The Care Quality Commission
  • Doctor
  • GP practice

Archived: Hendon Way Surgery

Overall: Good read more about inspection ratings

67 Elliot Road, Hendon, London, NW4 3EB (020) 8102 9830

Provided and run by:
Hendon Way Surgery

Important: This service is now registered at a different address - see new profile

All Inspections

12 July 2018

During a routine inspection

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

19 March 2018

During an inspection looking at part of the service

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: http://www.cqc.org.uk/location/1-1593169343.

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. At this inspection we did not review the ratings for the key questions; we will consider the practice’s ratings when we carry out a comprehensive inspection at the end of the period of special measures.

At the inspection on 19 March 2018 we found that the practice had made significant improvements and were no longer in breach of regulations 17 and 18.

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

  • There was evidence of completed two cycle clinical audits identifying quality improvement to patient care.

  • 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 were improved and staff were adhering to the improved protocols.

  • Systems for managing staff training and induction were significantly improved.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

11 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hendon Way Surgery on 11 October 2017. Overall the practice is rated as inadequate.

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

  • Patient outcomes were hard to identify. Although there were audits carried out, there was no evidence of completed two cycle audits or other quality improvement to improve patient outcomes.

  • Data from the Quality and Outcomes Framework showed patient outcomes were above the national average, however exception reporting rates were significantly higher than both CCG and national averages.

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, the system for managing high risk medicines was inconsistent and we found evidence of risks to patient safety.

  • The practice had a leadership structure, however there was a lack of clarity around key roles within the practice

  • There were systematic weaknesses in governance arrangements. For example, in the arrangements for managing uncollected prescriptions, patient safety alerts, significant events and the recording of consent.

  • There were ineffective systems in place for managing staff training and limited evidence of a formal induction programme.

  • Patient satisfaction was significantly below local and national averages for access to the service and clinical consultations with GPs and nurses.

The areas where the provider must make improvements are:

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

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training and professional development necessary to enable them to carry out the duties.

The areas where the provider should make improvement are:

  • Improve governance processes for sharing learning identified through significant events, safeguarding adults, and cascading of nationally recognised guidance.
  • Improve the audit system in relation to the monitoring of prescription pads in accordance with national NHS guidelines.
  • Review clinical exceptions for all long term conditions to ensure they meet the clinical criteria for exception reporting and identify ways to reduce exception reporting.
  • Review the processes for improving the uptake of child immunisations, cervical screening, bowel cancer screening and breast cancer screening.
  • Improve patient satisfaction around access to the service and clinical consultations with GPs and nurses.
  • 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.

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