• Doctor
  • GP practice

Headstone Road Surgery

Overall: Good read more about inspection ratings

107 Headstone Road, Harrow, Middlesex, HA1 1PG (020) 8863 8923

Provided and run by:
Headstone Road Surgery

Latest inspection summary

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Background to this inspection

Updated 12 November 2021

Headstone Road Surgery is located at 107 Headstone Road, Harrow, Middlesex, HA1 1PG. The provider rents the premises which comprise of a two-storey mid-terrace commercial property. There are no parking facilities onsite and limited parking in the area. The practice is located on a busy main road with good transport links by bus and train. The practice is part of a primary care network of ten other local practices.

The practice provides NHS services through a Personal Medical Services (PMS) contract to approximately 4,800 patients. The practice is part of NHS Harrow Clinical Commissioning Group (CCG) and has a deprivation score of 7 out 10 (1 being the most deprived). Headstone Road Surgery cares for a diverse population (with approximately 54% of its patients from Black and minority ethnic backgrounds).

The practice’s clinical team is led by two female GP partners (working five sessions each per week). A female practice nurse works at the practice (0.6 whole time equivalent) along with a female locum advanced nurse practitioner (0.3 whole time equivalent) and a male health care assistant (0.35 whole time equivalent). Two part time clinical pharmacists also work at the practice (combined 0.4 whole time equivalent). The clinical team are supported by a practice manager and five reception/administration staff.

The practice is registered with the Care Quality Commission to provide the following regulated activities:

  • Diagnostic and screening procedures
  • Treatment of disease, disorder or injury and
  • Maternity and midwifery services.

The practice’s opening hours are 8:30am to 6:30pm on weekdays with extended hours appointments operating between 6:30pm to 7:30pm on Wednesdays.

Patients can also book appointments to be seen at local hub centres between 6:30pm and 8:30pm on weekdays and 8:00am to 8:00pm at weekends.

Overall inspection


Updated 12 November 2021

We carried out an announced, focussed inspection at Headstone Road Surgery on 30 September 2021. Overall, the practice is rated as Good.

Ratings for each key question

Safe – Good

Effective -Good

Well-led – Good

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

Why we carried out this inspection

We had previously carried out an announced, comprehensive inspection at Headstone Road Surgery on 12 February 2019. At that time, the practice was rated as Good for providing caring and responsive services; and was rated as Requires Improvement for providing safe, effective and well led services. The practice was rated as Requires Improvement for all six population groups and was overall also rated as Requires Improvement.

We served Requirement Notices for breaches of Regulations 12 and 17 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

This inspection took place to confirm that the necessary actions had been taken to address the breach of regulation.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering 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 and Good for all population groups (except people with long term conditions which is rated as requires improvement).

We found that:

  • Action had been taken since our last inspection such that effective systems and processes were now in place to keep patients safe. These included fire safety and health and safety risk assessments, improved staff recruitment systems, improved Infection Prevention and Control systems; and improved systems for sharing learning when things went wrong.

  • Action had been taken since our last inspection, such that clinical audits and other quality improvement activity were now routinely being used to improve patient outcomes.

  • Action had been taken since our last inspection, such that governance arrangements now supported the delivery of patient centred care.

  • Action had been taken since our last inspection such that the practice now had processes in place for managing risks, issues and performance.

  • Leaders spoke positively about the practice’s patient centred approach and we noted the practice’s latest GP national survey results exceeded local and national averages on every indicator (including, for example, phone access, appointments access, helpfulness of reception staff and quality of clinical care received).

Whilst we found no breaches of regulations. The provider should:

  • Continue to improve systems for patient recall and patient monitoring.

  • Continue to develop patient safety alerts protocols.

  • Take action to implement a protocol to ensure that appropriate authorisations are in place prior to administering vaccines.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care