The Care Quality Commission
  • Doctor
  • GP practice

The Pinner Road Surgery

Overall: Good read more about inspection ratings

196 Pinner Road, Harrow, Middlesex, HA1 4JS (020) 8427 0130

Provided and run by:
Dr Samia Hasan

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about The Pinner Road Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about The Pinner Road Surgery, you can give feedback on this service.

18 August 2021

During an inspection looking at part of the service

We carried out an announced inspection at The Pinner Road Surgery on 18 August 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection on June 2019. the practice was rated Requires improvement overall and for safe and well-led. It was rated good for being effective, caring and well-led.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Pinner Road Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on concerns identified at the previous inspection which included breaches of regulations 12 and 17 in relation to safety and governance. At the inspection in June 2019 we found safety concerns around medicines management, emergency equipment and fire safety. We had also found concerns around governance procedures, specifically those relating to practice policies, staff induction and the practice’s response to patient feedback. At this inspection we found improvements had been made.

For this inspection we covered the safe, effective and well-led key questions only.

At the previous inspection in June 2019 we said the practice should consider how to evacuate patients with mobility problems and consider increasing the frequency of patient participation (PPG) meetings. At this inspection in August 2021 we found the practice had carried out a risk assessment which included evacuation plans and no concerns were found. We spoke to the practice manager and chair of the PPG who told us meetings were planned to take place quarterly.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

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 have rated this practice as Good overall and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

  • Review the coding and wording used by the physician’s associate to ensure the type of review being carried out was clear.
  • Review the identification of significant events to ensure staff understood the distinction and were able to prioritise them.
  • Review and improve achievement in the care of patients with long-term conditions, childhood immunisations and cervical cancer screening.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

19 June 2019

During a routine inspection

We carried out an announced comprehensive inspection at The Pinner Road Surgery on 19 June 2019 as part of our inspection programme.

At this inspection, we followed up on breaches of regulations identified at a previous inspection on 14 May 2018. Previous reports on this practice can be found on our website at: .

At this inspection, we found that the practice had demonstrated improvements in most areas, however, they were required to make further improvements.

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 have rated this practice as requires improvement overall and good overall for all population groups, with the exception of working age people (including those recently retired and students) which is rated as requires improvement.

We rated the practice as r equires improvement for providing safe and well-led services because:

  • Fridge temperatures were not always adequately monitored.
  • The practice had not identified and raised concerns and reported incidents when fridge temperatures were recorded higher or lower than the recommended range.
  • The practice did not have a paediatric pulse oximeter which could be required to enable assessment of a child patient with presumed sepsis.
  • The practice was unable to provide evidence of regular fire drills.
  • We found expired products and several opened and partially used items.
  • The practice was unable to provide documentary evidence of an asbestos survey. This issue was highlighted during the previous inspection.
  • Safeguarding policies were recently reviewed, but they did not include up to date details.
  • The practice was aware of and complied with the requirements of the Duty of Candour.
  • The practice had demonstrated good governance in most areas, however, they were required to make further improvements.

We rated the practice as good for providing effective, caring and responsive services because:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • The practice’s uptake of the childhood immunisations rates was in line with the national averages.
  • The practice’s uptake of the national screening programme for cervical cancer was below the local and the national averages.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Feedback from most patients and recently published (11 July 2019) annual national GP patient survey results reflected that they were able to access care and treatment in a timely way. However, some improvements were required.
  • The practice was encouraging patients to register for online services and 35% of patients were registered to use online Patient Access.
  • The practice organised and delivered services to meet patients’ needs.
  • Information about services and how to complain was available.

We rated all population groups as good for providing responsive services. We rated all population groups as good for providing effective services, with the exception of working age people (including those recently retired and students) which is rated as requires improvement, because of low cervical screening rates.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way.
  • 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).

The areas where the provider should make improvements are:

  • Consider how to evacuate patients with mobility problems.
  • Continue to develop a patient participation group (PPG) and increase the frequency of PPG meetings.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

14 May 2018

During a routine inspection

This practice is rated as requires improvement overall.

The key questions are rated as:

Are services safe? - Requires improvement

Are services effective? - Good

Are services caring? - Good

Are services responsive? - Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at The Pinner Road Surgery on 14 May 2018. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether The Pinner Road Surgery was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

  • We noted the current provider had inherited the number of challenges when they took over the practice in August 2017. We found the practice had implemented the number of measures to mitigate the challenges.
  • There was a lack of good governance in some areas.
  • Risks to patients were assessed and well managed in some areas, with the exception of those relating to fire safety, staff vaccination and management of blank prescription forms.
  • The practice was unable to provide documentary evidence to demonstrate that all staff had received training relevant to their role.
  • The practice was unable to demonstrate that all appropriate recruitment checks had been undertaken prior to employment.
  • The practice had not provided curtains in all consulting/ treatment rooms to maintain patients’ privacy and dignity during examinations, investigations and treatments.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Information about services and how to complain were available and easy to understand.
  • The practice was aware of and complied with the requirements of the Duty of Candour.
  • Staff we spoke with informed us the management was approachable and always took time to listen to all members of staff.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Review the management and security of blank prescription forms, to ensure this is in accordance with national guidance.
  • Implement a system to ensure the effective monitoring of uncollected prescriptions.
  • Ensure all staff have received formal training relevant to their role including sepsis awareness training.
  • Ensure all actions required in response to legionella risk assessment are completed in a timely manner.
  • Ensure information about a translation service is displayed in the reception area informing patients this service is available. Ensure information posters and leaflets are available in multiple languages.
  • Ensure curtains are provided in all consulting and treatment rooms to maintain patients’ privacy and dignity during examinations, investigations and treatments.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice