30 August 2023
Dormers Wells Medical Centre is situated at 143 Burns Avenue, Southall, Ealing, UB1 2LU. The practice provides NHS primary care services through a General Medical Services (GMS) contract to approximately 7,000 people living in the North West London Integrated Care Board (ICB) which includes the London Borough of Ealing.
The practice population is ethnically diverse with a higher than average number of children of all ages and adults 44 years and below. The practice has a much lower than average number of older patients. The practice area is rated in the third most deprived decile of the Index of
Multiple Deprivation (IMD). People living in more deprived areas tend to have greater need for health services. The practice is registered with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures, maternity and midwifery services,
surgical procedures, family planning and treatment of disease, disorder or injury.
The practice team consists of a male GP partner, a female GP partner and a regular locum GP. The partners do 8 sessions and the locum 10 sessions per week. The practice also has a full time practice nurse, a health care assistant, a practice manager, a practice secretary and five reception staff.
The practice is open between 8am and 6.30pm Monday to Friday. It offers a range of appointment types including book on the day, telephone consultations and advance appointments. All initial requests for appointments go through the practice’s triage system where a clinician assesses and decides which patients are appropriate for a face to face appointment and which can be safely seen digitally or directed to other more appropriate services. The practice provides a range of services including childhood immunisations, joint injections, anticoagulation, long-term condition management, smoking cessation advice, cervical screening, spirometry, electrocardiogram, phlebotomy, wound care and pre-diabetic assessments.
The practice is part of a wider network of GP practices called North Southall primary care network (PCN) which consists of 10 GP practices.
Extended access is provided locally by the local GP hub where late evening and weekend appointments are available. Out of hours services are provided by the NHS 111 service.
30 August 2023
We carried out an announced comprehensive inspection at Dormers Wells Medical Centre on 21 June 2023 and 5 July 2023. Overall, the practice is rated as requires improvement.
Safe - requires improvement
Effective - requires improvement
Caring - good
Responsive - good
Well-led - good
Following our previous inspection on 23 January 2018 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 Dormers Wells Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities. We inspected all five key questions.
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.
- 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.
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 provider had some systems and process in place to provide safe care and protect patients. However these were not always followed in practice. In particular, regarding the management of safety alerts and management of some high risk medicines.
- The provider was aware of current guidance and standards for the care of patients diagnosed with a long term condition, however these guidelines were not always followed in practice.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Patients could access care and treatment in a timely way.
- The way the practice was led and managed mostly promoted the delivery of high-quality, person-centred care.
We found one breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
Whilst these were not breaches of the regulations, the provider should:
- Improve the identification of patients at risk of safeguarding concerns to include family members where appropriate.
- Improve the recording of fire drills to ensure sufficient detail and consistency.
- Take action to improve the results of the national GP patient survey and uptake of childhood immunisations and cervical screening.
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