The Care Quality Commission
  • Doctor
  • GP practice

Winchmore Surgery

Overall: Good read more about inspection ratings

808 Green Lanes, Winchmore Hill, London, N21 2SA (020) 8350 5000

Provided and run by:
Winchmore Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Winchmore Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Winchmore Surgery, you can give feedback on this service.

28 September 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Winchmore Surgery on 28 September 2022, with the remote clinical interview on 26 September 2022. Overall, the practice is rated as good, with the following ratings for each key question:

Safe – Good

Effective – Good

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

Responsive – Not inspected, rating of good carried forward from previous inspection

Well-led – Good

Following our previous inspection on 18 May 2021, the practice was rated as requires improvement overall. We rated the practice as requires improvement for the safe and well-led key questions and good for the effective, caring and responsive key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Winchmore Surgery 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 regulation from our previous inspection in May 2021.

This inspection was a focused inspection focusing on whether:

  • Care and treatment was being provided in a safe way to patients.
  • There were effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.

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.
  • Information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall.

We have rated this practice as Good for providing safe, effective and well-led services because:

  • The practice had clear systems, practices and processes to keep people safe from abuse.
  • The practice had addressed all concerns identified in our previous inspection in May 2021 in relation to the monitoring of high-risk medicines and now had a process in place to effectively monitor patients prescribed these medicines.
  • The practice now had an effective system in place to implement patient safety alerts and to check that staff had read and understood alerts.
  • The premises were well managed and there were effective systems for managing staff and training records.
  • Emergency medicines and equipment on site were organised, in date and effectively managed.
  • The practice had processes to ensure that patients with long-term conditions were managed and monitored appropriately.
  • The practice’s uptake for cervical screening remained below the 80% coverage target for the national screening programme, however the practice had put in place systems to address barriers to the uptake of screening.
  • The practice had not met the minimum 90% uptake for one of the childhood immunisation indicators. The practice had met the WHO based national target of 95% (the recommended standard for achieving herd immunity) in two of the childhood indicators, was close to meeting this target in two other indicators, and was below 90% in one of the indicators. The practice had put in place systems to address barriers to the uptake of childhood immunisations.
  • The practice had worked towards providing effective care for patients during the Covid-19 pandemic.
  • The practice had made improvements in providing well-led services in relation to good governance. It had implemented systems and processes in response to the findings of our previous inspection.
  • The practice strongly encouraged personal and professional development and learning amongst staff and was supportive in staff undertaking appropriate learning for their roles and in their future aspirations.
  • The practice had a strong focus on the well-being of its staff and encouraged feedback from staff, which it acted upon. Staff members spoke positively about their employment at the practice and felt supported.
  • We received feedback from the Patient Participation Group (PPG) that the practice was responsive in listening to patients. We received feedback from a care home that used the services of the practice who told us that the practice provided a good service.
  • The practice was working on initiatives to reduce its carbon footprint and become a more environmentally friendly service.

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

  • Take steps to summarise all medical records within four weeks of arriving on site, in accordance with practice policy.
  • Continue to review and monitor patients with long-term conditions, including respiratory conditions and issue steroid warning cards where appropriate.

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

18 May 2021

During an inspection looking at part of the service

We carried out an announced comprehensive inspection at Winchmore Surgery on 18 May 2021, and a remote clinical review on 12 May 2021 to follow up on breaches of regulations. Overall the practice is rated Requires Improvement, with the following ratings for each key question:

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive – Good

Well-led - Requires Improvement

Why we carried out this inspection

This inspection was a comprehensive follow-up inspection to follow up on:

  • Breaches of regulation found at our last inspection; and,
  • Action the practice had taken in regard to areas where it should make improvements.

The practice was previously inspected on 28 November 2019. Following that inspection, the practice was rated Requires Improvement overall (and for the key questions including: Safe, Effective, Responsive and Well-led and Good for providing a Caring service) for issues relating to medicines management, Safety alerts, Fire drills, patient follow-up, prescription management, staff training, maintaining staff records, safe premises, Medication reviews, quality outcomes for childhood immunisations, patients with diabetes and hypertension, booking appointments and telephone access. It was also rated as requires improvement for population groups: People with long-term conditions; and Working age people (including those recently retired and students). It was rated good for all other population groups.

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

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 rated the practice as Requires Improvement for providing safe services because:

  • The practice was not recording evidence on patients records of regular blood test monitoring for all patients being prescribed the high-risk medicines: methotrexate, azathioprine and lithium.
  • When issuing prescriptions for methotrexate the practice did not indicate the day of the week patients should take the medicine, contrary to a medicine’s safety alert.
  • Medical alerts and minutes of meetings were distributed to all relevant staff, and copies of alerts were added to the shared computer files so all were able to access them. However, there was no requirement for staff to confirm they had received and read medical alerts or meeting minutes.

We rated the practice as Good for providing effective services because:

  • The practice had implemented an effective system to ensure regular medicines and health reviews were undertaken for elderly patients and patients with gestational diabetes.
  • Child immunisation uptake rates remained below the World Health Organisation (WHO) targets; however, the practice had significantly improved its performance.

We rated the practice as Good for providing caring services because:

Staff dealt with patients with kindness and respect and involved them in decisions about their care.

The practice carried out its own patient surveys to gain patient feedback.

  • During the Covid-19 Pandemic:
  • the practice was a vaccination’s hub for its own and other local practices’ patients. It had conducted a survey of patient’s experiences of attending the practice and found: 100% (165 out of 165 patients) responded positively about their overall experience of attending the practice.
  • it had delivered in excess of 35,000 vaccinations to patients. It had achieved a 0% wastage, with every vaccine dose it received being used in the vaccination of a person attending for vaccination.
  • During the 2020-2021 flu season the practice administered vaccinations to its patients. It had also conducted a survey and found: 97% (63 out of 65 patients) responded positively about their overall experience of attending the practice.

We rated the practice as Good for providing responsive services because:

  • The practices’ own survey and the 2021 GP Patient Survey found significantly higher levels of patient satisfaction than at the time of our previous inspection.

We rated the practice as Requires Improvement for being well-led because:

  • The practice had revised its policies and procedures. However, it did not always have clear and effective processes for ensuring safe care and treatment and managing risks, issues and performance. In particular, the practice procedures for distribution of medical alerts and minutes of meetings did not ensure all clinicians were made aware of these.
  • Patient notes did not record up to date blood test monitoring for all patients being prescribed high-risk medicines.

We have rated this practice as Requires Improvement overall and Good for all population groups except for People with long-term conditions which we have rated as Requires Improvement.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Consider recording whether do not attempt cardiopulmonary resuscitation (DNACPR) records are either subject to a review date, or state that the decision was indefinite.
  • Continue to work to improve uptake by eligible patients of childhood immunisations and cervical screening.
  • Work to improve its performance for its cervical screening programme.

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

28 November 2019

During a routine inspection

We carried out an announced comprehensive inspection at Winchmore Surgery on 28 November 2019 following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection. The practice was previously rated in September 2017 and rated as good in all domains and population groups.

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 rated the practice as requires improvement for providing safe services because:

  • Two safety medication alerts had not been actioned.
  • The practice did not follow best practice guidelines with regards to vaccination storage.
  • The practice did not offer immunisations or hold a record of immunisation status for non-clinical staff members.
  • Fire drills had not been regularly carried out and fire marshals had not received appropriate training.
  • All patients were not followed up after being referred into the two-week wait (TWW) cancer referral system.
  • Comprehensive health and safety risk assessments had not been carried out.
  • The serial numbers of blank prescription pads given to specific prescribers were not recorded.

We rated the practice as requires improvement for providing effective services because:

  • The practice’s QOF performance was lower than local and national averages for the long-term conditions’ indicators relating to diabetes and hypertension.
  • Child immunisation uptake rates were significantly below the World Health Organisation (WHO) targets.
  • We were not satisfied that the practice had an effective system in place to ensure regular medicines and health reviews were undertaken for elderly patients and patients with gestational diabetes.
  • We were not satisfied the practice had an effective system for sharing and cascading clinical learning amongst relevant staff.

We rated the practice as requires improvement for providing responsive services because:

  • Since the last inspection in September 2017 there was continuing concerns and patient dissatisfaction regarding; timely access to the practice via telephone; experience of making an appointment; and the appointment times offered.

We rated the practice as requires improvement for providing well-led services because:

  • The overall governance arrangements required improvement.
  • The practice did not always have clear and effective processes for managing risks, issues and performance.
  • The practice did not always act on appropriate and accurate information.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

For the responsive domain, we rated all the population groups as requires improvement as we identified continuing concerns regarding timely access to the service which affected all patients.

For the effective domain, we rated working age people; people whose circumstances may make them vulnerable; and people experiencing poor mental health as good. We rated older people as requires improvement because medication reviews for all older patients had not been carried out. We rated people with long-term conditions as requires improvement because performance indicators for diabetes and hypertension were below national and local averages. We rated families, children and young people as requires improvement because performance in the uptake of childhood immunisations were below the World Health Organisation targets.

The above ratings of the population groups across the effective and responsive domains resulted in all the population groups being rated as overall requires improvement.

The areas where the provider must make improvements are:

  • Ensure that care and treatment is provided in a safe way (Please see the specific details on action required at the end of this report).
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • Review how they will respond to and meet the needs of patients who request to see a male clinician
  • Continue with efforts to improve the up-take of cervical screening.
  • Continue with efforts to improve the uptake for the childhood immunisation programme.

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

27 September 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

This inspection was an unannounced focused inspection undertaken on 27 September 2017. The inspection was carried out in response to concerns arising from information received by the Commission. This information included concerns around the management of patient related correspondence as well as concerns around how significant events were identified, recorded and investigated. There were also concerns around the number of GPs employed at the practice, patient access to GP appointments and other services and concerns that staff morale had been adversely affected by recent changes at the practice and was impacting on patient care.

This report covers our findings in relation to those concerns.

Overall the practice is still rated as good.

Our key findings were as follows:

  • There were systems in place to ensure that patient correspondence was managed in a timely manner.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Although a number of experienced GPs had left the practice in recent years, these were mostly due to planned retirements and the practice had been able to recruit salaried GPs who had trained at the practice to these vacancies.
  • Results from the national GP patient survey published in July 2017 showed that patient’s satisfaction with how they could access care and treatment was comparable to local and national averages.
  • Appointments were available on the day of the inspection and staff we spoke with told us that access to appointments was a strength of the practice.
  • The practice offered extended hours on a Monday and Wednesday evening until 8.00pm for working patients who could not attend during normal opening hours.
  • The practice had a mission statement which was displayed in the waiting areas and staff knew and understood the values.
  • The practice had a clear strategy and supporting business plans which reflected the vision and values and were regularly monitored.
  • There was an open culture within the practice but not all staff we spoke with felt that their views were taken into account.
  • Practice meetings were divided into clinical and non-clinical staff, some staff we spoke with told us the absence of whole practice meetings meant communications between clinical and non-clinical staff were not always effective.

However, there were also areas of practice where the provider should make improvements.

  • Consider taking steps to improve communication between practice management and staff as well as between clinical staff and non-clinical staff.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

22 February 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Winchmore Surgery on 11 November 2015. The overall rating for the practice was good with safe rated as requires improvement. The full comprehensive report on the inspection can be found by selecting the ‘all reports’ link for Winchmore Surgery our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 22 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach in regulations that we identified in our previous inspection on 11 November 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as good.

Our key findings were as follows:

  • All relevant staff had undertaken basic life support training to the appropriate level in accordance with UK Resuscitation Council guidelines

  • All emergency equipment had been regularly tested to ensure it was in good working order.

  • Checklists and cleaning schedules for the practice had been reviewed and followed NHS guidelines.

  • Written references for recruitment of all staff are were in place.

  • Staff annual appraisal had been undertaken.

  • Complaints were acknowledged in accordance with the timescales outlined in the practice's complaints policies and procedures.

  • Patients wanting to access their preferred GP could book in person, online and via telephone. In addition, patients could leave messages for their GP’s and call backs were arranged.

At our previous inspection on 11 November 2015, we rated the practice as requires improvement for providing safe services as not all staff had undertaken basic life support training. At this inspection we found all relevant staff had undertaken annual basic life support training to the appropriate level. Consequently, the practice is rated as good for providing safe services.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

11 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Winchmore Surgery on 11 November 2015. 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 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.
  • Patients said they found it easy to make an appointment; 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.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Ensure that all staff undertake basic life support training to the appropriate level in accordance with UK Resuscitation Council guidelines.

In addition the provider should:

  • Ensure that all emergency equipment is regularly tested to ensure it is in good working order.

  • Ensure that the practice follows NHS guidelines in relation to infection control.Specifically, checklists and cleaning schedules for each area of the practice; highlighting frequency, how and what to be cleaned and with what equipment.

  • Obtain written references for recruitment of all staff.

  • Ensure that all staff receive an annual appraisal.

  • Ensure that all complaints are acknowledged in accordance with the timescales outlined in the practice's complaints policies and procedures.

  • Look at ways to improve access for patients wanting to see their preferred GP

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