The Care Quality Commission
  • Doctor
  • GP practice

The Everglade Medical Practice

Overall: Good read more about inspection ratings

Grahame Park Health Centre, The Concourse, London, NW9 5XT (020) 8432 8641

Provided and run by:
The Everglade Medical Practice

Important: The provider of this service changed - see old profile

All Inspections

During an assessment under our new approach

Everglade Medical Practice is a GP practice that delivers services to approximately 11,000 patients under a contract held with NHS England. National GP profiles state the ethnic makeup of the practice area is 40.71% White, 23.01% Asian, 19.66% Back, 6.19% Mixed and 10.43% Other. Information published by the Office for Health Improvement and Disparities shows that the deprivation within the practice population is in the 3rd decile of 10. The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working in and how this impacted service delivery. Where relevant, further commentary is provided in the quality statement section of this report.

People and staff were kept safe and protected with incidents and complaints investigated. Learning outcomes were discussed. There was a robust Infection Prevention and Control (IPC) system with regular audits. Staff received regular training and appraisals. Staff managed medicines well and involved people in planning and changes.

People were involved in assessments of their needs. Regular health checks and reviews took place. Evidence based care in line with good practice was delivered. The service worked with other agencies to enable good outcomes of care. People made informed decisions about their health.

People were treated with kindness and compassion. Dignity and privacy were respected. A chaperone service was provided to those who requested it.

People were involved in decisions about their care and information needed to make a decision was provided. Interpretation services were available. Complaints were handled appropriately.

Leaders and staff had a shared vision and culture. Leaders had an understanding of equality, human rights and safe compassionate care. Staff understood their roles and responsibilities, however some expressed concern over supervision.

Since the last inspection, the practice had made improvements and is no longer in breach of regulations 12 and 17 of the Health and Social Care Act 2012.

01 November 2022 and 24 November 2022

During a routine inspection

We carried out an unannounced comprehensive inspection at The Everglade Medical Practice on 1 November 2022. We continued the inspection with a revisit of the practice on 24 November 2022. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - good

Responsive - requires improvement

Well-led - requires improvement

At our previous inspection on 17 May 2017 the practice was rated good overall and for all key questions. The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Everglade Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up concerns reported to us.

How we carried out the inspection

This inspection was carried out by:

  • Conducting staff interviews
  • Completing clinical searches on the practice’s patient records system
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A site visit over two days.

Our findings

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 rated the practice as requires improvement for providing safe services because we had concerns relating to: infection prevention control; administration of Rotavirus vaccine; out of date and/or missing emergency medicines and equipment.

We rated the practice as requires improvement for providing effective services because the uptake for cervical screening was well below the national target of 80%, and the uptake of childhood immunisations were also well below the world health organisation target of 95%. We also found there was no documented evidence confirming nurse prescribing was being regularly monitored.

We rated the practice as good for providing caring services because staff dealt with patients with kindness and respect and involved them in decisions about their care.

We rated the practice as requires improvement for providing responsive services because the GP patient survey data and patients we interviewed showed dissatisfaction with telephone access and the types of appointments offered.

We rated the practice requires improvement for well-led because we were not assured there was appropriate governance, systems and processes in place to ensure appropriate infection prevention control measures were in place; systems were in place to ensure medicines and equipment remained in-date; there were up-to-date policies; documented supervision of the nurse prescriber; and the safe administration of the rotavirus vaccine.

The provider took immediate action to address the concerns identified above and introduced systems and processes to prevent recurrence. However, as these changes are new, they need to be monitored and become embedded in practice before we can be satisfied the concerns have been fully mitigated. Please see the evidence tables for more details.

We found two breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way (Please see the specific details on action required at the end of this report).
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please see the specific details on action required at the end of this report).

In addition, the provider should:

  • Take action to improve the uptake of cervical screening and childhood immunisations.
  • Take action to improve patient experience evidenced by GP patient survey results data, particularly in regard to access.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

17 May 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Everglade Medical Practice on 17 May 2017. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. However, patient survey results were mixed in relation to access to the practice.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

  • Review arrangements for displaying fire safety posters to ensure patients and staff are informed. .

  • Develop quality improvement arrangements to maximise outcomes for patients.

  • Review systems and processes to ensure the management of patient results is failsafe.

  • Review arrangements for identifying carers in line with national guidelines.

  • Consider formalising supporting business plans to ensure they are in line with the practice’s vision and mission.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice