Elmtrees Surgery

Updated 14 November 2023

Elmtrees Surgery is located in Greenford, West London, at:

2a Horsenden Lane North

Greenford

UB6 0PA

The provider is registered with CQC to deliver the following Regulated Activities; Diagnostic and screening procedures, Family planning, Maternity and midwifery services, Surgical procedures and Treatment of disease, disorder or injury.

The practice is situated within the borough of Ealing and is part of the North West London

Integrated Care System (ICS). The practice delivers General Medical Services (GMS) to a patient population of about 7,400. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices known as North Greenford Practice Group Primary Care Network (PCN).

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the eighth decile (8 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 45% White, 36% Asian, 11% Black, 3% Mixed, and 5% Other.

The practice is led by a GP principal (female) who is supported at the practice by 4 regular GP locums (male and female), a clinical pharmacist, a physicians associate, a practice nurse, a health care assistant, 2 phlebotomists, a practice manager, an assistant practice manager and a small team of reception/administration staff.

The practice is open between 8.00am and 6.30pm Monday to Friday. Extended hours appointments are offered on Thursday evening from 6.30pm-8.00pm. Appointments are available on Saturdays on a rotational basis with other practices within the PCN. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Updated 14 November 2023

We carried out an announced comprehensive inspection at Elmtrees Surgery on 14 September 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

Why we carried out this inspection

We carried out this inspection because the new provider had yet to be rated since registration in March 2022. We reviewed all key questions as part of this inspection.

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:

• 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.
• 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:

• Take action to ensure staff recruited by the predecessor provider have received disclosure and barring service checks at the appropriate level.
• Improve the system for maintaining records relating to staff vaccination.
• Improve the system for documenting action taken in response to safety alerts.
• Take steps to ensure fridge temperatures can be measured in line with National guidance.
• Continue to improve the systems and processes to increase childhood immunisations and cervical screening uptake.

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