Background to this inspection
Updated
19 September 2018
Hendon Way Surgery is located in the London Borough of Barnet within the NHS Barnet Clinical Commissioning Group. The practice holds a General Medical Services contract (an agreement between NHS England and general practices for delivering primary care services to local communities). The practice provides a full range of enhanced services including childhood immunisation and vaccination, meningitis immunisation, extended hours access, dementia support, influenza and pneumococcal immunisations, learning disabilities support, rotavirus and shingles immunisation and unplanned admissions avoidance.
The practice is registered with the Care Quality Commission to carry on the regulated activities of family planning, maternity and midwifery services, treatment of disease, disorder or injury and diagnostic and screening procedures.
At the inspection on 11 October 2017, the clinical team at the practice included four GP Partners (two females, two males), one locum practice nurse (female) and one full-time midwife (female). As part of the practice’s plan to improve services following being placed into special measures the leadership team began recruitment to expand the clinical team. A full-time practice nurse (female), and a full-time healthcare assistant (male) and were recruited. In addition, the practice was recruited a locum phlebotomist (male) and were in the process of recruiting an Advanced Nurse Practitioner to join the clinical team.
At the inspection on 11 October 2017, the non-clinical team at the practice included one practice manager, an interim practice manager covering maternity leave, and seven administrative staff. As part of the practice’s plan to improve services following being placed into special measures, the leadership team recruited two additional members of non-clinical staff. There were nine administrative staff employed by the practice at the inspection in July 2018.
The practice is open Monday to Friday from 8am to 6.30pm. Phones lines are closed daily between 1pm and 2pm and covered by the practices out of hours provider during this time. The surgery closes every Wednesday between 12.30pm and 2pm for training purposes.
Extended hours access is available Monday to Friday from 6.30pm to 7.10pm for pre-booked appointments.
Urgent appointments are available each day and GPs also provide telephone consultations for patients. An out of hour’s service is provided for patients when the practice is closed. Information about the out of hour’s service is provided to patients on the practice website and the practice phone system.
Updated
19 September 2018
This comprehensive inspection was undertaken on 12 July 2018 following a period of special measures, the practice is now rated as overall good. (Previous rating October 2017 – Inadequate)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Requires Improvement
Are services well-led? - Good
We had previously carried out an announced comprehensive inspection at Hendon Way Surgery on 11 October 2017. Overall the practice was rated as inadequate and placed in special measures. We identified concerns with regards to safe, effective, responsive and well-led care provided by the practice.
We served warning notices under regulations 17 (good governance) and 18 (staffing) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. The report for the comprehensive inspection can be found by selecting the ‘reports’ link for Hendon Way Surgery on our website at: .
The practice sent us a plan of action to ensure the service was compliant with the requirements of the regulations. We undertook a focussed inspection on 19 March 2018 to review the breaches of regulation identified at the inspection in October 2017 and to ensure the service had made improvements in line with the Warning Notices we had issued. At the focussed inspection we found that the practice was compliant with the regulatory breaches we identified at the comprehensive inspection in October 2017. The report for the focussed inspection can be found by selecting the ‘reports’ link for Hendon Way Surgery on our website at:
This report relates to the follow up comprehensive inspection carried out on 12 July 2018. At the inspection in July 2018 we found that the practice had made significant improvements overall.
Our key findings across all the areas we inspected were as follows:
- There was a comprehensive system in place to ensure the safe management of high risk medicines.
- Improvements to governance systems had been made. For example, the practice was able to provide evidence that processes for managing uncollected prescriptions and patient safety alerts had improved and staff were adhering to the revised protocols.
- Systems for managing staff training and induction were significantly improved.
- Patient feedback in relation to GP and Nurse consultations had improved, however patient feedback relating to access to the service was below local and national averages.
- There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
- There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
- The practice had good facilities and was well equipped to treat patients and meet their needs.
- Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
The areas where the provider should make improvements are:
- Improve how patients with caring responsibilities are identified and recorded on the patient record system to ensure information, advice and support is made available to them.
- Continue to review the processes for improving the uptake of child immunisations, cervical screening, bowel cancer screening and breast cancer screening.
- Review processes with a view to improve patient satisfaction around access to the service and clinical consultations with GPs and nurses.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice