The Care Quality Commission
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  • GP practice

Archived: Chalfont Road Surgery

Overall: Good read more about inspection ratings

2 Chalfont Road, London, N9 9LW (020) 8807 4505

Provided and run by:
Evergreen Surgery Limited

Important: The provider of this service changed. See new profile

All Inspections

6 October 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced focussed inspection at Chalfont Road Surgery on 6 October 2016. We found the practice to be good for providing safe and well led services and it is rated as good overall.

We had previously conducted an announced comprehensive inspection of the practice on 14 January 2016. As a result of our findings during the visit, the practice was rated as good for being effective, caring and responsive and requires improvement for being safe and well led, which resulted in a rating of requires improvement overall. We found that the provider had breached two regulations of the Health and Social Care Act 2008; Regulation 12(1)(2)(a)(b)(c)(g)(h) safe care and treatment and Regulation 17 (1)(2) (a) (b) good governance.

The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements. We undertook this focussed inspection to check that the practice had followed their plan, and to confirm that they had met the legal requirements.

This report only covers our findings in relation to those areas where requirements had not been met. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Chalfont Road Surgery on our website at http://www.cqc.org.uk/location/1-2208206845

Our key findings across all the areas we inspected were as follows:

  • Significant events reporting was now sufficiently thorough, such that when something went wrong, there was an appropriate, thorough review or investigation that involved all relevant staff and which maintained or improved patient safety.

  • A medical equipment cleaning schedule had been introduced for equipment such as nebuliser and ear irrigator machines.

  • Records showed that clinical and non clinical staff had received basic life support training within the last 12 months.

  • Staff had received annual appraisals.

  • There was a system in place to regularly check the practice’s emergency oxygen.

  • Appropriate arrangements were now in place to monitor the cleaning undertaken by the provider’s external cleaning contractor.

  • Staff had undertaken mandatory training such as infection prevention and control training.

  • Appropriate arrangements for performance management were in place and enabled the practice to manage current and future performance.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

14 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chalfont Road Surgery on 14 January 2016. Overall the practice is rated as requires improvement.

Since 1 August 2015, Chalfont Road Surgery has been managed by Evergreen Primary Care under a temporary caretaking agreement with NHS England. The agreement terminates on 30 April 2016. Evergreen Primary Care has employed two long term locum GPs and seconded a salaried GP, who is designated as senior GP for the practice. Evergreen Primary Care’s Medical Director provides clinical support and supervision to the designated senior GP.

Our key findings across all the areas we inspected were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. However, reviews and investigations were not thorough enough and lessons learned were not communicated widely enough to support improvement.
  • Risks to patients were assessed and well managed with the exception of those relating to infection prevention and control; and risks associated with staff not having received mandatory training such as annual basic life support training.
  • Data showed patient outcomes were above average compared to the locality and nationally.

  • Audits had been carried out and we saw evidence of how they were used to improve patient outcomes but there were no systems in place for results to be monitored, shared or discussed with clinical staff.

  • Patients said they were treated with compassion, dignity and respect and that they felt cared for, supported and listened to.

  • Information about services was generally available.

  • Urgent appointments were usually available on the day they were requested.

  • The practice had a number of policies and procedures to govern activity, but some of these had not been specifically produced for the practice.

  • The practice had proactively sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvement are:

  • Introduce a system for regularly checking the practice’s emergency oxygen.

  • Introduce a cleaning schedule for specific equipment such as nebuliser and ear irrigator.

  • Review arrangements for monitoring cleaning undertaken by the provider’s external cleaning contractor.

  • Ensure that all staff undertake mandatory training including infection prevention and control training; and annual basic life support training.

  • Review its significant events systems to ensure that learning is being shared and used to continuously improve patient safety.

  • Ensure that all clinical staff receive an annual appraisal.

The areas where the provider should make improvement are:

  • Ensure that regular fire drills take place.

  • Ensure there is a record of clinical meeting discussions, so as to monitor progress and reflect on patient outcomes achieved.

  • Review systems in place for identifying and supporting carers.

  • Review systems in place for analysing complaints and sharing learning amongst staff.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice