We carried out an announced comprehensive inspection at Enderley Road Medical Centre on 20 July 2017. The overall rating for the practice was good. The practice was rated as requires improvement for providing safe services as the practice had not taken action on a number of areas related to safety within the practice environment. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Enderley Road Medical Centre on our website at www.cqc.org.uk.
This inspection was an announced comprehensive inspection carried out on 18 September 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 20 July 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
The practice is now rated as good for providing safe services. Overall the practice remains rated as good.
The key questions at this inspection are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
At this inspection we found:
- Since our last inspection the practice had taken action to improve safety of the environment and for patients and staff. There were clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Some patients reported difficulty accessing the practice by telephone. The practice had reviewed this feedback and were taking action to improve telephone access. Other feedback from patients relating to their experience during consultations was positive.
- There was a strong focus on continuous learning and improvement at all levels of the organisation.
We saw an area of outstanding practice:
- Unverified practice data showed the practice’s catchment area of patients in Wealdstone was one of the highest sources of new referrals to children’s services. The practice proactively contacted social services every two weeks to receive an update on patients on the safeguarding register. We were told this was to ensure safety given the transient population.
The areas where the provider should make improvements are:
- Review and improve the system for documenting staff annual appraisals.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.