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Jai Medical Centre (Brent) Good

Reports


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Jai Medical Centre (Brent) on 9 September 2021. 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 Jai Medical Centre (Brent), you can give feedback on this service.

Inspection carried out on 03 December 2020

During a routine inspection

We carried out an announced comprehensive inspection at Jai Medical Centre (Brent) on 1 October 2019. The overall rating for the practice was inadequate, it was placed into special measures and warning notices were issued. We carried out an announced follow up inspection on 13 March 2020 and found that the practice had made sufficient improvements and that the warning notices had been met.

The full comprehensive reports on the November 2019 and March 2020 inspections can be found by selecting the ‘all reports’ link for Jai Medical Centre (Brent) on our website at www.cqc.org.uk

We took account of the exceptional circumstances arising as a result of the COVID-19 pandemic when considering how we carried out this inspection. We therefore undertook some of the inspection process remotely and spent less time on site. We conducted medical record searches on 25 November 2020, remote staff interviews on 2 December 2020 and a site visit on 3 December 2020.

At this inspection we visited the Stag Lane site. 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 the older people, people with long term conditions, families, children and young people, vulnerable pople and people experiencing poor mental health (including dementia) population groups.

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.
  • 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.

We rated the working age population group as requires improvement due to the poor uptake for the cervical screening programme.

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

  • Continue to look at ways to improve uptake for the childhood immunisation and cervical screening programmes.
  • Ensure calcium testing is up to date.
  • Consider updating risk assessment templates to show target and completion dates for actions identified.

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

Inspection carried out on 13 March 2020

During an inspection looking at part of the service

We carried out an announced, focused inspection at Jai Medical Centre (Brent) on 13 March 2020. The purpose of the inspection was to follow up on breaches of regulations identified at our previous inspection on 1 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). The practice was required to address these breaches by 28 February 2020.

At this inspection, we visited the Sheldon surgery. 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.

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

Inspection carried out on 1 October 2019

During an inspection looking at part of the service

We carried out an announced focused inspection at Jai Medical Centre (Brent) on 1 October 2019 as part of our inspection programme. We decided to undertake an inspection of this service following our annual review of the information available to us. This inspection was planed to focus on the following key questions:

  • Is the service effective?
  • Is the service caring?
  • Is the service well-led?

During the inspection we decided to additionally include the following key question:

  • Is the service safe?

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.

  • During our inspection, we visited one surgery, the Sheldon practice. But our findings relate to both sites.

  • Because of the assurance received from our review of information we carried forward the rating for the following key question: Is the service responsive? The practice is rated as Good for this key question.

We have rated this practice as inadequate overall.

We rated the practice as

inadequate

for providing safe services because:

  • The practice did not have clear systems and processes to keep patients safe.
  • The practice did not have appropriate systems in place for the safe management of medicines.
  • The practice did not have effective systems in place to follow-up urgent referrals.
  • The practice did not have an effective system to learn and make improvements when things went wrong.

We rated the practice as

inadequate

for providing well-led services because:

  • While there were some governance systems in place these were not comprehensive
  • The practice had not identified clear gaps in governance and was not managing risks effectively.
  • Systems and processes for sharing learning were weak.

We rated the practice as

good

for providing effective and caring services because:

  • 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 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:

  • Review any further appropriate actions that could be taken to improve the cervical screening uptake rate and take action on related issues (such as read coding) which have already been identified

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

Inspection carried out on 13 July 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Stag Holyrood Surgery on 13 July 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.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • 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.
  • Most patients said they found it easy to make an appointment with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice was creative in its approach to removing the barriers to care faced by individual patients.
  • There was a clear leadership structure and staff felt supported by the partners, the lead GP and management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw one area of outstanding practice:

The practice had recently taken on a caretaking role for a nearby practice that had temporarily closed. However initially, the practice had been given no notice of the closure and was suddenly faced with patients from the closed practice arriving to consult with a doctor. The practice successfully set up a parallel reception, secured additional resources from its staff pool and started running the service the same day without cancelling patient appointments. 

The areas where the provider should make improvement are:

  • The practice should ensure its stock of emergency medicines is suitable to cover the needs of its patients, for example, including an injectable antibiotic.
  • The practice should put in place a written protocol for its use of patient specific directions (PSDs) and use PSDs more consistently to govern the administration of vaccines by the health care assistants.
  • The practice should increase the use of two-cycle audit to demonstrate that improvements to practice are well embedded and sustained.
  • The practice should consider ways to improve patient uptake of the national bowel cancer screening programme.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection carried out on 29 April 2014

During an inspection looking at part of the service

At a previous scheduled inspection that took place on 31 October 2013 we found shortfalls in relation to the provider's staff recruitment processes. In particular we found that references had not been obtained for all staff prior to them commencing work at the surgery. The provider sent us an action plan on 09 december 2013 explaining how the shortfalls would be addressed.

During this inspection we spoke with the practice manager and looked at records relating to the recruitment of staff. We found that appropriate staff recruitment checks had taken place and recruitment procedures had been updated to ensure that more robust checks were completed before new staff were employed at the surgery.

Staff were encouraged to participate in on going learning and development to ensure they had the skills to carry out their role effectively.

Inspection carried out on 31 October 2013

During a routine inspection

During this inspection, we spoke with five patients. They confirmed that they had been treated with respect and dignity and were satisfied with the services provided. One patient told us, "I am satisfied with my GP. They explain my treatment and have referred me to the hospital specialist when needed�. Another patient said, �I have been coming here for many years. They are pleasant and respectful. They talk nicely to me�.

Patients said they had no problems getting an appointment to see a doctor and rarely had to wait long before being seen. Records indicated that patients were carefully assessed and their care and treatment had been carefully monitored. Reviews of care and treatment with the GP took place and these were recorded.

The practice had a recruitment policy. However, some essential checks had not been carried out prior to new staff being employed. Staff had been provided with essential training and updates. They were aware of action to take when responding to allegations or incidents of abuse.

The practice had an effective system to regularly assess and monitor the quality of service that patients received. A recent patient survey indicated that people were generally satisfied with the quality of services provided. Two members of the patients� participation group indicated that the views of patients were noted in the way the practice was run.