The Care Quality Commission
  • Doctor
  • GP practice

Archived: The Pinner Road Surgery

Overall: Good read more about inspection ratings

196 Pinner Road, Harrow, Middlesex, HA1 4JS (020) 8427 0130

Provided and run by:
The Pinner Road Surgery

All Inspections

6 June 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Pinner Road Surgery on 7 June 2016. The overall rating for the practice was inadequate and the practice was placed in special measures for a period of six months. The full comprehensive report on the June 2016 inspection can be found by selecting the ‘all reports’ link for The Pinner Road Surgery on our website at www.cqc.org.uk.

This inspection was undertaken following the period of special measures and was an announced comprehensive inspection on 6 June 2017. We found that improvements had been made since the previous inspection and the practice was meeting the regulations which it had previously breached. Overall the practice is now rated as good.

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

  • There was a more positive, transparent approach to safety and an effective system in place for reporting, recording and learning from significant events and other incidents.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained and had the skills, knowledge and experience to deliver effective care and treatment.
  • The practice had implemented a programme of clinical audit to identify areas for improvement and acted on the findings.
  • The practice had implemented mechanisms for multidisciplinary working for example to support care planning and palliative care.
  • The feedback we received from patients was positive. The practice scored in line with the local and national averages on the national GP patient survey.
  • Information about services and how to complain was now available and easy to understand. Improvements were made to the quality of care as a result of complaints.
  • Patients said they found it easy to make an appointment with a named GP. Urgent appointments were available the same day.
  • The practice had recently renovated the premises and had secured funding for further expansion.
  • The practice was developing its leadership structure and staff said they were supported by management through this process. The practice proactively sought feedback from staff and patients, which it acted on.
  • On being placed in special measures the practice had sought and engaged with external advice and support to improve its service.

The area where the provider must make improvement is:

  • The practice must establish effective systems and processes to ensure good governance is embedded and sustained in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • The practice should focus on improving its cervical screening uptake rate which remains below the local average.
  • The practice should implement an effective induction programme to support newly recruited staff members.
  • The practice should include information about the NHS independent advocacy service in its complaints procedure and leaflet.
  • The practice was in the process of recruiting a permanent practice manager. The partners should provide the post holder with appropriate and ongoing support and training so that current improvements are sustained.
  • The practice should publicise changes and improvements to patients, for example changes in staffing, premises development, the range of services offered and changes in opening hours.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

7 June 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Pinner Road Surgery on 7 June 2016. Overall the practice is rated as inadequate.

Specifically, we found the practice inadequate for providing safe and being well led. It was also inadequate for providing services for; older people, people with long-term conditions, families, children and young people, working age people, people whose circumstances make them vulnerable and people experiencing poor mental health. Improvements were also required for providing responsive and effective services. It was good for providing caring services.

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example appropriate recruitment checks on staff had not been undertaken prior to their employment.

  • Staff were not clear about reporting incidents, near misses and concerns and there was no evidence of learning and communication with staff.

  • Patient outcomes were hard to identify as little or no reference was made to audits or quality improvement and there was no evidence that the practice was comparing its performance to others; either locally or nationally.

  • There was no induction programme for non-clinical staff and there was no evidence they had been given information on safeguarding, infection control, fire safety, health and safety and confidentiality when they first started working at the practice.

  • Not all staff had training to recognise or respond appropriately if they suspected abuse had occurred and the practice did not have formal policies for staff to follow.

  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

  • Patients said they were involved in their care and decisions about their treatment.

  • The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

  • Practice specific policies were not implemented and were not available to all staff, this meant that staff were not always aware of what process to follow if something went wrong.

  • There was a no formal system for recording and analysing complaints.

  • 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 areas where the provider must make improvements are:

  • Introduce clear and effective processes for reporting, recording, acting on and learning from significant events, incidents and near misses.

  • Ensure recruitment arrangements include all necessary employment checks for all staff.

  • Implement a system for clinical audits including re-audits to ensure improvements are identified and achieved.

  • Provide staff with appropriate policies, guidance and training to carry out their roles in a safe and effective manner so that they can safely and effectively meet the needs of the patients.

  • Ensure that there is a formal system in place for recording andcomplaints.

  • Ensure that there is an effective process in place for staff appraisal to be undertaken on a regular basis, for staff to access training and a system for induction for new staff

  • Ensure that DBS checks are undertaken as part of the recruitment process for all staff employed at the practice or a risk assessment to indicate the risks of not having one have been assessed.

The areas where the provider should make improvement are:

  • Improve the care of patients with asthma.
  • Update polices and processes to improve screening uptake for cervical cytology.
  • Amend the process for recording discussions of internal meetings
  • Revise arrangements in place to ensure that patients with caring responsibilities are identified, so their needs are identified and can be met.

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.

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

16 May 2014

During a routine inspection

On our inspection of 7 February 2014 we found that the provider had not made arrangements for all staff to attend safeguarding training for children and adults, and the provider had not undertaken the appropriate recruitment checks prior to some staff commencing their employment. We also found the provider did not have records relating to cleaning and infection control.

The provider wrote to us to inform us they would arrange training for staff in safeguarding children and adults, update staff records to ensure the required recruitment documentation was filed and improve records in relation to cleaning and infection control.

During this inspection we reviewed the progress the provider had made to meet essential standards in requirements relating to safeguarding people who use services from abuse, cleanliness and infection control and requirements relating to workers. We found that the provider had made arrangements to ensure that staff and people who use the service were aware of the safeguarding process. We saw that a formal system was in place for planning and recording cleaning tasks. The provider had carried out the relevant recruitment checks for staff who work at the surgery.

7 February 2014

During a routine inspection

During our inspection, we spoke with four people who used the service, one member of the Patient Participation Group (PPG) and five members of staff.

Overall people were satisfied with the service provided. One person told us that they were 'really happy' and said that they were able to get an appointment with a doctor generally within a day. Another person said 'doctors listen and they never dismiss you'. Another person told us that 'the doctors are the best'.

People's needs were assessed and care and treatment was planned and delivered in line with their individual care plan.

We observed that the provider had a safeguarding policy for adults and children. However, the majority of staff had not attended safeguarding adult's training.

We found that the practice was not following government guidelines in relation to the safe management of healthcare waste.

We observed that there was a lack of evidence available to confirm that appropriate checks had been carried out for members of staff.

We saw evidence that the provider had a system in place to monitor quality and safety.