The Care Quality Commission
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  • GP practice

Archived: The Ashchurch Medical Centre

Overall: Requires improvement read more about inspection ratings

134 Askew Road, Shepherds Bush, London, W12 9BP (020) 8735 3550

Provided and run by:
The Ashchurch Medical Centre

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

All Inspections

10 October 2018

During a routine inspection

This practice is rated as requires improvement overall.

The practice was previously inspected on 10 October 2017. At that inspection the rating for the practice was good overall. This rating applied to the safe, caring, responsive and well led domains. Effective was rated as requires improvement.

The 2017 report stated where the service must make improvements:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, there were areas identified where the provider should make improvement:

  • Review the storage arrangements of environment cleaning equipment and consider an independent external led Infection and prevention control review.
  • Consider installing an independent thermometer to confirm accuracy of the vaccine fridge temperature.
  • Implement a tracking system to monitor the use of blank prescription pads.
  • Continue to monitor and improve Quality and Outcomes Framework performance.
  • Continue to encourage the uptake of childhood immunisations.
  • Continue to encourage the uptake of the cervical screening programme to eligible women.

We carried out an announced comprehensive inspection at Ashchurch Medical Centre on 10 October 2018 to follow up on breaches of regulations.

At this inspection the key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires improvement

At this inspection we found:

  • The practice had 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. However, there was no system in place to ensure that all staff were aware of the learning outcomes.
  • 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.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way for patients.
  • Ensure that learning from incidents, safeguarding and complaints is shared with all staff within the team.

The areas where the provider should make improvements are:

  • Review staff training system to ensure staff are up-to-date with training requirements.
  • Continue to monitor prescription stationary to ensure they are maintained securely.
  • Provide all members of staff with a copy of team meeting minutes to ensure they are aware of developments within the service.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

10 October 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Ashchurch Medical Centre on 6 January 2016. The overall rating for the practice was requires improvement. The practice was rated requires improvement for providing safe, effective, caring, responsive and well-led services. This was specifically in relation to aspects of risk management, systems to improve the quality of care, multi-disciplinary team working, service provision, and patient satisfaction and engagement.

The full comprehensive report on the 6 January 2016 inspection can be found by selecting the ‘all reports’ link for The Ashchurch Medical Centre on our website at www.cqc.org.uk.

An announced comprehensive inspection was undertaken on 10 October 2017. The practice is rated as requires improvement for providing effective services and good for providing safe, caring, responsive and well-led services. Overall the practice is now rated as good.

Our key findings were as follows:

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had some defined and embedded systems to minimise risks to patient safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Data from the Quality and Outcomes Framework 2016/17 showed some patient outcomes were below average for the locality and compared to the national average.
  • There was evidence of quality improvement activity including clinical audit.
  • Patient satisfaction survey information we reviewed showed patients felt the practice offered a good service and staff were helpful, friendly, attentive and polite and treated them with dignity and respect.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with 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 accessible facilities and was equipped to treat patients and meet their needs.
  • There was a leadership structure and staff felt supported by management.
  • The practice proactively sought and analysed feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider must make improvement are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvement are:

  • Review the storage arrangements of environment cleaning equipment and consider an independent external led Infection and prevention control review.
  • Consider installing an independent thermometer to confirm accuracy of the vaccine fridge temperature.
  • Implement a tracking system to monitor the use of blank prescription pads.
  • Continue to monitor and improve   Quality and Outcomes Framework performance.
  • Continue to encourage the uptake of childhood immunisations.
  • Continue to encourage the uptake of the cervical screening programme to eligible women.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

6 January 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Aschurch Medical Centre on 6 January 2016. Overall the practice is rated as requires improvement.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, however there was no practice policy in place for the reporting of near misses, incidents and significant events; and reviews and investigations were not thorough enough.

  • The practice had not undertaken risk assessments for infection control, control of substances hazardous to health (COSHH), the lack of provision of a defibrillator and staff providing a chaperoning service for patients not having a Disclosure and Barring Service (DBS) check.

  • The provider was aware of and complied with the requirements of the Duty of Candour.
  • Data showed a number of patient outcomes were low compared to the locality and nationally.
  • Patients said they were treated with compassion, dignity and respect.
  • Urgent appointments were usually available on the day they were requested.
  • The practice had a number of policies and procedures to govern activity, but some key policies including safeguarding adults and significant events were absent.
  • The practice had not proactively sought feedback from patients and did not have a patient participation group.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.

The areas where the provider must make improvement are:

  • Ensure clear processes for the review and learning from near misses, incidents and significant events in order to promote continuous improvement and the health, safety and welfare of patients and staff.

  • Ensure risks are assessed and take action tomitigate risks associated with infection control, control of substances hazardous to health (COSHH) and the provision of a defibrillator.

  • Ensure a clear process and training for all staff in safeguarding adults.

The areas where the provider should make improvement are:

  • Develop multidisciplinary team meetings to engage with relevant health and social care professionals to deliver a multidisciplinary package of care for patients with complex needs.

  • Advertise the chaperoning service for patients within the treatment or consultation rooms.

  • Advertise the interpreting service within the practice to inform patients of this service.

  • Formulate action plans around patient feedback sought from all sources including the national GP survey, NHS Choices and the Friends and Family Test.

  • Consider improving communication with patients who have a hearing impairment.

  • Strengthen governance arrangements for practice meetings including standing agenda items and minuting of all meetings.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice