The Care Quality Commission
  • Doctor
  • GP practice

The Ecclesbourne Practice

Overall: Requires improvement read more about inspection ratings

1 Warwick Terrace, Lea Bridge Road, Leyton, London, E17 9DP (020) 8539 2077

Provided and run by:
The Ecclesbourne Practice

Important: We are carrying out a review of quality at The Ecclesbourne Practice. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

During an assessment under our new approach

The Ecclesbourne Practice is a GP practice that provides various primary medical services. It is registered with the Care Quality Commission under the Health and Social Care Act 2008 to provide the following regulated activities: diagnostic and screening procedures, family planning, midwifery and maternity services, surgical procedures, and treatment of disease, disorder, or injury. At the previous inspection on 9 November 2022, we conducted a comprehensive inspection of the practice, rating it as inadequate overall and in the safe and well-led key questions. We rated the practice as requiring improvement in the effective and responsive key questions and as good in the caring key question. We conducted an inspection that comprised an on-site visit on 13 March 2024 and a remote assessment on 15 and 27 March 2024 to follow up on the breaches of regulation in the safe and well-led key questions from the previous inspection in November 2022. We examined 10 quality statements. Under the safe key question, we looked at learning culture, safeguarding, safe environments, infection prevention and control, and medicine optimisation. Under the well-led key question, we reviewed shared direction and culture, capable, compassionate, and inclusiveness, freedom to speak up, governance, management, and sustainability, and learning improvement and innovation. At this inspection, we found that the practice had taken action to address previous concerns, which led to improvements. However, we also identified areas that still require further improvement. Concerns about the relationship within the practice's partnership impacted their ability to work in cohesion, resulting in some outstanding and delayed tasks. Despite that, we did not find evidence that these challenges impacted patient outcomes. We undertook an unannounced inspection on the 24 May 2024 in response to concerns raised about the practice. This report presents the findings from both inspections.

9 November 2022

During a routine inspection

We carried out an announced comprehensive inspection at The Ecclesbourne Practice on 9 November 2022. Overall, the practice is rated as inadequate.

Safe - inadequate

Effective - requires improvement

Caring - good

Responsive - requires improvement

Well-led - inadequate

Following our previous inspection on 13 January 2017, the practice was rated good overall and for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Ecclesbourne Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • A site visit to the branch surgery.
  • Conducting face to face staff interviews.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.

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 did not have clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • There were gaps in systems to assess, monitor and manage risks to patient safety.
  • Staff did not always have the information they needed to deliver safe care and treatment.
  • The practice did not always have safe systems for the appropriate and safe use of medicines, including high-risk medicines.
  • The practice was unable to demonstrate that staff had the skills, knowledge and experience to carry out their roles.
  • The practice was unable to demonstrate that it always obtained consent to care and treatment in line with legislation and guidance.
  • People were not always able to access care and treatment in a timely way.
  • Complaints were not used to improve the quality of care.
  • There were gaps in governance structure.
  • There was compassionate and leadership; however, effective monitoring was required to ensure this was taking place at all levels.
  • The practice culture did not effectively support high quality sustainable care.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice respected patients’ privacy and dignity.
  • There was evidence of systems and processes for learning, continuous improvement and innovation but improvement was required.

We found breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way.

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

  • Ensure sufficient numbers of suitably qualified, competent, skilled and experienced staff are deployed to meet people’s care and treatment needs.

In addition, the provider should:

  • Take action to improve patient satisfaction and carry out patient surveys.
  • Take action to update the practice website.
  • Consider patient accessibility to online appointments.
  • Take steps to appoint a Freedom to Speak up Guardian.

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.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

13 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Ecclesbourne Practice on 13 January 2017. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were generally assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their 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.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvements are:

  • Review arrangements for patients with learning disabilities annual health care checks.
  • Implement effective systems for checking contents of the first aid kit, and premises fixed wiring and maintaining non-clinical staff pre-employment reference checks.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

29 May 2014

During an inspection looking at part of the service

We last inspected on the 7 January 2014 and found non-compliance in relation to cleanliness and infection control, safety and suitability of premises and requirements relating to workers. At this inspection we found that the service had met these essential standards of care.

We found there were effective systems in place to reduce the risk and spread of infection and quality monitoring systems were in place to identify, assess and manage risks.

The provider had taken steps to provide care in an environment that was suitably designed and adequately maintained.

There were effective recruitment and selection processes in place. We found that people were cared for and supported by, suitably qualified, skilled and experienced staff.

7 January 2014

During a routine inspection

We spoke to nine people and received written comments from ten people. We spoke to eight staff including a doctor, a nurse, a health care assistant, reception staff and managers.

We observed that people were treated with dignity and respect. Reception staff spoke politely. People told us that the care was always explained to them.

We looked at patients records on the computer system. We found comprehensive health checks including urine assessments, height, weight a BP and lifestyle checks were completed when they first registered.

There were clear safeguarding and whistleblowing policies. Staff were aware that these policies were in place and told us that they would alert the doctors if they witnessed or suspected any abuse.

There were effective systems in place to reduce the risk and spread of infection. There were quality monitoring systems in place to identify, assess and manage risks to the health, safety of people using the service. However, people were not always cared for in a clean, hygienic environment.

We found that the provider did not ensure that the waiting area was adequately maintained. Recruitment checks were inconsistent and occupational health checks were not always completed.