The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Sirisena & Partners

Overall: Good read more about inspection ratings

Medical Centre, 156 Deans Lane, Edgware, Middlesex, HA8 9NT (020) 8906 3337

Provided and run by:
Dr Sirisena & Partners

All Inspections

15 June 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out a focussed, desk based review inspection at Dr Sirisena and Partners on 15 June 2017. We found the practice to be good for providing safe and effective services and it is rated as good overall.

We previously conducted an announced comprehensive inspection of the practice on 8 November 2016. As a result of our findings, the practice was rated as requires improvement for providing safe and effective services and rated as good for providing responsive, caring and well led services, which resulted in an overall rating of requires improvement. At that time, we found that the provider had breached Regulation 12 (1) (Safe care and treatment) and Regulation 18 (Staffing) of the Health and Social Care Act 2008, due to the absence of pre-employment checks and recent basic life support training for one of the practice’s two locum GPs. In addition, we did not see evidence that completed, two cycle clinical audits were being used to drive quality improvement.

The practice wrote to us to tell us what they would do to make improvements and meet the legal requirements. We undertook this focussed desk based inspection to check that the practice had followed their plan, and to confirm that they had met the legal requirements.

This report only covers our findings in relation to those areas where requirements had not been met. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Dr Sirisena and Partners on our website at www.cqc.org.uk/location/ 1-551197997.

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

  • The practice had taken action to ensure that there were appropriate pre-employment checks on file for locum GPs and that annual basic life support training had taken place.

  • The practice was using clinical audit to improve patient outcomes and drive quality improvement activity.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

8 November 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Sirisena & Partners (also known as Deans Lane Medical Centre) on 8 November 2016. Overall the practice is rated as requires improvement.

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.
  • Risks to patients were assessed and well managed with the exception of locum GP pre-employment checks.
  • Clinical audit was not being used to drive quality improvement.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

  • Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect.

  • People were treated compassionately when they complained and we noted that complaints were investigated in an open, transparent and timely manner. However, we did not see evidence of how learning from complaints was used to improve quality of care.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • 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 must make improvement are:

  • Ensure recruitment arrangements include all necessary locum GP pre-employment checks.
  • Take action to ensure that the locum GP update their annual basic life support training which had lapsed by six months at the time of our inspection.

The areas where the provider should make improvement are:

  • Carry out clinical audits and re-audits to improve patient outcomes.

  • Ensure that a second thermometer is installed or undertake monthly checks of the existing thermometer to ensure that it is accurate.

  • Ensure that emergency medicines are stored in a location which is readily accessible.

  • Consider introducing systems to ensure that learning from complaints is formally shared amongst staff and used to improve the service.

We inspected this location in September 2015 and rated it as good for providing effective, caring, responsive and well led services; and good overall. The practice was rated as requires improvement for providing safe services because we identified concerns regarding infection control and the process for recording fridge temperatures. At this inspect, we noted that these concerns had been addressed but other concerns were identified.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

15 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Sirisena & Partners on 15 September 2015. Overall the practice is rated as Good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned with the exception of training in infection control.
  • 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.
  • 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 well equipped to treat patients and meet their needs.
  • 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.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must:

  • Ensure safe systems are in place for the management of medicines. The appropriate action must be taken to ensure the fridge temperature is independently calibrated every month against the independently powered external thermometer and review the recording of temperatures.

  • Assess the risks associated with not having an automated external defibrillator (AED) (a portable electronic device that automatically diagnoses the life-threatening cardiac arrhythmias of ventricular fibrillation and ventricular tachycardia in a patient).

Importantly the provider should:

  • Ensure regular clinical and multi-disciplinary meetings with other service providers to plan care for patients are held.

  • Ensure monitoring systems are in place to ensure all clinical staff have read and understood NICE guidelines.

  • Ensure a fire risk assessment is in place.

  • Ensure an action plan is implemented to address the practice in house patient survey results.

  • Ensure there is a register of all patients who are identified as carers.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice