Colney Hatch Lane Surgery

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• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support.

The scores for the quality statements not assessed as part of this key question are based on the previous inspection rating for effective for the previous provider of services at this location.

This is the first inspection for this service since its registration with CQC.

This key question has been rated as Good.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

The service triaged patients when they first contacted the service. Patients requesting to see a doctor or a home visit had their details taken by reception staff (if they contacted the service by telephone), who passed this information on to the duty GP. Triaging was undertaken by the duty GP, to ensure that patients with the most urgent needs were prioritised. A similar process was undertaken for those patients who contacted the service online requesting an appointment.

Staff checked people’s health, care, and wellbeing needs during health reviews and consultations. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

We reviewed several medication reviews undertaken by the service and found that most reviews had been completed in line with national guidelines.

The provider had systems to identify people with previously undiagnosed conditions. For example, people whose blood tests results showed they had pre-diabetes were offered appointments to advise them how they could prevent it developing into diabetes.

The service used digital flags within their care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present.

The service did not always plan and deliver people’s care and treatment with them and in conjunction with requests from other healthcare providers or had evidence of clinical improvements achieved as a result of delivering care and treatment.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated most care was provided in line with current guidance. Staff had access to local and national guidelines which could be accessed easily through online platforms with links to guidance also available through their clinical system. We were told by the service that updates to guidance were shared with all relevant staff and discussed at clinical meetings, however we saw no evidence of this occurring from the clinical meetings minutes provided to us.

Overall, staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring. However, we identified during our remote clinical records review that appropriate monitoring for patients prescribed lithium was not always being undertaken according to national guidelines. We identified two patients who had not had a blood test in line with national guidelines of every three months. We spoke with the provider regarding this and emphasised the importance of maintaining regular monitoring and testing of patients on this medication, which cannot be undertaken through telephone reviews of patients alone.

We also identified that patients on a specific medicine prescribed to manage diabetes were not being monitored appropriately. One clinical record we reviewed, showed that the service had not acted on a request from secondary care, where the service had been asked to reduce the current dosage of medication being prescribed to a patient. A follow-up second request from secondary care was submitted to the service two months later to reduce the dosage after it had been discovered that the first request had not been actioned. We spoke with the service about our findings in relation to the monitoring of this specific medication on the day of the clinical records search. The service provided assurances (via evidence from their clinical system) that the patient in question had received a change in their medication dosage.

Finally, from our clinical searches we identified 7 patients who were on the contraceptive pill whose clinical records had been coded as having a history of venous thromboembolism, a preventable condition which comprises of deep vein thrombosis. We asked the service to review the patient record to ensure they were coded correctly, and if required contacting the patients to discuss the potential risk of taking this medicine with the identified condition.

We asked the service to provide the assessment team with evidence of quality improvement and/or clinical audits that had been undertaken during the past two years. The service did provide us with evidence of quality improvement audits undertaken, but none of these had reference to improvement in the outcomes of applied evidence-based care and clinical treatment for patients registered at the service.

Service staff we spoke with told us they held clinics to support people with long term conditions such as asthma, diabetes and chronic heart disease. They told us they used local and national guidelines and kept up to date through training and updates circulated within the service.

We did not look at how staff, teams and services work together. The score for this quality statement is based on the previous rating for this key question from the previous provider for this location. The previous provider of services at this location is a partner at this service.

We did not look at supporting people to live healthier lives. The score for this quality statement is based on the previous rating for this key question from the previous provider for this location. The previous provider of services at this location is a partner at this service.

Staff told us they routinely monitored people’s care, booking follow up consultations and requesting additional interventions such as blood tests to continuously improve people’s health outcomes. Staff used service registers to ensure that patients requiring monitoring including health assessments and checks were being contacted appropriately.

The service monitored people’s care and treatment to continuously improve it, but this was not always consistent. The service worked so that outcomes were positive but again this was not consistent, which meant that not all clinical expectations and the expectations of people themselves were met.

The service did not meet national targets for childhood immunisations. National data collected on 31 March 2025 showed all 5 indicators for childhood immunisations were below the 95% World Health Organisation (WHO) based target for uptake, and not above the 80% minimum uptake for four of the indicators or the required 90% for the remaining indicator expected nationally for these immunisations. There were effective systems in place to follow up individuals who failed to attend for these appointments, and missed vaccines would be offered to patients if they were in the surgery for another reason.

National data (collected on 31 March 2024) showed that the targets for cervical cytology screening ranged between 70 - 80%. The service just fell short of these targets, achieving 69% for women aged between 25 – 49, and 76% for women aged between 50 - 64. Unverified data provided to us on the day of our site visit, revealed that the service had achieved 86% (for women aged between 25-49) and 90% (for women aged between 50-64) from 1st of April 2025. The service had systems to invite eligible women, using their preferred method of contact and language.

Staff told us they routinely monitored people’s care, booking follow up consultations and requesting additional interventions such as blood tests to continuously improve people’s health outcomes. Staff used service registers to ensure that patients requiring monitoring including health assessments and checks were being contacted appropriately.

The assessment team were not assured by the system that was in place regarding two-week wait referrals, provided a ‘safety net’ for patients. The system described to us by the GP partners placed the emphasis on patients to follow-up with the service and then with secondary care if no contact had been made with the patient by the end of the two weeks.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded prior to treatment being given. We viewed three Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) records of patients registered and found that decisions were appropriate and were made in line with relevant legislation.