• Doctor
  • GP practice

Archived: Boundary House Surgery

Overall: Good read more about inspection ratings

Forest Primary Care, London, N9 7HD (020) 8344 3120

Provided and run by:
Boundary House Surgery

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

All Inspections

29 November 2018

During a routine inspection

We carried out an announced comprehensive inspection at Boundary House Surgery on 9 December 2015. The overall rating for the practice was requires improvement.

We carried out an announced follow-up inspection at Boundary House Surgery on 21 September 2016. The practice was rated as inadequate for providing safe, effective and well-led services and was rated inadequate overall and urgent enforcement action was taken to

suspend the provider of Boundary House Surgery from providing primary medical services under Section 31 of the Health and Social Care Act 2008 ("the Act”) for a period of six months to protect patients. The practice was also placed in special measures for a period of six months.

We carried out a further announced comprehensive inspection on 21 March 2017. The practice was rated as good for providing caring services, requires improvement for providing safe and responsive services but continued to be rated inadequate for providing effective and well-led services and was rated inadequate overall. The practice was issued with a requirement notice and remained in special measures as it had not made sufficient improvements to achieve compliance with the regulations.

We carried out a further announced comprehensive inspection on 29 November 2017 following the extended period of special measures to confirm 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 21 March 2017. The practice was rated requires improvement overall and for providing effective and responsive services but was not in breach of regulations. Although we found improvements had been made, we were not assured the actions taken were sustainable. The practice was rated good for providing safe, caring and well-led services and taken out of special measures.

We carried out an announced comprehensive inspection at Boundary House Surgery on 29 November 2018 to confirm whether the improvements put in place at the time of the November 2017 inspection had been maintained.

The reports from the December 2015, September 2016, March 2017 and November 2017 inspections can be found by selecting the ‘Reports’ link for Boundary House Surgery on our website at http://www.cqc.org.uk/location/1-583321983.

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 good overall and good for all population groups.

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.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
  • The practice offered extended hours which included later appointments on Tuesday and Wednesday evenings.
  • The practice was actively engaged with the local community and worked closely with the Patient Participation Group on projects to improve health outcomes and combat social isolation.

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

  • Continue to monitor patient satisfaction and consider taking further actions to bring about improvements so that practice performance is in line with national survey results.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

29 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Boundary House Surgery on 9 December 2015. The overall rating for the practice was requires improvement. Subsequent to this the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

We carried out an announced follow-up inspection at Boundary House Surgery on 21 September 2016. The practice was rated as inadequate for providing safe, effective and well-led services and was rated inadequate overall and urgent enforcement action was taken to suspend the provider of Boundary House Surgery from providing primary medical services under Section 31 of the Health and Social Care Act 2008 ("the Act”) for a period of six months to protect patients. The practice was also placed in special measures for a period of six months. Subsequent to this the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

We carried out a further announced comprehensive inspection on 21 March 2017. The practice was rated as good for providing caring services, requires improvement for providing safe and responsive services but continued to be rated inadequate for providing effective and well-led services and was rated inadequate overall. The practice was issued with a requirement notice and remained in special measures as it had not made sufficient improvements to achieve compliance with the regulations.

This inspection was an announced comprehensive inspection on 29 November 2017 and was undertaken following the extended period of special measures 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 21 March 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. Overall the practice is now rated as requires improvement.

The reports from the December 2015, September 2016 and March 2017 inspections can be found by selecting the ‘Reports’ link for Boundary House Surgery on our website at http://www.cqc.org.uk/location/1-583321983.

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Our key findings at the November 2017 inspection were as follows:

  • When we inspected in March 2017, we were told that the practice had initiated the process to add two new GP partners to the practice’s registration. At this inspection, we saw that this process had been completed in that a GP who had been a partner at the time of the previous inspection had resigned from the partnership and had been employed as a salaried GP at the practice.
  • Clinicians had a thorough knowledge and understanding of the patient management and document management systems.
  • The practice had commenced a programme of quality improvement initiatives and had carried out one completed audit cycle as well as undertaking three further single cycle audits.
  • There was a failsafe system in place to ensure that urgent referrals were received by secondary care providers and patients received and attended appointments. When patients did not attend appointments, the practice would contact them and encourage them to attend a re-arranged appointment.
  • Data showed patient outcomes had improved since the previous inspection in March 2017 and were now similar to the national average for most indicators.
  • Improvements which had been put in place with the support of a caretaker practice had been embedded in the practice and were understood and overseen by practice management.
  • When we inspected in March 2017, systems to manage clinical correspondence in a safe and timely manner were still relatively new and we were not assured that these would be sustainable when the support of the caretaker practice was withdrawn. At this inspection, we saw that these systems had been successfully maintained.
  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had undertaken a recent fire drill and had reviewed the exercise to identify and carry out learning actions.
  • The practice had engaged with commissioners to change the leadership structure to improve governance and bring about improvements to patient outcomes.
  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity although some patients said they had concerns about continuity of care by some clinicians.
  • The practice had continued to take action to reduce waiting times for appointments.
  • The practice business continuity plan had been reviewed to ensure it contained accurate information.

The areas where the provider should make improvement are:

  • Continue to assess and monitor the performance of the practice with a view to improving clinical outcomes for patients such as those with diabetes.
  • Continue to monitor patient satisfaction and consider taking further actions to bring about improvements so that practice performance is in line with national survey results.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by the service.


Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

21 March 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Boundary House Surgery on 9 December 2015. The overall rating for the practice was requires improvement. Subsequent to this the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

We carried out an announced follow-up inspection at Boundary House Surgery on 21 September 2016. The practice was rated as inadequate for providing safe, effective and well-led services and was rated inadequate overall and urgent enforcement action was taken to suspend the provider of Boundary House Surgery from providing primary medical services under Section 31 of the Health and Social Care Act 2008 ("the Act”) for a period of six months to protect patients. The practice was also placed in special measures for a period of six months. Subsequent to this the provider submitted an action plan detailing how it would make improvements and when the practice would be meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

A caretaker practice was put in place by NHS England to provide primary medical services to patients of the practice during the period of the suspension.

The full comprehensive report on the December 2015 and September 2016 inspections can be found by selecting the ‘all reports’ link for Boundary House Surgery on our website at www.cqc.org.uk.

This inspection was undertaken prior to the end of the six month suspension period whilst the practice remained in special measures on 21 March 2017. Overall the practice is still rated as inadequate.

Our key findings were as follows:

  • It was unclear whether concerns about the lead GP’s lack of knowledge of the patient record management system had been addressed as they had been unable to undertake training during their absence from the practice. Following the inspection, the lead GP told us they could use all systems at the practice but we did not see evidence to support this.

  • When we inspected in September 2016, we were told that difficulties recruiting permanent GPs had a significant impact on the lead GP’s capacity to manage the practice. Since the inspection, the practice had recruited two new GP partners to the practice and the process of adding these to the practice’s CQC registration was ongoing.

  • There was some evidence of recent clinical and non-clinical audit being carried out at the practice. However, there was no evidence that these had been used to bring about improvements.
  • Data showed patient outcomes for some conditions were low compared to the national average although current but unvalidated data indicated that these had recently begun to improve.
  • The practice had worked closely with a caretaker practice, the local clinical commissioning group and NHS England to improve leadership capacity and governance arrangements. However, as the lead GP had been absent from the practice since the September 2016 inspection, their contribution to improvement was limited. We were told the lead GP had had a role in developing the action plan produced in response to the September 2016 inspection report, but this action plan had been substantially realised and implemented by the caretaker practice and practice management. Following the inspection, the lead GP responded by telling us that they had been significantly involved in bringing about improvements at the practice but we did not see evidence of this during the inspection.

  • With the support of the caretaker practice, the practice had put effective systems in place to manage clinical correspondence in a safe and timely manner.

  • There was now an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice was actively engaging with commissioners to change the leadership structure to improve governance and bring about improvements to patient outcomes.

  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity although some patients said they had concerns about continuity of care by some clinicians.

  • The practice had taken action to reduce waiting times for appointments.

  • The practice had a number of policies and procedures to govern activity and had recently reviewed and updated these.

There were areas of practice where the provider needs to make improvements.

Importantly, the provider must:

  • Ensure that all clinicians have a thorough knowledge and understanding of the patient management and document management systems.
  • Ensure that the practice’s quality improvement programme includes effective audit arrangements that drive improvement across key clinical outcomes.

In addition the provider should:

  • Continue with plans to change the leadership structure at the practice to improve quality of service provision.

  • Continue to closely monitor systems used to review and act on clinical correspondence to ensure all correspondence is acted upon without delay and that decisions made about patient care are clearly documented in the clinical patient’s notes.
  • Continue to closely monitor systems used to refer patients to secondary care to ensure that these are fully embedded into practice procedures.
  • Continue to ensure management arrangements for overseeing performance (for example QOF) in the practice are robust and that actions are recorded, planned, implemented and reviewed.
  • Make arrangements to carry out regular fire drills.
  • Review patient access and availability of appointments to better meet the needs of patients.
  • Continue to take action to reduce the length of patient waiting times for GP consultation.

  • Review the practice business continuity plan to ensure that information is up to date.

This service was placed in special measures in February 2017. Insufficient improvements have been made such that there remains a rating of inadequate for providing effective services and well-led services. The service will remain in special measures, be kept under review and if needed could be escalated to urgent enforcement action. Another inspection will be conducted within six months, and if there is not enough improvement we will move to take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

Professor Steve Field CBE FRCP FFPH FRCG 

Chief Inspector of General Practice

21 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Boundary House Surgery on 21 September 2016. The inspection was a comprehensive follow up of an inspection on 9 December 2015 where the practice was rated inadequate for safe, requires improvement for effective and well led and good for caring and responsive. Overall the practice was rated requires improvement. At this inspection we found breaches of legal requirements and we issued an urgent suspension of the provider's registration for a period of six months to enable the provider to take action to improve while removing patients from the risk of harm. A caretaker practice has been identified to provide care and treatment to patients at the practice during this period. Overall, at this inspection the practice is rated as inadequate.

The report from our last comprehensive inspection can be found by selecting the 'all reports' link for Boundary House Surgery on our website at www.cqc.org.uk.

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

  • Patients were at significant risk of harm because systems and processes were not in place to keep them safe. Approximately 22000, items of clinical correspondence had not all been acted on dating back to 2012. These included abnormal test results and requests for changes in medicine; and information in relation to safeguarding cases.

  • Systems for reporting and recording significant events had been implemented. However, the process was not inclusive of all staff and we had concerns that the practice was under reporting incidents. For example, with regard to the practice’s known significant issues in managing clinical correspondence.

  • Data showed patient outcomes were low compared to the national average in key clinical areas such as Diabetes.

  • Data showed that although patients were satisfied with GP waiting times the length of time to see a GP was comparatively longer than the local and national average. Patients often waited more than 15 minutes to see a GP. An audit conducted by the practice showed that consultations with the lead GP routinely ran late.

  • The practice had a number of policies and procedures to govern activity, but some required further review to ensure they reflected practice arrangements and best practice. However, it was not clear which required review or what the arrangements were for reviewing policies in the light of changes made in the practice’s working processes.

  • The practice leadership had insufficient capacity and knowledge of governance systems. For example, the lead GP did not have a clear understanding of the practice’s performance (QOF) and had not developed plans to improve outcomes.

  • Although some audits had been carried out and were showing some improvement over time in outcomes for patients, there remained a need to further improve clinical recording practices and quality improvement systems to ensure that clinical audit continued to drive positive consistent change.

  • Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

The areas where the provider must make improvements are:

  • Ensure formal governance arrangements including systems for assessing and monitoring risks and systems and processes for assessing the quality of service provision are effective. For example, ensure all significant events are identified and ensure all staff participate, contribute and learn from events.
  • Record, review and share how changes have impacted on patient care and treatment. Demonstrate that effective audit arrangements lead to improvement across key clinical outcomes.
  • Ensure all policies and procedures reflect published best practice and locally agreed ways of working. For example, processes that support timely referrals.
  • Ensure that all clinicians and those supporting clinical work have a thorough knowledge and understanding of the patient management and document management systems. For example, how to code actions as a result of clinical decisions in order to clearly identify patients, how to access registers for children on a child protection plan and how to ensure clinical correspondence is reviewed and acted upon without unnecessary delay; that decisions made about patient care are clearly documented in the clinical patient’s notes.
  • Ensure management arrangements for overseeing performance (for example QOF) in the practice are effective and that actions are recorded, planned, implemented and reviewed by practice leads.
  • Develop a clear strategy for the practice that is supported by a set of business plans that drive forward improvements in the practice’ governance.

The areas where the provider should make improvement are:

  • Review storage arrangements for emergency equipment to ensure they are easily accessible should there be an emergency situation.

  • Review patient access and availability of appointments to better meet the needs of patients and to reduce the length of patient wait to see their GP.

  • Continue with plans to recruit more GP’s permanently to improve the quality of service provision.

  • Ensure that both verbal and written complaints are recorded as part of the practice’s complaints system.

  • Review arrangements for compliance with the Duty of Candour (the duty of candour is a set of specific legal requirements that providers of services must follow when things go wrong with care and treatment).

On 26 September 2016 we took urgent enforcement action to suspend the providers of Boundary House Surgery from providing primary medical services under Section 31 of the Health and Social Care Act 2008 ("the Act”) for a period of six months to protect patients. We will inspect the practice again prior to the end of the six month suspension. A caretaker practice has been put in place by NHS England to provide primary medical services to patients of the practice during this period.

I am also placing this practice in special measures. Practices placed in special measures will be inspected again within six months. If insufficient improvements have been made so a rating of inadequate remains for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

Special measures will give people who use the practice the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

9 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Boundary House Surgery on 9 December 2015. Overall the practice is rated as requires improvement.

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

  • Patients were at risk of harm because systems and processes were not in place to keep them safe. For example, those relating to recruitment checks, emergency equipment and quality assurance of record keeping.
  • Staff were not clear about reporting incidents, near misses and concerns and there was inconsistent evidence of learning and communication with staff.
  • Data showed patient outcomes were mixed for the locality. Although some clinical audits had been carried out, we saw no evidence that they were being used to drive improvement in performance to improve patient outcomes.
  • 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.

The practice had proactively sought feedback from patients and had an active patient participation group. The areas where the provider must make improvements are:

  • Ensure that all significant events are recorded and identified to the reduce the likelihood of risks occurring. Ensure that risks are continually monitored and appropriate action taken.

  • Ensure recruitment arrangements include all necessary employment checks for all staff. Specifically in regard to DBS checks.

  • Ensure emergency equipment is fit for use for both adults and children and is stored appropriately and easily accessible should there be an emergency situation.

  • Ensure all chaperones are trained appropriately and have undertaken a DBS check.

  • Ensure staff are appropriately trained in protecting vulnerable adults.

  • Ensure that their audit and governance systems remain effective. Ensure internal and clinical audits drive sustained improvement in patient outcomes.

In addition the provider should:

  • Ensure that care plans for the most high risk patients are shared with patients and their carers to assist in reducing admission to hospital where appropriate.
  • Ensure that changes to patient medicines is clearly recorded on all appropriate clinical systems to avoid the potential for risk of an error.
  • Improve the identification of carers.
  • Increase the level of identification of patient records through appropriate coding. For example those on the child protection register and those with long term conditions.

  • Review the availability of non-urgent appointments.

  • Ensure there is a record of clinical and governance meeting discussions so as to enable reflection on outcomes being achieved and to identity improvement areas.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice