The Care Quality Commission
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  • GP practice

Archived: Yeading Medical Centre

Overall: Good read more about inspection ratings

18 Hughenden Gardens, Northolt, Middlesex, UB5 6LD (020) 8845 3434

Provided and run by:
Yeading Medical Centre

Important: The provider of this service changed. See new profile

All Inspections

9 June 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at Yeading Medical Centre from 6-9 June 2023. Overall, the practice is rated as good.

Safe - Good

Effective - Good

Caring - Not inspected, rating of good carried forward from previous inspection

Responsive - Good

Well-led - Good

Following our previous rated inspection in March 2022, the practice was rated requires improvement overall. It was rated requires improvement for providing safe, effective and well-led services. The practice was rated good for providing caring and responsive services at an earlier inspection in December 2016.

At the inspection in March 2022, we found shortcomings in the management of risk. For example, patients prescribed certain medicines were not always monitored appropriately; patient safety alerts were not being implemented and the management of some long-term conditions was inconsistent. We also found that ‘Do not attempt cardiopulmonary resuscitation’ records were not always complete or easy to follow. The practice had experienced management instability which had a negative impact on the wider team.

Why we carried out this inspection

This inspection was a focused inspection to follow up on previous breaches in regulations. At this inspection, we covered the following key questions:

  • Are services safe?
  • Are services effective?
  • Are services responsive?
  • Are services well-led?

How we carried out the inspection/review

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

  • 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 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. However, the practice was underperforming on childhood immunisation targets and there remained scope to further improve its management of asthma and hypothyroidism.
  • Patients could access care and treatment in a timely way. The practice prioritised patients with more urgent needs. Feedback about getting through to the practice by telephone was lower than average. The practice had adjusted its appointment system in response to patient feedback.
  • The way the practice was led promoted the delivery of high-quality, person-centre care.
  • The practice had taken action to address the issues identified at the previous inspection.

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

  • Take action to ensure that all patients with asthma and hypothyroidism are followed up in line with guidelines and chronic kidney disease is coded correctly on the practice system.
  • Take action to improve performance in relation to childhood immunisation targets.
  • Continue to build effective working relationships with local stakeholders.
  • Monitor telephone access to the practice.

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 Health Care

10 March 2022

During an inspection looking at part of the service

We carried out an announced inspection at Yeading Medical Centre on 15 March 2022. Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective - Requires Improvement

Well-led - Requires Improvement

Following our previous inspection on 24 February 2017, 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 Yeading Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to follow up on:

  • Specific concerns or risks

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 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 Requires Improvement overall

We found that:

  • Patients on high risk medications were not always monitored appropriately.
  • The practice did not have an effective system to implement patient safety alerts. Some patients who had long term diseases had not received their blood tests and reviews in a timely manner.
  • Records of DNACPR were not always complete, contemporaneous or easy to follow. In some cases appropriate DNACPR documentation forms were not present, and patients had not had a review of their DNACPR within the last 12 months.
  • There was not yet an established leadership team in place.
  • Governance around patient safety alerts was not robust.
  • Quality improvement measures were not properly in place nor embedded into everyday practice.
  • There was not effective oversight of risks, such as management of patients on high-risk medicines.

We found a breach of regulations. 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:

  • Appropriately review and monitor patients with long term conditions or DNACPRs.
  • Keep clear and up to date records, particularly for patients with long term conditions or DNACPRs.
  • Continue efforts to increase uptake of childhood immunisations and screening tests.

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

08 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Yeading Medical Centre on 08 December 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.
  • Risks to patients were assessed and well managed.
  • 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 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.
  • 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.
  • 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.
  • The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

  • Should continue to review and improve areas where the practice have scored below average from the national GP survey results published in July 2016.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice