The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Patrick Lai Chung Fong Also known as Gloucester Road Surgery

Overall: Good read more about inspection ratings

Gloucester Road Surgery, 1b Gloucester Road, Barnet, Hertfordshire, EN5 1RS (020) 8449 7677

Provided and run by:
Dr Patrick Lai Chung Fong

All Inspections

6 December 2021

During an inspection looking at part of the service

We carried out an announced focussed inspection at Gloucester Road Surgery on 6 December 2021. Overall, the practice is rated as Good.

Safe - Good

Effective -Good

Responsive - Good

Well-led - Good

Following our previous inspection on 7 June 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 Gloucester Road Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on information of concern including potential issues with access to appointments.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • 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 have rated this practice as Good overall

We found that:

  • The practice provided a sufficient number and range of appointments but we noted appointments access, including telephone access, was not being routinely monitored.
  • When something went wrong, there was an appropriate, thorough review that involved all relevant staff. Lessons were learned and communicated to support improvement.
  • There was evidence of systems for learning and continuous improvement (including use of clinical audit).
  • Although childhood immunisations and cervical screening uptake rates were below local and national averages, we noted this was in part due to the Covid-19 pandemic. The practice was monitoring and actively seeking to improve performance.
  • Patients generally received effective care and treatment that met their needs, although our remote clinical records review highlighted some instances where patients’ treatment was not being regularly reviewed.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • We saw scope for improved governance regarding conducting fire safety risk assessments and regarding assessing risks associated with a bacterium called Legionella (which can proliferate in building water systems). Overall however, practice management supported the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Take action to monitor appointments access.
  • Continue to monitor and take action to improve child immunisation and cervical screening uptake rates.
  • Take action to review Legionella and fire safety governance arrangements.
  • Review systems for timely medication review of patients with long term conditions.

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

7 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Patrick Lai Chung Fong (also known as Gloucester Road Surgery) on 4 May 2016. The overall rating for the practice was Requires Improvement. The full comprehensive report on the May 2016 inspection can be found by selecting the ‘all reports’ link for Dr Patrick Lai Chung Fong on our website at www.cqc.org.uk.

At our previous inspection in May 2016, we rated the practice as Requires Improvement for providing safe, responsive and well-led services. At this time included amongst the issues we identified was not all staff at the practice had received basic life support and other important training, that there were no systems in place to support the regular monitoring of policies and procedures to ensure they were in date. In addition, the practice had not risk assessed having a Mercury thermometer/sphygmomanometer and what they would do in the event of spillage of Mercury at the practice.

This inspection was an announced focused inspection carried out on 7 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 4 May 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. At this inspection, we found that the practice had made improvements to provide safe, responsive and well-led services. As a result of these findings, the practice is now rated as Good for providing safe, responsive and well-led services.

The change in the ratings for safe, responsive and well-led, means that the practice is now rated as Good overall.

Our key findings were as follows:

  • All practice staff had undertaken basic life support training within the last 12 months.
  • Risks to patients were assessed and managed.
  • A system had been put in place to ensure practice policies and procedures were reviewed regularly. All of the policies and procedures we checked had been reviewed within the last 12 months.
  • The practice had recently devised a practice business development strategy, which looked at long-term goals and practice achievement.
  • Prescription pads held at the practice were securely stored and usage is monitored.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

4 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Patrick Lai Chung Fong (also known as Gloucester Road Surgery) on 4 May 2016. Overall the practice is rated as Requires Improvement.

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

  • The majority of patients said they were treated with compassion, dignity and respect.
  • Some but not all risks to patients were assessed and managed.
  • The practice had good facilities and was equipped to treat patients and meet their needs.
  • The practice had a number of policies and procedures to govern activity, but some were overdue a thorough review.
  • There was no strategy in place which looked at long-term goals and their achievement by the practice.
  • Patients said that they were treated with compassions, dignity and respect and that they were involved in their care and decisions about their treatment.

The areas where the provider must make improvements are:

  • To arrange mandatory training for members of staff who have not previously attended including but not exclusive to basic life support and information governance.
  • Establish effective systems to review and update procedures and guidance, with a view to ensuring that information reflect the current requirements of the practice.

In addition the provider should:

  • Explore options that would allow patients to book appointments and request repeat prescriptions online.
  • Examine the possibility of extended hours surgery to give the option to working patients of an early morning or late afternoon/early evening appointments.
  • Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is available to them.
  • To establish systems to ensure usage of prescription pads is monitored and logged.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

5 August 2013

During a routine inspection

We spoke with five patients during our visit. All patients were very satisfied with the service they received from their GP. Patients understood the care and treatment choices available to them and felt they were given appropriate information and support regarding their care or treatment. A patient told us 'the GP explains everything to me. I have diabetes, he sends me to the hospital and looks after me very well.'

Patients confirmed that they were treated with dignity and respect. Patients were protected from the risk of abuse, because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening. Care and treatment was planned and delivered in a way that was intended to ensure patient's safety and welfare. All five patients spoken with confirmed that they were always able to see their GP when they needed to.

Patients were protected against the risk of infection and measures to prevent the spread of infection were in place. Patients commented positively about the surgery's premises. The surgery had undergone a number of changes to upgrade the premises so that it met current standards.

There were systems in place to monitor the quality of service provided and patients were asked for their views about their care and treatment. The arrangements for obtaining repeat prescription of medications were effective and patients were happy with this service. Patients confirmed that the GP reviewed their medication.