The Care Quality Commission
  • Doctor
  • GP practice

Chichele Road Surgery

Overall: Good read more about inspection ratings

25 Chichele Road, London, NW2 3AN (020) 8452 4666

Provided and run by:
Chichele Road Surgery

All Inspections

2 August 2023

During an inspection looking at part of the service

We carried out an announced inspection at Chichele Road Surgery from 28 July - 2 August 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

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

Responsive – requires improvement

Well-led - good

Following our previous comprehensive inspection which took place on 12 December 2021 the practice was rated requires improvement overall. It was rated good for providing safe, caring and responsive services and requires improvement for providing effective and well-led services. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Chichele Road Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

We carried out this inspection to follow up a breach of regulations from a previous inspection in line with our inspection priorities. This inspection was a focused inspection to follow up on:

  • The key questions of safe, effective, responsive and well-led
  • A breach of regulation 17 (Good governance)
  • Any additional areas identified for improvement.

At our previous inspection we found a lack of good governance in some areas. In particular, we found that the provider did not have a clear strategy in place to achieve stated goals. Governance systems in relation to the oversight of delegated responsibilities, staff performance, competency assessment and clinical supervision were not fully developed or recorded. The provider was not always maintaining accurate, complete and contemporaneous patient records. The provider did not have effective systems in place to ensure the safe management of patients prescribed medicines which required ongoing monitoring. The provider had not effectively used risk assessment to demonstrate that the environment was maintained to a standard to protect patient confidentiality and staff safety. The provider did not have an effective prescription security system in place.

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 and
  • information from the provider, patients, the public and other organisations.

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 practice had improved childhood immunisation uptake levels since our previous inspection.
  • The practice had focused on improving access to the service and levels of demand remained high at the time of the inspection. Patient survey feedback about access remained below average.
  • The practice had improved its governance systems since our previous inspection. 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:

  • Follow-up patients who have been prescribed a course of rescue steroids for an exacerbation of asthma in line with current guidelines.
  • Implement a system to ensure that patients newly prescribed SGLT2 inhibitors (a type of medicine typically used to treat diabetes) are made aware of potential side effects.
  • Assure itself that chronic kidney disease is being coded appropriately going forward.
  • Take action to improve patient experience in relation to access to the service.
  • Take action to improve cervical screening coverage.
  • Take action to further improve childhood immunisation uptake rates where these remain below target.

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 Health Care

12 November 2021

During a routine inspection

We carried out an announced inspection at Chichele Road Surgery from 8 November to 13 December 2021. Overall, the practice is rated as requires improvement.

Safe - Good

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led – Requires improvement

Following our previous comprehensive inspection which took place on 20 December 2020 the practice was rated requires improvement overall. It was rated good for providing safe, caring and responsive services and requires improvement for providing effective and well-led services.

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

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on:

  • All key questions
  • Breaches of regulations 17 (Good governance)
  • Areas we said the practice should improve

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

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

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients’ needs were assessed and care and treatment was delivered in line with current guidelines.
  • Staff dealt with patients with kindness and respect and were committed to involving people in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

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

  • The practice was not managing some long term conditions (asthma and hypothyroidism) in line with guidelines.
  • The practice was performing below target for cancer screening uptake and childhood immunisations.

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

  • Governance was variable and there remained some gaps in systems and lines of accountability were not always clear.
  • We received mixed feedback from staff about the practice as a place to work.
  • The practice provided supervision, competency assessment and oversight to clinicians working in advanced practice and documented annual appraisals. However, supervision and competency assessment of the wider team was largely reactive in nature and not documented.

We found a breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

  • Continue work to increase the uptake of childhood immunisations.
  • Ensure that complaints are responded to in a timely way and updates are provided to complainants when appropriate.
  • Assess and put in place measures to support staff wellbeing at work as appropriate.
  • Ensure that key documentation supporting the recruitment and complaints process is accessible when required.

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

10 December 2020

During a routine inspection

We carried out an announced comprehensive inspection at Chichele Road Medical Centre on 10 December 2020 as part of our inspection programme.

At this inspection we followed up on breaches of regulations identified at a previous inspection on 24 October 2019. Following the October inspection, the practice was placed in special measures and issued with warning notices for breaches of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). We carried out a virtual assessment of the practice’s progress in September 2020 and found that the practice had made the required improvements set out in the warning notices. We did not re-rate the practice at that time.

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.

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

  • Some performance data was significantly below local and national averages and the practice did not yet have a convincing strategy to improve in these areas.
  • The practice could not assure us that it proactively assessed the physical health needs of patients with learning disabilities.
  • The practice was not always treating patients in line with guidelines (for example, in relation to certain combinations of medicines) and could not always provide a rationale in these cases.
  • The practice had not developed a clinical audit programme linked to practice priorities and could provide only limited evidence of recent audit. The practice was not auditing its prescribing of controlled drugs.

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

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

We rated the practice as requires improvement for providing services to the population group of Families, Children and Young People. This was because recent performance data on childhood immunisations was not meeting the national targets.

We rated the practice as requires improvement for providing services to the population group of Working Age People (including those recently retired and students). This was because relevant performance data for population cancer screening programmes was below local and national averages and targets. Published practice performance on these indicators had remained static since 2017. The practice provided unverified data following the inspection that cervical cancer uptake rates were improving.

We rated the practice as requires improvement for providing services to the population group of People whose circumstances may make them vulnerable. The practice was not carrying out annual health checks for patients with a learning disability or carrying out other active monitoring of their physical health needs.

The areas where the provider must make improvements are:

  • 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:

  • Continue to look at ways to improve uptake for the childhood immunisation programme.
  • Implement a system to follow-up patients diagnosed with serious mental problems who fail to collect prescribed medicines.
  • Consider ways to involve staff and patients in developing the practice mission statement and values.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

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

17 September 2020

During an inspection looking at part of the service

This report was created as part of a pilot which looked at new and innovative ways of fulfilling CQC’s regulatory obligations and responding to risk in light of the Covid-19 pandemic. This was conducted with the consent of the provider. Unless the report says otherwise, we obtained the information in it without visiting the provider.

We carried out an announced, focused inspection of Chichele Road Surgery on 17 September 2020. The purpose of the inspection was to follow up on breaches of regulations identified at our previous inspection on 24 October 2019. We did not re-rate the practice on this occasion.

Following the October inspection, the practice was placed in special measures and issued with warning notices for breaches of Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance). The practice was required to address these breaches by 20 December 2019.

We based our judgement of the quality of care at the practice 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 found that the practice had made the required improvements.

  • The practice was providing care in a way that kept patients safe and protected them from avoidable harm.
  • The practice had made improvements to the way the service was led and managed and was promoting the delivery of high-quality, person-centred care.

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

  • Ensure that written risk assessments are sufficiently detailed, for example, to properly justify why the practice has not stocked certain emergency medicines.
  • Clearly document in the patient record who is monitoring any patient prescribed a high-risk medicine when this is the responsibility of a different provider.
  • Establish a more active internal reporting culture to encourage greater learning opportunities in line with practice policy.

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

24 October 2019

During a routine inspection

We carried out an announced comprehensive inspection at Chichele Road Surgery on 25 October 2019 as part of our inspection programme. At this inspection, we followed up on breaches of regulations identified at a previous inspection on 26 June 2018.

On 26 June 2018, we carried out a comprehensive inspection and the practice was rated as Good overall. Specifically, it was rated as Requires Improvement for providing effective services and also rated Requires Improvement in the population groups of long-term conditions, families, children and young people, working age and people experiencing poor mental health population groups.

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.


At this inspection, we have rated this practice as inadequate overall.

We rated the practice as inadequate for providing safe services because:

  • There were no clear systems, practices and processes to keep people safe and safeguarded from abuse.
  • Appropriate standards of cleanliness and hygiene were not met.
  • There were gaps in systems to assess, monitor and manage risks to patient safety.
  • Staff had the information they needed to deliver safe care and treatment; however, improvement was required.
  • The practice did not always have systems for the appropriate and safe use of medicines, including medicines optimisation.
  • The practice did not have an adequate system to learn and make improvements when things went wrong.

We rated the practice as inadequate for providing effective services because:

  • There was limited monitoring of the outcomes of care and treatment.
  • The practice was unable to show that staff had the skills, knowledge and experience to carry out their roles.
  • Some performance data was significantly below local and national averages.

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

  • While the practice had made some improvements since our last inspection, it had not appropriately addressed the Requirement Notice in relation to the improving clinical performance. At this inspection we also identified additional concerns that put patients at risk.
  • There was a lack of established clinical leadership and leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
  • While the practice had a clear vision, that vision was not supported by a credible strategy.
  • The practice culture did not effectively support high quality sustainable care.
  • The overall governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.
  • We saw little evidence of systems and processes for learning, continuous improvement and innovation.

These areas affected all population groups so we rated all population groups as inadequate.

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

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access the service in a timely manner.
  • However, learning from complaints was not always clear.

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:

  • Ensure sharps injury guidance is available in consulting or treatment rooms.
  • Review the availability of practice Accessible Information Standard policy.
  • Improve the recording of complaints and ensure learning is shared effectively.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

26 June 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating 15/12/2016 – Good overall)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Chichele Road Surgery on 26 June 2018. We carried out this inspection to follow up a breach of regulations identified at the previous inspection. At the previous inspection we found that patients’ privacy was not always protected at the reception desk and this was a breach of regulation 10.

At this inspection we found:

  • The practice had improved patient privacy at the reception desk since our previous inspection.
  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • 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.
  • Practice performance was below the local and national averages for cervical screening coverage; child immunisations and the management of diabetes and hypertension. The practice could not provide recent validated data to show improvement. This was an area identified for improvement at the previous inspection.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients reported that they were able to access care when they needed it. The practice operated a walk-in morning surgery which patients said was convenient. However, it resulted in regular queues outside the practice in the early morning.
  • There was a focus on continuous learning and improvement at all levels of the organisation. The practice had addressed most of the areas for improvement identified at the previous inspection.
  • There was a lack of clarity about the reasons for the practice’s below average performance of long-term conditions; immunisation and screening uptake rates and a lack of accessible information to assess current progress.

The areas where the provider must make improvements are:

  • The practice must establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. This includes the use of information to assess practice performance.

The areas where the provider should make improvements are:

  • The practice should review its appointment system to ensure that patient queues are minimised and the risks have been assessed.

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

Please refer to the detailed report and the evidence tables for further information.

15 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Chichele Road Surgery on 15 December 2016. 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.
  • Risks to patients were assessed and well managed.
  • 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.
  • Data showed patient outcomes were low compared to the national average for QOF.
  • Although some audit and data collection had been carried out, there was no evidence that a programme of audits was being used to drive improvements to patient outcomes.
  • Patients said they were treated with compassion and dignity, however not all felt that they were respected by staff. Not all patients felt that they were given enough time or information to make decisions about their treatment. This was not supported by the GP survey findings
  • People told us that confidentiality was not always maintained at the reception desk, although there was a private room available for people to speak confidentially to staff.
  • We also observed that it was possible to hear patients’ names and who they were seeing when receptionists were speaking on the telephone. All reasonable measures had not been taken to ensure confidentiality.
  • 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, however the provider could not evidence how learning outcomes were shared with staff.
  • The practice had facilities and was 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 and complied with the requirements of the duty of candour.

The areas where the provider must make improvement are:

  • Implement further measures to improve patient confidentiality at the reception desk to ensure the privacy of people.

The areas where the provider should make improvement are:

  • Review systems to identify carers in the practice to ensure they receive appropriate care and support.
  • Consider improving communication with patients who have a hearing impairment and make people aware of translation services available to them.
  • Continue to make improvements in the performance for QOF, including patient outcomes in long-term conditions, childhood immunisations and cervical screening programme to align with local and national averages.
  • Review complaints systems to include recording and review of all complaints, verbal and written to improve services and share learning outcomes with staff and those involved.
  • Develop an ongoing programme of audits to monitor and improve the quality of service being provided to people.
  • Review and establish systems to manage uncollected prescriptions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

14 January and 7 February 2014

During a routine inspection

Patients' views and preferences were taken into account in the way the service was provided and delivered. The feedback from patients was largely positive. Patients told us they were involved in their care.

There was evidence to indicate that patients had been asked for their consent to the examination, care, treatment and support they received. Patients told us that they were given enough information to make decisions.

Patients' needs were assessed and their care and treatment were planned and delivered in line with their individual care plans. Key information relevant to patients' care was recorded. This included a record of their medical history, allergy details and health status.

The practice had taken reasonable steps to identify the possibility of abuse. The practice had nominated lead staff for children and adult safeguarding. Staff were aware of what constituted abuse and how to raise a concern.

Patients who used the service and their representatives were asked for their views about their care and treatment and these were acted upon.

The provider had systems in place to regularly gather feedback from patients who used the service. We reviewed the records of some patients. In all cases we were satisfied that the practice had taken action to ensure patients' records were accurate, fit for purpose and held securely.