• Doctor
  • GP practice

Northfields Surgery

Overall: Good read more about inspection ratings

61 Northfield Avenue, Ealing, London, W13 9QP (020) 8567 1612

Provided and run by:
Northfields Surgery

All Inspections

During an assessment under our new approach

Date of Assessment: Remote clinical searches date was 16/07/2025 and the site visit date was 17/07/2025.

This assessment was carried out due to inherent risk as the provider was rated requires improvement at the last assessment in December 2021.

At the last assessment the provider was found to be in breach of regulations relating to fit and proper persons employed and good governance. The provider was issued requirement notices for the breaches identified.

Dr D Cowen Partners is a GP practice and delivers service to 8,600 patients under a GMS contract held with NHS England. The National General Practice Profiles states that the ethnicity of the practice population is 69% White, 13% Asian, 6% Black, 6% Mixed and 6% Other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the ninth decile (9 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.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interests where they did not have capacity.

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.

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.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.

Since the last inspection, the practice had made improvements and is no longer in breach of regulations relating to fit and proper persons employed and good governance.

7, 8 and 9 December 2021

During a routine inspection

We carried out an announced inspection at Dr D Cowen & Partners (Northfields Surgery) on 7, 8 and 9 December 2021. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Requires improvement

Well-led - Requires improvement

Following our previous inspection on 9 February 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 Dr D Cowen & Partners (Northfields Surgery) on our website at www.cqc.org.uk.

Why we carried out this inspection

This was a comprehensive inspection. 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. 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 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 found that:

  • There was a lack of good governance in some areas.
  • Recruitment checks including Disclosure and Barring Service (DBS) were not always carried out in accordance with regulations or records were not kept in staff files.
  • The practice did not have any formal monitoring system in place to assure themselves that blank prescription forms were recorded correctly, and their use was monitored in line with national guidance.
  • Risks to patients were not assessed and well managed in relation to some safety alerts and the monitoring of the prescription box for uncollected prescriptions.
  • Some staff had not received safeguarding adults, infection control, basic life support, legionella, sepsis awareness, equality & diversity, chaperone and fire safety training relevant to their role.
  • People were not able to access the telephone system in a timely manner.
  • Complaints were not responded to in writing and the register was not maintained appropriately.
  • Policies and procedures were not always updated or followed appropriately.
  • 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.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • The Care Quality Commission (CQC) rating poster was not displayed on the premises.

We found two breaches of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

  • Continue to monitor, encourage and improve cervical cancer screening and childhood immunisation uptake.
  • Take steps to collect patient feedback and review Patient Participation Group (PPG) feedback.
  • Document when significant events have occurred.
  • Take necessary steps to ensure staff are clear about their responsibilities to report cases of Female Genital Mutilation (FGM).

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

9 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Cowen & Partners (also known as Northfields Surgery) on 9 February 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.
  • Most risks to patients and staff were assessed and well managed however there were some areas that necessitated review.
  • 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 felt the practice offered an excellent service and staff were helpful, caring, professional and kind and treated them with dignity and respect.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was equipped to treat patients and meet their needs. Due to building constraints there was no dedicated toilet for disabled patients however the general toilet had been adapted to address this.
  • 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:

  • Ensure a mercury spill kit is available to deal with any spillage from the mercury gauge blood pressure monitor kept at the practice.

  • Ensure that regular fire drills are carried out.

  • Review the arrangements in place for the disposal of cytotoxic waste.

  • Review the frequency of infection control audits carried out to ensure they comply with recommended guidance.

  • Ensure that water temperature checks are carried out to reduce the risk of legionella.

  • Review the arrangements in place for the storage of emergency medicines and equipment to ensure timely access and security of all emergency medicines.

  • Advertise the availability of translation services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice