The Care Quality Commission
  • Doctor
  • GP practice

Archived: Dr Su Su Thwe Also known as The Surgery

Overall: Requires improvement read more about inspection ratings

209 Ballards Lane, Finchley, London, N3 1LY (020) 8346 0726

Provided and run by:
Dr Su Su Thwe

All Inspections

19 January 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Su Su Thwe on 19 January 2017. 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, and to report incidents and near misses. However, reviews, investigations and learning's were not thorough enough.
  • Although risks to patients who used services were assessed, the systems and processes to address these risks were not in all instances implemented well enough to ensure patients were kept safe, specifically in relation to fire risk assessments, fire drills and training for staff, no health and safety and legionella risk assessments, gas certificate and fixed wire testing.
  • Data showed patient outcomes were low compared to the national average. Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.
  • Patients said they were treated with compassion, dignity and respect, and they were involved in their care and decisions about their treatment.
  • Patients commented that the premises needed updating and there was poor disabled access.

  • Information about services and how to complain was available and easy to understand.

  • Patients 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.

  • Staff did not always feel supported by management. The practice 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 practice had a number of policies and procedures to govern activity, but not all were being followed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

17 July 2014

During an inspection looking at part of the service

At the inspection on 27 March 2014, we saw that the provider did not have an infection prevention and control (IPC) lead for the surgery. An IPC risk assessment had also not been carried out. This meant that the provider could not be assured that appropriate measures were in place and people were protected from the risk of acquiring a health care associated infection. The provider had failed to comply with the requirements of Regulation 12 HSCA 2008 (Regulated Activities) Regulations 2010. At this inspection, we were told that the IPC lead role was shared between the senior GP and practice nurse, who had both received training in their joint role. We saw evidence that the provider had undertaken a recent risk assessment to determine the cleaning frequency and intensity of practice areas. We judged that the action taken was sufficient to comply with the requirements of the regulation.

27 March 2014

During a routine inspection

We spoke with four patients attending appointments at the surgery on the day of our visit. They told us they were happy with the care and treatment provided. For example, one patient told us 'I am happy here, the doctor treats me very well.' Another patient said, 'I get very good care here.' Patients said they received clear explanations of care and treatment from doctors and nurses.

The practice worked in cooperation with others to ensure that appropriate care planning took place. Staff shared appropriate information with others when patients were referred to specialist services. Patients felt safe with staff and confident in the skills of doctors and nurses. Staff demonstrated the knowledge and skills needed to protect children and adults from possible abuse.

The surgery was working through an infection control action plan developed with NHS England to ensure that essential standards were met. This also involved a potential move to more suitable premises. Patients we spoke with considered the surgery was always very clean and we saw there were some systems in place to reduce the risk of infection. However, although staff told us they were aware of infection control risks; there was no qualified infection prevention and control lead with the appropriate skills to ensure that the surgery was fully compliant with infection control requirements. As a result the provider could not be assured that people were protected against the risk of exposure to a health care associated infection.