Background to this inspection
Updated
3 September 2021
Cloister Road Surgery is located at 41-43 Cloister Road, Acton, London, W3 0DF. The surgery is a purpose-built health facility has good transport links and there is a pharmacy located nearby.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning and treatment of disease, disorder or injury.
The practice is situated within the Ealing Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to 10,638 registered patients. This is part of a contract held with NHS England. The practice is part of a wider network of GP practices called Acton Primary Care Network. The practice is also a GP training practice.
Information published by Public Health England shows that deprivation within the practice population group is in the fifth lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 50.7% White, 20.3% Asian, 12.3% Black, 5.8% Mixed, and 11% Other.
There is a clinical team of female two GP partners, five salaried GPs, three practice nurses and three healthcare assistants. The clinical team is supported at the practice by a team of reception/administration staff. The practice manager is based at the location to provide managerial oversight.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone or video consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment to be seen onsite.
The practice reception is open Monday to Friday 8am to 6.30pm with appointments available throughout the opening hours. Out of Hours services are provided by London Central and West Unscheduled Care Collaborative.
Updated
3 September 2021
We carried out an announced inspection at Cloister Road Surgery on 20 August 2021. Overall, the practice is rated as Good.
Set out the ratings for each key question
Safe - Good
Effective - Good
Well-led - Good
Following our previous inspection on 21 August 2019 the practice was rated Requires Improvement overall and for the key questions Safe and Effective. The key questions Caring, Responsive and Well-led were rated Good.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Cloister Road Surgery on our website at www.cqc.org.uk
This inspection was a focused inspection on the key questions Safe, Effective and Well-led. It was also carried out to follow-up on breaches of Regulation 17 Good governance.
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 and good for all population groups.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
Whilst we found no breaches of regulations, the provider should:
- Continue to improve childhood immunisation and cervical cancer screening uptake to bring in line with national targets.
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