Background to this inspection
Updated
28 June 2022
Uxendon Crescent Surgery is a GP practice located in Wembley, to the north of London. The practice operates from a converted residential property at 1 Uxendon Crescent, Wembley, Middlesex HA9 9TW. The practice had access to four clinical consulting rooms, two located on the ground floor and two located on the first floor.
The practice provides NHS primary care services to approximately 5,500 patients. The practice operates under a General Medical Services (GMS) contract (a contract between NHS England and general practices for delivering general medical services and is the commonest form of GP contract). The practice is part of NHS Brent Clinical Commissioning Group (CCG). The practice is one of six practices making up the KWH primary care network (PCN)
The practice is registered as a partnership with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures, treatment of disease, disorder or injury and maternity and midwifery services.
The practice staff is comprised of one lead GP and four locum GPs, two of whom work four sessions a week and the other two work two sessions a week. In addition, the practice has a full time advanced nurse practitioner (ANP) and practice nurse who works two days a week and two healthcare assistants who both work part time. The practice also had access to additional healthcare professionals such as a physician’s associate, physiotherapist, social prescriber and pharmacists who worked across the PCN. The clinical team are supported by nine reception and administrative staff.
Information published by Public Health England shows that deprivation within the practice population group is in the seventh decile out of 10. The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 47% Asian, 33% White, 9% Black, 4% Mixed, and 7% Other.
The age distribution of the practice population showed an above average number of older patients (22% compared to the local average of 11%) and below average of working age people (58% compared to the local average of 71%).
The practice is open between 8am to 6.30 pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.
When the practice was closed, patients could access GP services at one of four local GP hubs which operated varying opening times. Out of hours, patients were directed to the NHS 111 service.
Updated
28 June 2022
We carried out an announced inspection at Uxendon Crescent Surgery on 21 April 2022. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive – Requires improvement
Well-led - Good
The provider had become registered with the CQC in November 2020. The practice had been inspected under its previous registration in April 2019 and was rated Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Uxendon Crescent Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection was the practice’s first inspection under the new provider’s registration with CQC. The inspection was a comprehensive inspection, meaning we looked at all five key questions; Safe, Effective, Caring, Responsive and Well-led.
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.
We have rated this practice as Good overall
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.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- Patients could not always access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
Whilst we found no breaches of regulations, the provider should:
- Review and improve the prescribing of antibiotics to bring it in line with local and national averages.
- Review and improve their achievement in childhood immunisation and cervical screening.
- Review and improve patient experience and feedback in relation to accessing the service and using the service.
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