• Doctor
  • GP practice

Barlby Surgery

Overall: Good

St Charles Centre for Health & Wellbeing, Exmoor Street, London, W10 6DZ (020) 8962 5100

Provided and run by:
AT Medics Limited

All Inspections

9 June 2022

During a monthly review of our data

We carried out a review of the data available to us about Barlby Surgery on 9 June 2022. 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 Barlby Surgery, you can give feedback on this service.

05 and 21 October 2021

During an inspection looking at part of the service

We carried out an announced inspection at Barlby Surgery on 5 and 21 October 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Following our previous inspection on 28 February 2019, the practice was rated Good overall and for the key questions effective, caring, responsive and well-led. The practice was rated requires improvement for providing safe services and issued a requirement notice for Regulation 12 Safe care and treatment.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Barlby 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 breaches of Regulation 12 Safe care and treatment.

At this inspection we covered the following key question:

  • Are services safe?

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. We rated the practice as Good for providing safe services.

We found that:

  • The practice had demonstrated improvements compared to the previous inspection.
  • Our clinical records searches showed that the practice had an effective process for monitoring patients’ health in relation to the use of medicines including high-risk medicines.
  • We found the prescription box for uncollected prescriptions was monitored effectively.
  • We noted the system for checking single-use equipment and the doctors’ bag was operating effectively.
  • Sepsis awareness had been discussed in the practice meetings, which included scenario based discussion and training.
  • Blind loop cords were secured appropriately.
  • We found the practice did not have any formal monitoring system in place to assure themselves that blank prescription forms were recorded correctly, and records were maintained as intended.
  • The practice had maintained a complaints log and all complaints were discussed and learning shared during team meetings at the practice and regional level.

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

  • Ensure that the newly written protocol for the safe and secure oversight of blank prescription management is embedded and appropriately reviewed to be assured that it is operating effectively.

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

28 February 2019

During a routine inspection

We carried out an announced comprehensive inspection at Barbly Surgery on 28 February 2019 as part of our inspection programme.

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

  • There were gaps in safety systems. This was in relation to single use equipment checks, health and safety, high-risk medicines.

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

  • Patients received effective care and treatment that met their needs.
  • The practice had a comprehensive programme of quality improvement and used information about care and treatment to make improvements.
  • 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.
  • The way the practice promoted the delivery of high-quality, person-centre care.
  • The practice had a strong visible and managerial leadership and a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements are:

  • 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).

The areas where the provider should make improvements are:

  • Review significant events policy to ensure all events are recorded as per the policy.
  • Monitor that non-clinical staff are aware of sepsis red flags and the actions to take in the event of a sharps injury.
  • Monitor vaccines fridge to ensure that old vaccines stock is not mixed with new stock.
  • Develop a system to check that relevant staff have read safety alerts.
  • Take action to analyse learning from complaints received.

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

15 July 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Barlby Surgery on 15 July 2015 Overall the practice is rated as outstanding.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example they had teamed up with a local charity to deliver a range of health projects in the local community.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure they met people’s needs.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG).
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand
  • The practice had a clear vision which had quality and safety as its top priority. A business plan was in place, was monitored and regularly reviewed and discussed with all staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

We saw several areas of outstanding practice including:

  • The practice had increased the flexibility of access to appointments and could demonstrate the impact of this by reduced use of the GP appointments during the day. The practice provided Skype consultations twice weekly, offering approximately 12 consultations per week and there was a GP who was based at the reception desk who provided both telephone consultations and a triage service. The practice was open from 8.00am to 9pm Mondays to Friday and 9am to 5pm on Saturday and Sundays
  • The practice had formed a partnership with a local charity to provide a multi-stranded approach to work on health access to primary care services for BME people for whom English was not a first language. The practice had co-produced a short film with patients, clinicians and faith groups called Talking from the heart” exploring mental health diagnosis and therapy by combining medical and faith advice
  • The practice had “Practice Champions” which was a project aimed at parents and children and young people aged 16-21. The Practice Champions supported other patients through education, signposting and peer support. This had increased the amount of young people who attended the surgery for both general information and specific concerns.
  • The chief executive sent all staff a weekly ‘staff matters’ bulletin by email. This provided them with any information about the practice including staffing matters, training opportunities, and any changes within the practice group.
  • They had developed two training packages. One for clinicians, which entailed fortnightly consultant-led training for GPs via webinars in a collaborative learning environment designed to enhance clinical knowledge and delivering excellent patient services and another for receptionists training as Healthcare Assistants (HCAs). The training was used by other local practices.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice