The Care Quality Commission
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Archived: Boleyn Road Practice

Overall: Inadequate read more about inspection ratings

162 Boleyn Road, Forest Gate, London, E7 9QJ (020) 8503 5656

Provided and run by:
Boleyn Road Practice

All Inspections

5 August 2020

During a routine inspection

We carried out an inspection of Boleyn Road Practice 5 August 2020. Due to issues associated with the coronavirus pandemic we then undertook a remote review of clinical records on 6 August 2020 and on 12 August 2020. The inspection of this service was to follow up concerns identified during our inspection undertaken on 4 December 2019. At that inspection we rated the practice as inadequate for all key questions and population groups. CQC served the provider with a Notice of Decision to cancel the provider’s registration.

This inspection was a comprehensive inspection focusing on all key questions:

  • Are services safe?
  • Are services effective?
  • Are services caring?
  • Are services responsive?
  • Are services well-led?

At this inspection we found that the provider had taken action to address some of the concerns identified at our last inspection. However, there were still a significant number of concerns in key areas of the organisation including in respect of; risk management, safeguarding, significant event management, recruitment and staffing, governance including clinical governance, complaint management, clinical performance and patient satisfaction.

The practice told us that Covid 19 had impacted on their ability to address the concerns raised at the last inspection and their ability to recruit a new practice manager and new partners.

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 Inadequate overall for all key questions and all population groups.

We rated the practice as inadequate for providing safe services because:

  • The practice’s child safeguarding policy contained outdated information. Not all staff had received the appropriate level of safeguarding training and management were not aware of the required level of training for some staff. Not all staff were involved in discussions around safeguarding or knew what amounted to a safeguarding concern. Lists of patients on the practice’s safeguarding register were not proactively shared with out of hours services and the safeguarding lead could not access these registers and had not reviewed the registers since starting at the practice in July 2020. We also found instances where patients who had safeguarding concerns raised were not being appropriately managed or followed up.
  • The practice did not have adequate systems in place to ensure risks associated with infection control, fire, legionella and substances hazardous to human health were mitigated.
  • Not all staff had contracts of employment in place and there was no evidence of inductions having been completed for some staff.
  • Systems around the management of medicines were not sufficiently comprehensive to ensure that patients remained safe.
  • Not all significant events had been reported using the practice policy. Staff at the practice were unaware of the requirements to report certain events to external bodies and the registered manager was initially unable to provide details of CQC’s notification requirements when asked.

We rated the practice as inadequate for providing effective services because:

  • We found several patients with diabetes who had not been informed of their diagnosis or had appropriate care and treatment in place. Systems to identified diabetic patients were therefore not effective.

  • The practice had not reviewed all of the 30 records where concerns had been raised by NHS England; despite telling us after the last inspection that they would do so. No audits of clinical consultations had been done since the provider undertook reviews following our last inspection.

  • The practice performance against targets was below local and national averages in a number of areas including some long term conditions and screening programmes and there was little evidence of action taken to try and improve patient outcomes.

  • There was some evidence of quality improvement activity.

  • Not all staff had completed the required training.

  • There was no documented clinical supervision.

  • Consent was not audited.

We rated the practice as inadequate for providing a service that is caring because:

  • The national GP patient survey indicated that patient satisfaction was below local and national averages for scores relating to practice consultations. The practice had taken action in an effort to address these concerns but had not engaged with patients to determine if the action taken had resulted in improved satisfaction.

We rated the practice as inadequate for providing responsive services because:

  • The practice was not following their own complaint process and had not provided a response to the last complaint received in March 2020.

  • The national GP patient survey indicated that patient satisfaction was below local and national averages for scores relating to access. The practice had taken action in an effort to address these concerns but had not engaged with patients to determine if the action taken had resulted in improved satisfaction.

We rated the practice as inadequate for providing a well-led service because:

  • Governance was not effective in key areas including risk management, safeguarding, infection control and clinical oversight and monitoring.

  • Some policies contained inaccurate or out of date information.

  • Staff said that new leadership was needed to make the service work effectively and the current leadership lacked the necessary vision to make improvements.

  • Staff reported that they were reluctant to raise concerns with leadership in the practice for fear of retribution.

  • Information was not effectively used to ensure patients were provided with appropriate care and treatment particularly those with diagnosis of diabetes.

The areas where the provider must make improvements are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

As the provider has not demonstrated sufficient improvement or adequately addressed the breaches identified at our last inspection, CQC are proceeding with action to cancel the provider’s registration.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the evidence tables for further information.

4 December 2019

During a routine inspection

Our initial announced comprehensive inspection of Boleyn Road Practice was carried out on 13 July 2018 where we rated the practice as inadequate and they were placed in special measures as breaches of regulation were identified in relation to medicines management, clinical governance, equipment safety, access to services, patient satisfaction, risk assessments and clinical oversight. We carried out a comprehensive inspection on 1 April 2019 to follow up on the breaches identified in the inspection in July 2018 and we extended the practice’s period of special measures as there continued to be breaches in relation to patient satisfaction, access to services, and governance arrangements and the practice was unable to demonstrate that any changes made had been embedded.

This inspection on 4 December 2019 found insufficient improvements had been made and the quality of services provided at the practice had deteriorated.

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 inadequate overall.

We rated the practice as inadequate for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe and safeguarded from abuse.
  • There were insufficient processes for sharing learning.
  • there was a lack of risk mitigation.
  • There was no evidence of clinical oversight and supervision.
  • The overall governance arrangements were ineffective.

We rated the practice as inadequate for providing effective services because:

  • There were insufficient systems for clinical oversight and supervision.
  • There were issues with quality improvement.
  • The practice was unable to demonstrate that all staff had the skills, knowledge and experience to carry out their roles.
  • Some performance data was significantly below local and national averages.

We rated the practice as inadequate for providing caring services because:

  • There was continued limited action taken as a result of low national GP patient satisfaction results resulting in a continued poor experience for patients.

We rated the practice as inadequate for providing responsive services because:

  • There had been little improvement with improving access to appointments at the practice.
  • There was continued limited action taken to improve patient satisfaction with services provided.
  • Evidence of shared learning from complaints was limited.

We rated the practice as inadequate for being well-led because:

  • There were no formal arrangements or effective processes in place for overall clinical oversight and clinical supervision.
  • There was limited capacity and skills demonstrated by members of the management team.
  • The practice did not have clear and effective processes for managing and mitigating risks including performance.
  • The practice culture did not support honesty, openness and transparency.
  • There were limited systems to act on and share information in response to patient satisfaction surveys.
  • The overall governance arrangements were ineffective.

At this inspection insufficient improvements had been made at the practice such that the practice was rated inadequate overall for the second time in 18 months. we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and, if needed, could be escalated to urgent enforcement action. Where necessary another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the service the reassurance that the care they get should improve.

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

1 April 2019

During a routine inspection

We carried out an announced inspection at Boleyn Road Practice on 1 April 2019.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 13 July 2018, where the practice was issued with a warning notice for Regulation 12 of the Health and Social Care Act due to issues with medicines management and infection prevention and control. The inspection also found issues with nurses not using patient group directives, data management. access to practice services, patient satisfaction with services provided and poor building maintenance,

We based our judgement at the inspection on 1 April 2019 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 rated this practice requires improvement overall.

We rated the practice as inadequate for providing responsive services because:

  • Appointments were not offered at the practice outside of normal working hours for patients who were unable to make it during these times. However, patients were able to access appointments at the local HUB extended hours service.
  • Although the practice’s own patient survey of 39 patients, results were higher than the national GP patient survey, the practice could not demonstrate what action had been taken to improve patient satisfaction on access to services.
  • Not all complaints were discussed with relevant members of staff where learning could be shared.

We rated the practice as requires improvement for providing safe services because:

  • Systems and processes kept patients safe and safeguarded from abuse.
  • Risk assessments had been carried out and all actions identified had been completed.
  • The practice learned lessons and made changes as a result of significant events.

We rated the practice as requires improvement for providing effective services because:

  • Childhood immunisation rates were above the 90% target.
  • The practice worked closely with other organisations to provide when necessary a multi-disciplinary package of care.
  • There was no formal programme for quality improvement.

We rated the practice as requires improvement for providing caring services because:

  • Although the practice’s own survey patient satisfaction survey results were higher than the national GP patient survey, the practice could not demonstrate what action had been taken to improve patient satisfaction.

We rated the practice as requires improvement for providing well-led services because:

  • While the practice had a vision, this was not supported by a credible strategy.
  • The overall governance structure did not include staff accountabilities.
  • There was no programme of clinical quality improvement activities.

The area where the provider must make improvement is:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Review the system for improving patient satisfaction with service provided and take action.
  • Review access to the practice.
  • Review the system to improve cytology screening uptake.
  • Review the documented approach for patient triage for reception staff to follow to ensure it is embedded in practice.
  • Consider formalising clinical audit documentation and implementing a programme of clinical audit.
  • Review the system for identifying carers with the aim of increasing the registered number and ensuring they are all provided with the appropriate services.
  • Review system for sharing learning from complaints.
  • Continue to work to improve governance systems.

Whilst the practice had made improvements following their inspection in July 2018, further improvements are required. The practice therefore remains in special measures.

Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

13 December 2018

During an inspection looking at part of the service

We previously carried out an announced comprehensive inspection of Boleyn Road Practice on 13 July 2018 and found that the practice was in breach of Regulation 17: ‘Good governance’ of the Health and Social Care Act 2008. In line with the Care Quality Commission’s (CQC) enforcement processes, we issued a warning notice which required Boleyn Road Practice to comply with the Regulations by 31 October 2018.

The full report of the 13 July 2018 inspection can be found by selecting the ‘all reports’ link for Boleyn Road Practice on our website at www.cqc.org.uk.

We carried out this announced focused inspection on 13 December 2018 to check whether the practice had addressed the issues in the warning notice and now met the legal requirements. This report covers our findings in relation to those requirements and will not change the current ratings held by the practice.

At the inspection on 13 December 2018 we found the provider had taken action to address the requirements of the Regulation 17 warning notice, except in relation to the system for monitoring staff training.

Our key findings were as follows:

  • The system for monitoring staff training was not effective.
  • The practice had taken action to ensure premises and equipment were fit for use.
  • There was medical equipment in place for use in an emergency which was regularly checked.
  • The system for receiving and acting upon safety alerts was effective.
  • The practice had business improvement and business continuity plans in place.
  • There was no evidence of underutilisation of appointments.
  • Practice staff were able to interrogate the clinical system and extract accurate data.
  • The practice was aware of low GP patient survey scores and had analysed results of the Friends and Family test, but there was no documented action plan to monitor, discuss and address all patient feedback on an ongoing basis.

We identified a Regulation that was not being met and the provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

You can see full details of the Regulation not being met at the end of this report.

We also identified areas where the provider should make improvements:

  • Consider documenting serial numbers in the reception log book for prescriptions taken by clinicians to consultation rooms.
  • Review how the practice analyses, discusses, actions and monitors patient feedback on an ongoing basis.
  • Consider documenting the regular checks of clinicians’ registration.
  • Ensure the recruitment policy identifies what checks the practice carries out to ensure new staff are appropriately qualified and safe.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and evidence table for further information.

13 July 2018

During a routine inspection

This practice is rated as Inadequate overall. (Previous inspection 17 October 2016 – Good)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires improvement

Are services caring? – Inadequate

Are services responsive? – Inadequate

Are services well-led? – Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) – Inadequate

We carried out an announced comprehensive Inspection at Boleyn Road Practice on 13 July 2018. We inspected the provider as part of our inspection programme.

At this inspection we found:

  • Arrangements to ensure patients safety had gaps including staff safety training, medicines management, premises and equipment safety, cervical screening, and lack of management oversight.
  • The practice had policies and protocols to govern activity but some were not implemented, were out of date, or did not belong to the practice including chaperoning, business continuity and prioritising patient appointments.
  • Learning and improvement following significant events and complaints was limited but individual patients received a prompt response and appropriate response including an apology, where appropriate.
  • Reviews of the effectiveness and appropriateness of care were limited, but treatment was delivered according to evidence based guidelines except for some patients with diabetes or those prescribed a high-risk medicine.
  • Staff had not always involved and treated patients with compassion, kindness, dignity and respect.
  • Patients were not always able to access care when they needed it and appointments were underutilised.
  • There were fundamental and significant concerns regarding governance and leadership and management capability.

The areas of practice where the provider must make improvements are:

  • Ensure that all patients are treated with dignity and respect.
  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure all premises and equipment used by the service provider is fit for use.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

17 October 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We undertook an announced focussed inspection of Boleyn Road Practice on 17 October 2016. We found the practice to be good for providing safe services and it is rated as good overall.

We had previously conducted an announced comprehensive inspection of the practice on 15 September 2015. As a result of our findings during that visit, the practice was rated as good for being effective, caring, responsive and well-led, and requires improvement for being safe, which resulted in a rating of good overall. We found that the provider had breached two regulations of the Health and Social Care Act 2008: Regulation 13(2) Safeguarding service users from abuse and improper treatment and Regulation 12(2)(g) Safe care and treatment. You can read the report from our last comprehensive inspection at http://www.cqc.org.uk/location/1-537763824. 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 on 17 October 2016 to check that the practice had followed their plan, and to confirm that they had met the legal requirements. While the inspection was planned to focus on those areas where requirements had not been met previously, the scope of the inspection was not limited to this.

Our key findings on 17 October 2016 were as follows:

  • All staff who undertook chaperone duties had received a Disclosure and Barring Service (DBS) check.

  • We reviewed a total of 101 prescriptions awaiting collection on the day of our inspection. Medication reviews were not overdue for any patient issued a repeat prescription.

  • A gate had been installed at the top of the stairs leading down to the basement from the waiting area to keep children safe.

The areas where the provider should make improvement are:

  • Continue to review and monitor systems that identify patients’ medication reviews.

  • Actions taken to deal with any prescription not collected after one month are recorded clearly.

  • All prescriptions for repeat medications include a medication review date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

15 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Boleyn Road Practice on 15 September 2015. Overall the practice is rated as good.

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

  • Shortfalls we identified at our last inspection of the practice in June 2014 had been remedied.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed, with the exception of those relating to medicines management.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and were being met.
  • Patients said they were treated with kindness and concern and that their treatment was explained to them.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they could get an appointment when they needed one and urgent appointments were available the same day.
  • The practice had facilities for disabled people and was well equipped to treat patients and meet their clinical needs.
  • 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.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

  • Ensure all staff acting as chaperones have received a Disclosure and Barring Service check.
  • Ensure repeat prescribing is carried out safely in line with the provider’s repeat prescription and medication review protocol for every patient.

In addition the provider should:

  • Review arrangements to keep children safe at the top of the stairs that lead down to the basement from the waiting area.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

19 June 2014

During an inspection looking at part of the service

Patients we spoke with indicated that they felt they were respected by staff working at the practice. They said that the GP or nurse would discuss choices of treatment with them.

Care and treatment was not planned and delivered to meet patient's individual needs. Patients found it difficult to make an appointment by telephone and when they attended the surgery had to wait for a long time to be seen. Appropriate arrangements were not in place to deal with foreseeable emergencies.

Patients who use the service were not protected from the risk of abuse because the provider had not taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

The staff member with responsibility for infection control did not have appropriate training and internal infection control audits and checks were not undertaken in a systematic way to ensure staff were following infection control procedures.

Appropriate arrangements were in place in relation to managing medicines.

Most staff had yearly appraisals and felt supported. There was no training matrix or system in place to identify which staff needed training and when.

Although patients were made aware of the complaints system it was not effective and the surgery's own complaints procedure was not always followed by staff.