Devonshire Lodge Practice

Updated 28 March 2023

Devonshire Lodge Practice is located in the Pinner area in West London at:

The Devonshire Lodge Health Centre

2a Abbotsbury Gardens, Eastcote

Pinner

Middlesex

HA5 1TG

We visited this location as part of this inspection activity.

The practice building is situated at the rear of a large public car park that can be used by patients. The practice is located on the ground floor in purpose-built premises and is shared with another GP practice and other services provided within the NHS. The practice is fully accessible.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, family planning and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the North West London Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of about 8,550. This is part of a contract held with NHS England.

The practice is part of the North Connect Primary Care Network (PCN).

Information published by Public Health England, rates the level of deprivation within the practice population group as ten, on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

According to the latest available data, the ethnic make-up of the practice area is 17% Asian, 76% White, 2% Black, 3% Mixed, and 2% Other.

The majority of the patients within the practice are of working age. Older people practice population is higher than the local and national averages.

There are three GP partners, three salaried GPs and two trainee GPs. Two GPs are female and six are male. The practice employs two practice nurses and a health care assistant. The partners are supported by a reception supervisor and a team of administrative and reception staff. A clinical pharmacist (employs by the primary care network) is offering six sessions per week at the practice. The practice is in the process of recruiting a new practice manager.

The practice is a training practice. There is one ST3 and one ST4 GPs at the practice currently.

Extended access is provided locally by the Hillingdon Confederation, where late evening and weekend appointments are available. Out of hours services are provided by Practice Plus.

Updated 28 March 2023

We carried out an announced focused inspection at Devonshire Lodge Practice on 09 and 10 January 2023. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question:

Safe - Requires improvement

Effective - Requires improvement

Caring - not inspected, rating of Good carried forward from the previous inspection.

Responsive - not inspected, rating of Good carried forward from the previous inspection.

Well-led - Requires improvement

Following our previous inspection in November 2021, the practice was rated requires improvement overall and for the key questions safe and well-led. The practice was rated good for providing effective, caring and responsive services.

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

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulations from a previous inspection.

This was a focused inspection. At this inspection we covered three key questions:

• Are services safe?
• Are services effective?
• Are services well-led?
• Breaches of regulations 17 and 19 and ‘shoulds’ identified in the previous inspection.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 found that:

• The practice demonstrated improvement in some areas, however, we found additional concerns and the practice was required to make further improvements.
• There was a lack of good governance in some areas.
• Our clinical records searches showed that the practice did not always have an effective process for monitoring patients’ health in relation to the use of medicines including high risk medicines and patients with long term conditions.
• The practice had a system in place to manage safety alerts but it did not always work effectively.
• We noted the monitoring of blank prescription forms was not working as intended and the blank prescription forms were not recorded correctly.
• Patient Group Directions (PGDs) were not signed by all the practice nurses.
• Some staff documents were not kept in staff files.
• Annual appraisals were carried out in a timely manner.
• Staff had received training relevant to their role.
• There was evidence of quality improvement activity. Clinical audits were carried out.
• The Patient Participation Group (PPG) was active.

We found two breaches of regulation. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

• Continue to encourage and monitor cervical cancer screening and childhood immunisation uptake rates.
• Consider the Patient Participation Group (PPG) feedback regarding improving access to the service.

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