The Care Quality Commission
  • Doctor
  • GP practice

Archived: The Stanmore Surgery

Overall: Inadequate read more about inspection ratings

71 Elm Park, Stanmore, Middlesex, HA7 4AU (020) 8954 4151

Provided and run by:
Dr Vyas Lingam

All Inspections

6 June 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection of The Stanmore Surgery on 25 May 2016. The practice was judged to be inadequate and placed in special measures. After this inspection the practice wrote to us to say what action they would take to meet the following legal requirements set out in the Health and Social Care Act (HSCA) 2008:

Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 Safe Care and Treatment.

This announced comprehensive inspection was carried out on the 6 June 2017 to check that action had been taken by the practice to make the improvements required from the inspection in May 2016.

Overall the practice is rated as inadequate from this inspection as it has failed to address a number of issues identified in the previous inspection and further issues were identified.

  • Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. However we found that some incidents that had occurred had not been recorded and investigated as significant events.

  • Where an incident had been recorded the practice had not carried out an analysis of the event and recorded learning points that had been identified to show that the practice was fostering a culture of learning and improvement.

  • Risks to patients were not assessed and managed.

  • Outcomes for patients who use services were not improving, for example latest unpublished QOF data showed the practice was currently achieving only 56% of the overall points available to them.

  • 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.

  • We were not assured that there was discussion and leadership around best practice and clinical guidelines at practice level.

  • Patients who completed comment cards said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • The practice did not have information on display that informed patients about language interpretation services available.

  • The practice had a number of policies and procedures to govern activity, but these were not being followed.

  • Though the practice had a leadership structure, there was insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvement are;

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

  • Ensure appropriate standards of hygiene for premises and equipment.

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

In addition the provider should:

  • Develop a system that obtains patients views on improving the service and review areas where the practice have scored below average from the national GP survey results.

  • Provide information or notices advising that formal translation services are available for patients who did not have English as a first language who require translation services.

This service was placed in special measures in May 2016. Insufficient improvements have been made such that there remains a rating of inadequate for safe, effective and well led Therefore we are taking 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 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

25 May 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Stanmore Surgery on 25 May 2016. Overall the practice is rated as inadequate.

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

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example there were no recruitment records for staff and appropriate recruitment checks on staff had not been undertaken prior to their employment. Actions identified to address concerns with infection control had not been taken.

  • There were serious concerns identified in incident reporting, safeguarding, chaperoning, medicines management, health and safety, fire safety and dealing with emergencies and major incidents.

  • Staffing arrangements were not adequate to keep patients safe.

  • Patient outcomes were poor because there were no routine patient health checks and non-urgent reviews of chronic health conditions which led to opportunistic patient reviews and poor outcomes.

  • Patients were positive about their interactions with clinical staff; however, satisfaction scores with reception staff were low.

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

The areas where the provider must make improvements are:

  • Care and treatment must be provided in a safe way for patients. This includes introducing processes for significant events, incidents and near misses, safeguarding children and vulnerable adults, addressing concerns with medicines prescribing, infection prevention and control as well as health and fire safety.

  • Ensure recruitment arrangements include all necessary employment checks for all staff, for example, Disclosure and Barring Service (DBS) checks or risk assessments for all staff providing a chaperone service for patients.

  • Ensure systems or processes are established and operated effectively to carry out quality improvement activity to monitor improvement and implement formal governance arrangements to assess, monitor and mitigate risk.

  • Ensure all staff receive training at appropriate intervals and annual appraisals.

  • Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.

  • Ensure there is a comprehensive business continuity plan in place.

  • Provide staff with appropriate policies and guidance to carry out their roles in a safe and effective manner which are reflective of the requirements of the practice.

  • Clarify the leadership structure and ensure there is effective leadership capacity to deliver all improvements.

The areas where the provider should make improvement are:

  • Improve processes for making appointments.

  • Establish an effective system for identifying and supporting carers.

  • Advertise within the practice the provision of the translation service for patients.

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

11 August 2014

During an inspection looking at part of the service

On our inspection of 13 March 2014 we found that the practice was clean, and all of the patients we spoke with said the practice was clean and tidy. However we found that systems for monitoring standards of cleanliness and infection control were not in place.

The provider wrote to us in April 2014 to inform us of the action they had taken to make improvements to cleanliness and infection control.

During this inspection we reviewed the progress the provider had made to improve the service. We found that an infection control audit had been carried out and areas for improvement had been identified. We also found the cleaning schedule was being monitored and three sets of cleaning equipment were being used for designated areas of the practice.

13 March 2014

During a routine inspection

We spoke with six patients, including members of the Patient Participation Group (PPG), and two members of staff. Patients told us they were treated with privacy and dignity during consultations, with staff explaining in laymans terms any examinations they were going to do as well as diagnoses and possible treatments. Any questions patients had were answered fully by clinical staff. The only negative comments we received from patients related to the politeness and helpfulness of the reception staff.

All the patients we spoke with told us that they were happy with their care and treatment at the practice. Patients told us that they were reminded to attend appointments. They were also reminded when a review or test was due although some patients said some of the reminders had only started recently. They told us that they were able to get referrals for specialist treatment when necessary. Waiting times and options were explained in case the patient wanted private treatment.

None of the patients we spoke with had concerns about the way they were treated. We found the practice took appropriate steps to safeguard adults and children from abuse.

Patients found the practice clean and tidy. However, the practice did not always follow best practice guidelines to prevent the spread of infection.

We were told by patients that their records were checked with them to ensure their accuracy. We found the most of the practice's records were up to date and fit for purpose.