Hendon Way Surgery

We carried out an announced comprehensive inspection at Hendon Way Surgery on 16 December 2019 in line with our methodology to identify whether the practice had maintained the improvements made following our decision to remove them from special measures in July 2018. We found that the practice had embedded and maintained improvements and were generally providing safe care to patients.

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. The domains were rated good for safe, effective, caring and well-led and requires improvement for providing responsive care. We rated the six population groups as requires improvement.

We rated the responsive domain as requires improvement because all population groups were rated requires improvement under the responsive key question. Patient satisfaction was significantly below the local and national averages for access and patients’ needs being met by their appointments. Although the practice had carried out their own patient survey and had put plans in place to improve patient satisfaction, we were not assured the issues around access had been improved. In line with our ratings system, the rating of requires improvement under the responsive key question for the six population groups resulted in an overall rating of requires improvement for:

• Older people
• People with long-term conditions
• Families, children and young people
• Working age people (including those recently retired and students)
• People whose circumstances may make them vulnerable
• People experiencing poor mental health (including people with dementia)

We rated the working age people (including those recently retired and students) requires improvement under the effective key question as the uptake for cervical screening was significantly below the national average. The practice had plans in place to improve uptake in this area, however they were unable to demonstrate improvement had been made at the time of inspection. The remaining five population groups were rated as good under the effective key question.

We found that:

• The practice provided care in a way that kept patients safe and protected them from harm.
• Patients received effective care and treatment that met their needs.
• Staff treated patients with kindness and respect and involved them in decisions about their care.
• Patient satisfaction around appointments and access to the practice was below the local and national averages and improvements were required in this area.
• The practice acted on patient feedback and monitored patient satisfaction on an ongoing basis.
• Staff felt supported and were given opportunities to develop.
• The practice used clinical audit as a method of identifying where improvements were required.

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

• Continue to monitor and improve the uptake of childhood immunisations and cervical screening.
• Continue to monitor and improve patient feedback relating to access and appointment satisfaction.

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