The Care Quality Commission
  • Doctor
  • GP practice

Church Lane Surgery

Overall: Good read more about inspection ratings

282 Church Lane, Kingsbury, London, NW9 8LU (020) 8200 0077

Provided and run by:
Church Lane Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Church Lane 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 Church Lane Surgery, you can give feedback on this service.

26 October 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Church Lane Surgery on 26 October 2022, with the remote clinical interview on 24 October 2022. Overall, the practice is rated as good, with the following ratings for each key question:

Safe – Good

Effective – Good

Caring – Not inspected, rating of good carried forward from previous inspection

Responsive – Not inspected, rating of good carried forward from previous inspection

Well-led – Good

Following our previous inspection on 4 August 2021, the practice was rated as requires improvement overall. We rated the practice as inadequate for providing safe services, requires improvement for providing effective and well-led services and good for the caring and responsive key questions. We carried out an announced remote inspection on 23 February 2022, which was an unrated inspection of the service. At this inspection, we found that the practice had addressed the issues identified at out inspection on 4 August 2021, in relation to the safe key question.

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

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulation from our previous inspection in August 2021.

This inspection was a focused inspection focusing on whether:

  • Care and treatment was being provided in a safe way to patients.
  • There were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • 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.
  • Information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall.

We have rated this practice as Good for providing safe, effective and well-led services because:

  • The practice had clear systems, practices and processes to keep people safe from abuse. We found that two non-clinical members of staff had not completed safeguarding children training to the appropriate level. The practice informed us that these members had completed this training after our inspection.
  • The practice had addressed all concerns identified in our previous inspection in August 2021. At this inspection, we found:
  • The practice now had a process in place to effectively monitor patients prescribed high risk medicines.
  • The practice now had an effective system in place to implement Medicines and Healthcare Products Regulatory Agency (MHRA) alerts.
  • The practice had made improvements to the monitoring of emergency medicines, emergency equipment and vaccinations. We saw that emergency medicines, supplies and vaccinations were all in date and that checking was completed routinely. The emergency medicines held on site were appropriate and risk assessments had been completed for emergency medicines not held on site.
  • The practice had made improvements to how it monitored the over usage of medicines, including the over usage of inhalers in patients with asthma. The practice now had safe systems and processes in place and oversight of over usage of medicines.
  • The practice now had a learning disabilities protocol and we were satisfied that there was a system in place and oversight to ensure that learning disability reviews were completed appropriately and actions taken where needed.
  • We found that the practice was appropriately managing long-term conditions, including diabetes, chronic kidney disease (CKD) and asthma. The practice had made improvements to coding of diabetes and had safe systems and processes in place and oversight of patients with a potential diagnosis of diabetes. We provided feedback to the practice regarding the following up of patients within the timeframe specified by The National Institute for Health and Care Excellence (NICE) guidance. The practice assured us that it was now actively following up patients.
  • The practice had processes and oversight in lace for the completion and review of do not attempt cardiopulmonary resuscitation (DNACPR) coding and forms.
  • The practice kept accurate and comprehensive clinical records. We saw that medication reviews were completed in detail in the clinical records system, including that all monitoring was up to date or requested and that any relevant safety information of advice had been addressed.
  • The practice now had processes in place for discussing the risks of some medicines with patients of childbearing age before prescribing.
  • The practice had a process for the review of palliative care patients and completion of personalised care plans in conjunction with the Royal College of General Practitioners guidelines.
  • The practice now had an adequate system in place for the evacuation of patients with mobility issues in the event of a fire. The practice now had an evacuation chair in place for use of evacuation of patients from the rear fire exit if required.
  • The premises were well managed and there were effective systems for managing staff records.
  • The practice’s uptake for cervical screening was below the 80% coverage target for the national programme, however the practice had put in place systems to address barriers to the uptake of screening and was working towards increasing uptake.
  • The practice had met the 90% uptake target in three of the childhood immunisation uptake indicators, was very close to meeting this in one of the indicators, and was above 80% in the other indicator. The practice had not met the WHO based national target of 95% (the recommended standard for achieving herd immunity) in all of the childhood indicators, however, it was close to reaching this target in three of the indicators. The practice had put in place systems to address barriers to the uptake of childhood immunisations and was working towards increasing uptake.
  • The practice had worked towards providing effective care for patients during the Covid-19 pandemic.
  • The practice had made improvements in providing well-led services in relation to good governance. It had implemented systems and processes in response to the findings of our previous inspection.
  • The practice strongly encouraged personal and professional development and learning amongst staff and was supportive in staff undertaking appropriate learning for their roles and in their future aspirations.
  • The practice had a strong focus on the well-being of its staff and encouraged feedback from staff, which it acted upon. Staff members spoke positively about their employment at the practice and felt supported.
  • We received feedback from the Patient Participation Group (PPG) that the practice was responsive in listening to patients.

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

  • Continue to take steps to ensure that all non-clinical staff have completed the appropriate level of safeguarding children training.
  • Continue to review and monitor patients with acute exacerbation of asthma in line with NICE guidance.
  • Continue with plans to improve uptake of childhood immunisations and cervical screening.

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

23 February 2022

During an inspection looking at part of the service

We carried out an announced remote inspection at Church Lane Surgery on 23 February 2022. This was an unrated inspection of the service.

Following our previous inspection on 4 August 2021, the practice was rated requires improvement overall, and specifically inadequate for providing safe services, requires improvement for providing effective and well-led services and good for providing caring and responsive services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Church Lane 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:

  • A breach of Regulation 12 (safe care and treatment) of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 at our previous inspection in August 2021. Following that inspection, we issued the provider with a Warning Notice to comply with the regulation by January 2022. The Warning Notice identified the following key areas of concern:
  • potential missed diagnosis/ coding issues of patients with diabetes;
  • medicines over usage (short-acting beta2 agonist (SABA) inhalers);
  • inadequate system for receiving and actioning Medicines and Healthcare Products Regulatory Agency (MHRA) alerts;
  • learning disability reviews; and
  • inadequate process for monitoring emergency medicines and vaccinations on site.

How we carried out the inspection

Throughout the pandemic CQC has continued to regular 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 included:

  • Completing clinical searches on the practice’s patient records systems remotely and discussing findings with the provider
  • Conducting an interview with the provider using video conferencing
  • Requesting evidence from the provider

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 and other organisations.

We found that:

  • The practice had addressed the issues identified in the Warning Notice issued after the previous inspection. The practice had developed policies and protocols to improve the review and management of patients in relation to the diagnosis of diabetes, management of asthma patients and over usage of SABA inhalers, review of learning disability patients and monitoring of emergency medicines and vaccinations on site.

  • In relation to the areas focused on at this inspection:

The practice provided care in a way that kept patients safe and protected them from avoidable harm.

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

04 August 2021

During a routine inspection

We carried out an announced inspection at Church Lane Surgery, with the remote clinical review on 2 August 2021 and site visit on 4 August 2021. Overall, the practice is rated as requires improvement.

Safe - Inadequate

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led – Requires improvement

Following our previous inspection on 6 March 2019, the practice was rated requires improvement overall and specifically requires improvement for providing safe and well-led services. We found that the practice was good for providing caring, effective and responsive services.

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

Why we carried out this inspection

This inspection was a comprehensive follow up inspection focusing on:

  • Ensuring care and treatment was being provided in a safe way to patients.
  • Establishing if there were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.

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 requires improvement overall. The population groups have been rated as inadequate for people with long term conditions, requires improvement for working age people (including those recently retired and students) and people whose circumstances may make them vulnerable and good for older people, families, children and young people and people experiencing poor mental health (including people with dementia).

We have rated this practice as Inadequate for providing safe services because.

  • The system for managing and acting on Medicines and Healthcare products Regulatory Agency (MHRA) alerts was not effective.
  • We found concerns relating to the coding and potential missed diagnosis of diabetes in some patients.
  • We were not assured there were safe systems and processes in place for the monitoring of over usage of inhalers in patients with asthma.
  • We found learning disability reviews were not always completed in detail and actions were not followed up appropriately.
  • We identified gaps in the process for monitoring emergency medicines and vaccinations at the practice. We found some emergency medicines missing from the emergency medicines boxes on site and did not see a risk assessment as to why these medicines were not present. We found out of date emergency medicines, vaccinations and supplies on site.
  • We found that monitoring for patients prescribed DMARDs, Methotrexate, Leflunomide and Azathioprine was completed appropriately.
  • The practice had made improvements in their infection prevention and control procedures and this was being managed effectively.
  • The practice now had an effective failsafe policy and systems in place to ensure that results were followed up in a timely manner.
  • The practice now had effective recruitment systems in place and DBS checks had been completed appropriately and staff training was up to date.

We rated the practice as requires improvement for providing effective services because:

  • We found that patient treatment was not always regularly reviewed and updated. We found issues with the management of medicines and the following of national clinical guidance.

We rated the practice as requires improvement for providing well-led services because:

  • The practice had acted to address the concerns we found during the last inspection with regard to well-led, however, we identified some new areas of concern:
  • We found recording of do not attempt cardiopulmonary resuscitation (DNACPR) decisions was not always consistent. We were not assured that there were processes and oversight in place for the completion and review of DNACPR coding and forms.
  • We were not assured that there were processes in place for discussing the risks of some medicines with patients of childbearing age before prescribing.
  • We found medication reviews, although coded, were not always completed in detail in the medical records.
  • We saw evidence of multidisciplinary team working with palliative care patients but could not identify formal palliative care reviews.
  • We found the practice did not have an adequate system in place for the evacuation of patients with mobility issues in the event of a fire.
  • We received feedback from the Patient Participation Group that the practice was open, honest and receptive to constructive feedback and that changes were made in collaboration with the group to improve services.
  • Staff spoke positively about their employment at the practice and felt supported.

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.
  • The practice organised and delivered services to meet the needs of patients.

We rated the practice as good for providing responsive services because:

  • The practice assisted patients attending in person who were unable to book appointments by telephone, email or online.
  • The practice took a proactive approach in identifying vulnerable patients and their carers to ensure that they were given priority access to appointments and longer appointments where appropriate.
  • The practice had made care calls to patients who had shielded during the Covid-19 pandemic to check on their health and well-being.

We found two breaches of regulations. The provide must:

  • 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).

In addition to the above, the practice should:

  • Continue to review and monitor the outcomes of patients with diabetes.
  • Continue to conduct routine fire risk assessments and checks, including the fire safety log for emergency/ escape lighting.
  • Ensure appropriate monitoring for patients on high risk medicines in line with clinical guidance.
  • Continue to identify carers in the practice population.

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

6 March 2019

During a routine inspection

We carried out an announced comprehensive inspection at Church Lane Surgery on 6 March 2019 as part of our inspection programme.

At the last inspection in April 2018, we rated the practice as requires improvement overall and specifically requires improvement for providing safe and well-led services because:

  • There were inconsistent arrangements in how risks were assessed and managed. For example, during the inspection, we found risks relating to health and safety of the premises and patients including fire safety arrangements, management of legionella and management of blank prescription forms.
  • There was a lack of good governance in some areas.

Previous reports on this practice can be found on our website at: www.cqc.org.uk/location/1-496491998. 

At this inspection, we found that the provider had demonstrated improvements in some areas, however, they were required to make further improvements in some areas and are rated as requires improvement for providing safe and well-led services.

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 for all population groups.

We rated the practice as requires improvement for providing safe services because:

  • Risks to patients were assessed and well managed in some areas, with the exception of those relating to safety alerts, infection control procedures and recruitment checks.
  • The provider did not have a second thermometer which could log all the data and provide assurance that temperatures had been within the required range, nor was the existing thermometer calibrated at least monthly, as recommended in Public Health England guidance.
  • Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes.

We rated the practice as requires improvement for providing well-led services because:

  • There was a lack of good governance in some areas.
  • The practice had not had an effective system to identify and monitor who was collecting the repeat prescriptions for controlled drugs from the reception.
  • The practice had failed to take appropriate action in a timely manner to address the risk identified during the previous inspection in April 2018, regarding the rear fire exit door, which required to be fitted with a panic or push bar.
  • The practice had not had a system to follow up women (after 12 weeks) who were prescribed contraceptive depot injections.
  • There were no failsafe systems to follow up women who were referred as a result of abnormal results after the cervical screening.
  • The practice was aware of and complied with the requirements of the Duty of Candour.
  • There was a clear leadership structure and staff felt supported by the management.

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 dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs.
  • Patients could access care and treatment in a timely way. Patients were able to ring a duty GP directly (bypassing the reception) for a telephone consultation between 8.30am to 9am and 11.30am to 12pm Monday to Friday.
  • The practice was encouraging patients to register for online services and 30% of patients were registered to use online Patient Access.
  • Information about services and how to complain were available and easy to understand.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.
  • 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 and improve the current arrangements to monitor effectively the use of blank prescription forms for use in printers and handwritten pads.
  • Consider ways to improve the identification of carers to enable this group of patients to access the care and support they need.
  • Continue to review and monitor the outcomes of patients with diabetes.
  • Continue to review, monitor and encourage uptake of bowel cancer screening.
  • Review ways to improve patients’ satisfaction with care and treatment, telephone access and refurbishment of the premises.

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

11 April 2018

During a routine inspection

This practice is rated as requires improvement overall.

(Previous inspection October 2014 - The practice was rated as good 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 Church Lane Surgery on 11 April 2018 as part of our inspection programme. 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 Church Lane Surgery was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

  • There were inconsistent arrangements in how risks were assessed and managed. For example, during the inspection, we found risks relating to health and safety of the premises and patients including fire safety arrangements, management of legionella and management of blank prescription forms.
  • There was a lack of good governance in some areas.
  • 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.
  • We found that completed clinical audits were driving positive outcomes for patients.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Patients were able to ring a duty GP directly (bypassing the reception) for a telephone consultation between 8.30am to 9am and 11.30am to 12pm Monday to Friday.
  • Information about services and how to complain were available and easy to understand. However, information about a translation service was not displayed in the reception areas and there were limited information posters and leaflets available in other languages.
  • Staff we spoke with on the day of inspection informed us there was a clear leadership structure and they felt supported by the management.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation. However, clinical meetings were not documented.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • 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:

  • Ensure all staff have received formal sepsis awareness training.
  • Implement the system to promote the benefits of bowel cancer national screening in order to increase patient uptake.
  • Review the process of identifying carers to enable them to access the support available via the practice and external agencies.
  • 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 multi-languages.
  • Improve access to patients with hearing difficulties.
  • Ensure the most recent CQC rating is clearly displayed.

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

23 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Church Lane Surgery on 23 October 2014. We rated the practice as ‘Good’ for the service being safe, effective, caring, responsive to people’s needs and well-led. We rated the practice as ‘Good’ for the care provided to older people and people with long term conditions and ‘Good’ for the care provided to, families, children and young people, working age people (including those recently retired and students), people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

  • The practice was visibly clean and infection control procedures were in place. Staff understood their responsibility to raise concerns and report incidents. Staff learnt from the outcomes of investigations into incidents and complaints. The practice had policies and procedures to monitor safety and respond to risk.
  • Patients were offered effective care from GPs who met their medical needs. Staff were qualified and trained and had the skills to carry out their role effectively.
  • Patients felt supported and said they were treated with dignity and respect by their GP.
  • Patients needs were met through the way in which services were organised and delivered. The appointments system was easy to use and overall patients were satisfied with the availability of appointments.
  • The leadership, management and governance of organisation and the practice supported learning and innovation. Staff and patients were involved in developing services and planning for the future.

However, there were also areas of practice where the provider needs to make improvements.

  • The provider should ensure all clinical staff are aware of the Mental Capacity Act 2005 and how this will impact on care and treatment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice