Archived: The Elgin Clinic

Updated 4 August 2022

The Elgin Clinic is a practice located in the Westminster Local Authority. Services are providing from 40 Elgin Avenue, London, W9 3QT. The premises are located in a residential area with transport links. The practice is registered with the CQC to provide the regulated activities: diagnostic and screening procedures; maternity and midwifery services; and treatment of disease, disorder or injury. The practice is situated within the North West London Clinical Commissioning Group (CCG) and provides services to approximately 4,653 patients under the terms of a General Medical Services (GMS) contract. This is a contract between general practices and NHS England for delivering services to the local community. There are two GP partners, a practice nurse prescriber, a healthcare assistant, a shared care worker and substance misuse advisor, a practice manager, and a team of administrative and reception staff. The practice is part of a Primary Care Network (PCN). According to the latest data available, the ethnic make-up of the practice is 51.8% White, 15.8% Black, 12.9% Other ethnic groups, 12.7% Asia and 6.7% Mixed. Information published by the UK Health Security Agency (UKHSA) rates the deprivation within the practice population groups as three, on a scale of one to ten. Level one represents the highest level of deprivation and ten the lowest.

Updated 4 August 2022

We carried out an announced inspection at The Elgin Clinic on 8 June 2022, with the remote clinical review on 6 June 2022. Overall, the practice is rated as requires improvement.

Set out the ratings for each key question

Safe - Requires improvement

Effective – Requires improvement

Caring - Good

Responsive - Good

Well-led – Requires improvement

Following our previous inspection on 5 April 2018, the practice was rated as good overall and for all key questions.

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

Why we carried out this inspection

This inspection was a comprehensive inspection focusing on:

• Ensuring care and treatment was being provided in a safe way to patients.
• Establishing if 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

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 this practice as requires improvement for providing safe services because:

• We identified some gaps in relation to staff member immunisations, in particular, for non-clinical staff. We found that the staff immunisation programme was not implemented as per UK Health Security Agency guidance.
• We identified issues with the monitoring of patients on some high risk medicines.
• We found that the system for managing and acting on Medicines and Healthcare Products Regulatory Agency (MHRA) alerts was not always effective.
• The premises were well managed and there were mostly effective systems for managing infection prevention and control. We provided some feedback to the practice in relation to securing blind loop cords and a soap dish found during our site visit.
• We found that emergency medicines and equipment on site were organised, in date and effectively managed. We provided feedback to the practice on some out of date supplies that we found during our site visit that the practice removed and disposed of.

We rated this practice as requires improvement for providing effectives services because:

• We identified some issues with the monitoring and management of long-term conditions, in particular in relation to patients with hypothyroidism and patients with acute exacerbation of asthma.
• The practice had worked towards providing effective care for patients during the Covid-19 pandemic.
• The practice uptake for cervical screening was markedly below the 80% coverage target for the national screening programme.
• The practice had not met the minimum 90% uptake for all of the childhood immunisation and was below 80% in three of the indicators, or the WHO based national target of 95% in all of the indicators. We saw evidence that the practice had started to put in place systems to address the uptake childhood immunisations.

We rated this 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 had arrangements for providing interpreters for patients who did not have English as a first language and made adjustments for patients to ensure access.
• The practice offered longer appointments for patients where appropriate.

We rated this practice as good for providing responsive services because:

• We found that people’s needs were met through the way services were organised and delivered.
• The practice offered extended pharmacist hours on three evenings a week to accommodate patients.
• The practice had maintained services throughout the Covid-19 pandemic and had facilitated face to face appointments where appropriate.

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

• The practice had a governance framework, however it was not always effectively managing risks. These included the risks associated with prescribing medicines that required ongoing monitoring and reviewing patients prescribed repeat or multiple medicines in line with guidance.
• The practice was not always keeping comprehensive clinical records, with medication reviews not always picking up on monitoring that was required for patients.
• The practice was not always appropriately managing patients with long-term conditions.
• Actions were taken to support the maintenance of the service during the Covid-19 pandemic.
• We received positive feedback from the Patient Participation Group that the practice was open and honest and sought the views of the group in relation to improvements.
• Staff spoke positively about their employment at the practice and felt supported.

We found breaches of regulations. The provider must:

• Ensure that care and treatment is provided in a safe way.
• 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).

In addition to the above, the practice should:

• Continue to review the uptake of childhood immunisations and demonstrate an understanding of what barriers there are to uptake in the patient population, and take action to address such barriers as appropriate.
• Continue to ensure adherence to infection prevention and control processes.
• Review the blind loop cords at the practice and arrange for securing these to minimise risk.
• Review the system for the recording of MHRA alerts, significant events and complaints to ensure accessibility and comprehensive recording.

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