Background to this inspection
Updated
25 October 2021
Pearl Medical Practice is located in London at:
Pearl Medical Practice,
Wembley Centre for Health & Care,
Ground Floor, 116 Chaplin Road, HA0 4UZ
The practice operates on the ground floor of a purpose-built medical facility which was shared with other healthcare providers, including another GP practice. The practice has access to four clinical rooms and shared the reception and waiting area with a neighbouring GP practice.
The practice holds a General Medical Services (GMS) contract with NHS Brent Clinical Commissioning Group (CCG) and provides services to approximately 4,900 patients. The practice is registered as an individual with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures, treatment of disease, disorder or injury and maternity and midwifery services. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices, Harness North Primary Care Network (PCN).
Information published by Public Health England rates the level of deprivation within the practice population group as five on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest. Data shows that almost 79% of patients at the practice area were from Black and Minority Ethnic (BME) groups.
The practice has one shared reception area, a records area, one nurse clinical room, three GP clinical rooms and a practice office which houses a small kitchenette. There are two staff toilets and both male and female toilets as well as a baby changing area and a toilet for disabled people.
The practice team currently consists of female lead GP, a female salaried GP and a male salaried GP (totalling 16 clinical sessions per week), two long term locum GPs, a part-time practice nurse and part-time healthcare assistant. A pharmacist is allocated to the practice two sessions per week from the PCN. They clinical team are supported by a practice manager and four administration and reception staff.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered a choice of either the main GP location or the local GP Hub, Wembley Centre for Health and Care.
Extended access is provided locally by the local GP Hubs, where late evening and weekend appointments are available. Out of hours services are provided by 111.
Updated
25 October 2021
We carried out an announced focused inspection at Pearl Medical Practice on 15 September 2021. Overall, the practice is rated as Requires Improvement.
Safe - Good
Effective - Requires Improvement
Well-led - Requires Improvement
Following our previous inspection on 18 February 2020, the practice was rated Requires Improvement overall and for key questions safe and well led, and good for providing effective, caring and responsive services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Pearl Medical Practice on our website at www.cqc.org.uk
Why we carried out this inspection
This inspection focused inspection to follow up on breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance. At the previous inspection we found:
- The provider had not undertaken risk assessments to ensure the health and safety of staff and people using the service.
- Systems and processes to ensure good governance in accordance with the fundamental standards of care required had not always identified the shortfalls within the service.
We also followed up on areas we identified the practice should improve at the last inspection. Specifically:
- Continue to review and improve the uptake of cervical screening and the childhood immunisation programme.
- Review staff’s understanding of the duty of candour.
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 and RI for all population groups.
We found that:
- Policies were monitored, reviewed and updated.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- Staff dealt with patients with kindness and respect.
- The practice proactively sought feedback from patients, which it acted on.
- There was evidence of quality improvement activity.
We found a breach of regulations. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
We also found the provider should:
- Continue to consider ways to improve uptake for cervical screening and childhood immunisations.
- Ensure that all staff are aware of who their Freedom to Speak Up Guardian is and how they can be contacted.
- Continue to consider ways to improve data not consistent with national targets, including diabetes and antibiotic prescribing.
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