The Care Quality Commission
  • Doctor
  • GP practice

Townfield Doctors Surgery

Overall: Good read more about inspection ratings

34 College Way, Hayes, Middlesex, UB3 3DZ (020) 8573 5856

Provided and run by:
Townfield Doctors Surgery

All Inspections

During an assessment under our new approach

Date of Assessment: 24/10/2025. Townfield Doctors Surgery is a GP practice and delivers service to 8,400 patients under a PMS contract held with NHS England. The National General Practice Profiles states that the ethnicity of the practice population is 47.2% Asian, 27.2% White, 12.4% Black, 3.6% Mixed and 9.6% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the fourth decile (4 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 within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.

We carried out a focused assessment of Townfield Doctors Surgery to follow up on a breach of Regulation 17 good governance identified at our last assessment. At the last assessment, the practice was in breach of legal regulation because people were not always able to access care and treatment in a timely way. This led to a rating requires improvement for providing responsive services. Therefore, our focus for this assessment was on all the quality statements for the responsive key question. However, after reviewing data whilst planning our site visit, a decision was made to expand the scope of the assessment to also include all the quality statements for the caring key question.

Caring: We found people were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.

Responsive: We found people were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

Since the last inspection, the practice had made improvements and is no longer in breach of regulation 17 good governance.

28 September 2022

During a routine inspection

We carried out an announced comprehensive inspection at Townfield Doctors Surgery on 28 September 2022. Overall, the practice is rated as Good.

The key questions are rated as:

Safe - Good

Effective - Good

Caring - Good

Responsive - Requires improvement

Well-led - Good

Following our previous inspection on 19 August 2016, 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 Townfield Doctors Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

This was a comprehensive inspection. We carried out this inspection in response to concerns we received as part of our regulatory functions. At this inspection we covered all key questions:

  • Are services safe?
  • Are services effective?
  • Are services caring?
  • Are services responsive?
  • Are services well-led?

How we carried out the inspection

Throughout the pandemic, CQC has continued to regulate and respond to risk. At this inspection, we visited the practice which included:

  • Conducting staff interviews.
  • 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.

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.
  • 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.
  • People were not always able to access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • There was evidence of quality improvement activity. Clinical audits were carried out.
  • The practice’s uptake of the national screening programme for cervical cancer screening and childhood immunisation uptake was below the national average.
  • Annual appraisals were carried out in a timely manner.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The Patient Participation Group (PPG) was active.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.

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.

The areas where the provider should make improvements are:

  • Carry out appropriate health checks during the recruitment process.
  • Develop a system to monitor repeat prescription box to ensure requesting and collecting repeat prescriptions process works effectively.
  • Maintain records when the prescribing competence of a non-medical prescriber is reviewed and discussed with them.
  • Continue to encourage and monitor cervical cancer screening and childhood immunisation uptake rates.
  • Take necessary steps to address CQC registration issues.

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 September 2019

During a routine inspection

We decided to undertake a comprehensive inspection of this service following our annual review of the information available to us. This inspection looked at the following key questions:

  • Are services safe?
  • Are services effective?
  • Are services caring?
  • Are services responsive?
  • Are services well-led?

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, for all key questions and all population groups.

  • The practice provided care in a way that kept patients safe and protected them from harm.
  • Patients’ needs were assessed, and they received care and treatment in line with guidelines.
  • The practice could demonstrate improved performance and active engagement with other health and social care agencies to provide coordinated care.
  • 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 practice leadership promoted the delivery of high-quality, person-centred care.
  • We received mixed feedback about the cohesiveness of team working and the practice culture but were consistently told this was improving.
  • The practice was acting to address issues identified after a serious incident.

We saw one area of outstanding practice:

  • The practice ran a programme of events aimed at meeting the needs of particular patient groups. In 2019, the practice had run events on mental health (to coincide with mental health awareness week); first aid training for parents; a healthy heart event; an early dementia awareness event; and a children's art workshop. The patient participation group was involved in suggesting ideas and running events. The events were used to raise awareness about the topic and the relevant services the practice provided and lead staff members. For example, the practice had provided relevant information for parents attending the art workshop about childhood immunisations. Feedback from people attending the workshops was very positive.

The areas where the provider should make improvements are:

  • Continue to monitor and encourage parents to have their children immunised in line with current guidelines.
  • Review patient feedback around clinicians’ listening skills and assess the scope for improvement.
  • Take action to improve the uptake of bowel cancer screening.
  • Ensure that actions taken to improve following a serious event are embedded into practice.
  • Review the scope to improve the quality of management and performance data, for example in relation to staff training.

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 August 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Townfield Doctors Surgery on 19 August 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 an effective 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.
  • Patients said they felt the practice offered an excellent service and staff were caring, understanding, helpful and treated them with dignity and respect.
  • 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.
  • Patients said they had a named GP and there was continuity of care, with urgent appointments available the same day. However, some patients told us they found it difficult to make a routine appointment.
  • 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 and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Revise the incident reporting form so that it supports the recording of notifiable incidents under the duty of candour.

  • Implement a process for the recording of completed actions taken in response to safety alerts.

  • Review options for the disposal of sharps used to administer cytotoxic medicines.

  • Implement a system to track blank prescriptions through the practice.

  • Complete a risk assessment for window blinds with free hanging looped cords installed in public areas.

  • Display notices informing patients of interpreting services available at the practice.

  • Identify and support more patients who are carers.

  • Formalise the practice strategy and business plans to demonstrate how they will be achieved.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice