The Care Quality Commission
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Archived: Bush Hill Park Trinity Surgery

Overall: Good read more about inspection ratings

22-24 Trinity Avenue, Enfield, Middlesex, EN1 1HS (020) 8363 4493

Provided and run by:
Bush Hill Park Trinity Surgery

All Inspections

12 December 2019

During an inspection looking at part of the service

We carried out an announced focussed inspection at Bush Hill Park Trinity Surgery on 12 December 2019.

We previously inspected the practice in February 2016, when we rated the practice as Requires Improvement for providing safe, effective and well-led services. Included amongst the issues we identified, the practice could not provide sufficient evidence regular clinical audits were being conducted, a programme of regular in-house infection prevention and control audits had not been established and the practice did not have oxygen at its premises.

We subsequently carried out a focused inspection on 8 May 2017 to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we had previously identified. At the inspection on 8 May 2017, we rated the practice good for providing safe and well led services and requires improvement for providing an effective service. We asked the practice to ensure the correct clinical pathways were being followed as current clinical pathways were not being adhered to. We rated the practice Good overall.

We carried out a further comprehensive inspection in June 2018, at which time we rated the practice good for providing a safe, caring, responsive and well led service and requires improvement for providing an effective service. The practice was rated as good overall. At the inspection we asked the practice to ensure all medical alerts were followed up, clinical pathways were being followed, to review the cold chain policy in respect of ensuring there was a backup thermometer for the fridge and to look at their rate of antibiotic prescribing as it was higher than the local average.

A further comprehensive inspection was undertaken in May 2019. We rated the practice good for providing a caring and responsive service and requires improvement for providing a safe, effective and well led service. The practice was rated requires improvement overall. We issued a requirement notice for Regulation 12 HSCA (RA) Regulations 2014 safe care and treatment because we found that infection prevention and control policies had not been reviewed, areas of the practice were dirty and omitted from cleaning schedules, there was no record of the cleaning of hand-held medical equipment, actions from the recent infection prevention and control audit had not been followed up, there was no register of staff vaccines and emergency medicines were monitored inconsistently.

At the latest inspection in December 2019 we found that action had been taken to address all of these areas.

At this inspection, on 12 December 2019, 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 found that:

  • Published child immunisation figures were below the minimum World Health Organisation target of 90%.
  • 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.
  • 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 was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Review and update health and safety and premises risk assessments;
  • Clarify who the infection and prevention control lead is when the nurse is absent;
  • Review current nursing provision to ensure patient needs are met;
  • Include the identification of members of staff who undertake the checking of medical devices and general cleaning schedules;
  • Continue to look at ways to improve the prescribing rate;
  • Continue to look at ways to improve outcomes for the childhood immunisation programme.

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

8 May 2019

During a routine inspection

We carried out an announced comprehensive inspection at Bush Hill Park Trinity Surgery on 8 May 2019.

We previously inspected the practice in February 2016, we rated the practice as Requires Improvement for providing safe, effective and well-led services. Included amongst the issues we identified, the practice could not provide sufficient evidence regular clinical audits were being conducted, a programme of regular in-house infection control audits had not been established and the practice did not have oxygen at its premises.

We carried out a focused inspection on 8 May 2017 to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations we identified in our previous inspection. At the inspection on 8 May 2017, we rated the practice good for providing safe and well led services and requires improvement for providing an effective service. We rated the practice Good overall. We asked the practice to ensure the correct clinical pathways were being followed.

We carried out a further comprehensive inspection in June 2018, at which time we rated the practice good for providing a safe, caring, responsive and well led service and requires improvement for providing an effective service. The practice was rated as good overall. At the inspection we asked the practice to ensure all medical alerts were followed up, clinical pathways were being followed, to review the cold chain policy in respect of ensuring there was a backup thermometer for the fridge and look at their rate of antibiotic prescribing as it was higher than the local average. At this inspection, we found those areas had been appropriately addressed.

At this inspection 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 safe services because:

  • The practice failed to ensure infection control procedures were kept up to date and had failed to ensure all areas of the practice were sufficiently clean.
  • Cleaning chemicals were kept in an unsafe location in an unlocked cupboard under the staircase. However, these were moved to another location before the end of the inspection.
  • The practice did not hold a register of staff vaccines or carry out a risk assessment if staff members did not want to be immunised.
  • The system for checking emergency medicines held on the premises was not monitored appropriately.

We rated the practice as Requires Improvement for providing an effective service because:

  • Published child immunisation figures were below the minimum World Health Organisation target of 90%.

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

  • There was a lack of clinical supervision resulting in some governance responsibilities such as checking of emergency medicines not being completed.
  • Infection control processes were inadequate.

We rated the practice as good for providing a caring and responsive 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 patients’ needs.
  • Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Consider improving systems to identify and support patients experiencing substance misuse.
  • Follow through with plans to improve outcomes for the child immunisation programme.

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

8 May 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bush Hill Park Trinity Surgery on 17 February 2016. The overall rating for the practice was Requires Improvement. The full comprehensive report on the February 2016 inspection can be found by selecting the ‘all reports’ link for Bush Hill Park Trinity Surgery on our website at www.cqc.org.uk.

At our previous inspection in February 2016, we rated the practice as Requires Improvement for providing safe, effective and well-led services. At this time included amongst the issues we identified, was the practice could not provide sufficient evidence that regular clinical audits were being conducted, a programme of regular in-house infection control audits had not been established and the practice did not have oxygen at its premises.

This inspection was an announced focused inspection carried out on 8 May 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 17 February 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. At this inspection, we found that the practice had made improvements to provide safe, effective and well-led services. As a result of these findings, the practice is now rated as Good for providing safe and well-led services, and requires improvement for effective.

The change in the ratings for safe and well-led, means that the practice is now rated as Good overall.

Our key findings were as follows:

  • The practice had devised a written Business Continuity Plan and had reviewed and updated practice guidance and procedures within the last 12 months.
  • The practice had access to oxygen, which could be used in the event of a medical emergency at the practice.
  • A programme of clinical audits and re-audits had been introduced at the practice to monitor and improve patient outcomes.
  • We saw evidence that on the day of inspection all but one member of staff had received a performance review in the last 12 months. Subsequent to the inspection, we received confirmation that the remaining member of staff had received an appraisal.
  • The practice conducted regular fire drills. All staff members had been trained in what to do in the event of a fire.
  • We saw evidence that electrical equipment at the practice had been Portable Appliance Tested (PAT) during the past 12 months.
  • Staff were informed of the strategy and vision of the practice devised by the GP Partners

The areas where the practice must make improvements are:-

  • Ensure that a clear record of patient health concerns, diagnosis and treatment following consultation are included on patient’s notes/treatment plan.

The areas where the practice should make improvements are:-

  • Continue to review arrangements to enable patients access to a female GP

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17th of February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

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

  • Although staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses, reviews and investigations were not thorough enough to learn lessons from incidents and prevent them from happening again.
  • Data showed that some patient outcomes were below the local and national averages. Although some audits had been carried out, we saw no evidence that audits were driving improvement in performance to improve patient outcomes.
  • The majority of patients said they were treated with compassion, dignity and respect.
  • Urgent appointments were usually available on the day they were requested.
  • The practice had a number of policies and procedures to govern activity, but some important policies were not in place. For example, there was no evidence of a Business Continutity Plan in place.
  • The practice had proactively sought feedback from patients and had an active patient participation group.
  • The practice had little evidence of effective processes for managing risks to patients. For example, the practice did not have oxygen on site and a risk assessment of not having oxygen had been conducted by the practice.

The areas where the provider must make improvements are:

  • Put in place a Business Continuity Plan with supporting arrangements.
  • Carry out regular clinical audits and re-audits to improve patient outcomes. In addition, a timetable for regular in-house infection control audits to be established
  • Ensure that the practice has access to a supply of oxygen in the event of a medical emergency at the practice.
  • Conduct regular fire drills and to appoint a designated lead with responsibility for fire evacuations, and that Portable Appliance Testing (PAT) of all electrical appliances used at the practice is conducted periodically.
  • Ensure that all reviews undertaken are documented and that outcomes identified as a result of review are shared with all practice staff in a timely manner.
  • Ensure that all staff have regular performance reviews.

In addition the provider should:

  • Review arrangements to enable patient access to a female GP

  • Review and update procedures and guidance in accordance with best practice and current regulation.

  • Inform all staff of the vision and strategy for the practice devised by the GP partners.

  •  Review practice strategy for identifying and supporting patients who are carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

28 May 2014

During a routine inspection

Trinity Avenue Doctors Surgery is a small general practice (GP) service located in the London Borough of Enfield. NHS Enfield Clinical Commissioning Group (CCG) is a membership organisation of 54 local GP practices, of which Trinity Avenue is one. Enfield CCG is responsible for commissioning health services for a population of around 310,000 people in Enfield.

Trinity Avenue provides patients with a primary care service. The practice is situated in two semi-detached houses on a residential street. The practice is registered with the Care Quality Commission (CQC) as a partnership with two GPs, one of whom is the practice’s registered manager.

All the patients we spoke with were complimentary about the service they received. We received twenty three comments cards completed by patients prior to our visit. The responses demonstrated patients were consistently pleased with the service they received.

The regulated activities carried out by the practice were diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury. We found the practice provided a safe service. Mechanisms were in place to report and record safety incidents, concerns, near misses and allegations of abuse. However patients were exposed to some risk because the process for checking medication was not sufficient. We have asked the practice to take action to address this.

The service was effective at planning care and treatment and meeting patient’s needs. Patients said the practice provided a caring service. We saw good interactions between patients and staff and patient’s privacy and confidentiality were protected. Services were organised so as to meet patient’s needs.

The service was well led. There were clear lines of accountability and the leadership culture was open and supportive. Improvements could be made by practice ensuring staff were able to articulate the values and ethos of the practice. The patient participation group was highly motivated and involved however they could be used more effectively.

The service met the needs of groups such as older people, people with long term conditions, mothers, babies, children and young people, the working age populations and those recently retired. Services for those patients experiencing poor mental health could be improved. Processes were in place to ensure people with long term conditions were supported to manage their conditions and received regular health reviews. All practice staff worked together as a team to provide patients with an effective and good quality service. Patients we spoke with and comment cards we received showed patients were happy with the quality of care and treatment they had received. There was good access to appointments with patients telling us they were always able to get appointments at times that suited them.