of regulations, the provider should:
- Continue to review and improve the uptake of cervical screening and the childhood immunisation programme.
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