GP Surgery @ Acton Gardens

We carried out an announced comprehensive inspection at the GP Surgery @ Acton Gardens (locally known as Chiswick Family Practice - Dr O'Connell & Dr Bennett) on 15 and 19 September 2023. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question:

Safe - Requires improvement.

Effective - Requires improvement.

Caring - Good.

Responsive – Good.

Well-led - Requires improvement.

Why we carried out this inspection

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

At this inspection, we covered the following key questions:

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

How we carried out the inspection

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

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 found that:

• There was a lack of good governance in some areas.
• Our clinical records searches showed that the practice did not always have an effective process for monitoring patients’ health in relation to the use of medicines including medicines that require ongoing monitoring.
• Recruitment checks including Disclosure and Barring Service (DBS) were not always carried out in accordance with regulations and some records were not kept in staff files.
• Risks to patients were not assessed and well managed in relation to the fire evacuation plan, the implementation of national patient safety and medicines alerts and the monitoring of the prescription box for uncollected prescriptions.
• The arrangements for managing and monitoring task workflow were not always effective. For example, we found that the specialist consultant advice and guidance recommendation regarding a child was not reviewed and followed up in a timely manner.
• Patients’ treatment was not always regularly reviewed and updated.
• There was a system in place to monitor the use of blank prescription forms. However, it did not work as intended.
• The Patient Participation Group (PPG) was not active.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• There was a system for recording and acting on significant events.
• There was an infection prevention and control policy and procedures were in place to reduce the risk and spread of infection.
• There was evidence of quality improvement activity. Clinical audits were carried out.
• Staff had received training relevant to their role.
• Annual appraisals were carried out in a timely manner.
• Feedback from patients was positive about the way staff treated people.
• The practice had systems to manage and learn from complaints.

We found two breaches of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The provider should:

• Continue to encourage eligible patients to attend for cervical cancer screening and childhood immunisation.
• Take steps to improve processes for monitoring the prescription box for uncollected prescriptions.

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 Health Care