The Care Quality Commission
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  • GP practice

Archived: Sandringham Practice

Overall: Good read more about inspection ratings

1A Madinah Road, Hackney, London, Greater London, E8 1PG (020) 7275 0022

Provided and run by:
McLaren Perry Limited

Important: The provider of this service changed. See new profile

All Inspections

25 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sandringham Practice on 28 January 2016. During the inspection we identified a range of concerns including an absence of systems in place to manage risk or improve the quality of care provided to patients. (The full comprehensive report on the January 2016 inspection can be found by selecting the ‘all reports’ link for Sandringham Practice on our website at www.cqc.org.uk).

The practice was rated as requires improvement for providing safe, effective and well led services and was rated as good for providing caring and responsive services. Overall the practice was rated as requires improvement.

An announced comprehensive inspection was undertaken on 25 May 2017. Overall the practice is now rated as good.

Our key findings were as follows:

  • Action had been taken to improve previous governance failings and we noted that practice management and governance arrangements now facilitated the delivery of high-quality person-centred care.
  • Action had been taken to improve how risks were assessed, monitored and actioned. For example, a central risk register had been introduced and we saw evidence that, with the exception of fridge temperature monitoring, risks to patients were routinely assessed and managed.
  • Action had been taken to improve quality improvement. For example, clinical audit was now routinely being used to drive quality improvement.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

    • Patients said they were treated with compassion, dignity and respect.

    • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

    • 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 provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Further investigate and take appropriate action to reduce exception reporting for the cancer clinical domain.
  • Introduce a fridge temperature recording protocol to ensure that governance arrangements for recording fridge temperatures are robust.
  • Consider introducing a fire evacuation plan to assist patients with mobility problems in vacating the premises.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

28 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sandringham Practice on 28 January 2016. Overall the practice is rated as requires improvement.

Since 1 December 2014, Sandringham Practice has been managed by Mclaren Perry Ltd. under a temporary caretaking agreement with NHS England. As of the day of our inspection, the agreement was due to terminate on 31 March 2016. Mclaren Perry Ltd has employed four GPs to support the delivery of care; one of whom is designated as senior GP for the practice.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.

  • The practice lacked robust arrangements for identifying, recording and managing risks and implementing mitigating actions. For example, it had failed to act on concerns identified regarding the practice’s baby changing unit in two successive 2015 risk assessments; and its latest infection prevention and control audit could not be located.

  • Data showed that some patient outcomes were low compared to the locality and nationally.
  • The majority of patients said they were treated with compassion, dignity and respect.
  • A review of appointment availability highlighted that urgent same day appointments were available on the day they were requested.
  • Although some audits had been carried out, they were not two cycle completed audits.

The areas where the provider must make improvement are:

  • Improve infection prevention and control systems (for example regarding training and arrangements for cleaning the building’s shared lift).

  • Ensure that it takes action regarding the risks identified in its April 2015 and November 2015 risk assessments of the premises.

  • Ensure that quality improvement systems are in place to drive improvements in patient outcomes.

The areas where the provider should make improvement are:

  • Review its systems for ensuring that CQC registration details are kept up to date; and for ensuring that applications to amend registration details are accurately submitted and in a timely fashion.

  • Ensure that all non clinical staff undertaking chaperoning duties have received training.

  • Ensure that all non clinical staff undertake safeguarding training.

  • Introduce a system to monitor use of prescription pads.

  • Ensure that supplies of liners and cleaning equipment are available for the practice’s baby changing unit.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice