The Care Quality Commission
  • Doctor
  • GP practice

Roxbourne Medical Centre

Overall: Good read more about inspection ratings

37 Rayners Lane, Harrow, Middlesex, HA2 0UE (020) 8422 5602

Provided and run by:
Dr Sarmad Zaidi

Important: The provider of this service changed - see old profile

All Inspections

5 May 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at Roxbourne Medical Centre from 3-5 May 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive – requires improvement

Well-led - good

Following our previous rated inspection in April 2022, the practice was rated requires improvement overall. It was rated inadequate for providing safe services and requires improvement for providing effective and well-led services. The practice was rated good for providing caring and responsive services at an earlier inspection in December 2019.

At the inspection in April 2022, we found that the practice was not addressing risks in the following areas: prescribing of medicines that require monitoring; medicines usage for asthma; potential missed diagnoses of diabetes; its implementation of selected national patient safety alerts; and its management of diabetes and hypothyroidism. We also found that the practice was not always managing clinical documents including letters, test results and referrals on the electronic system in a timely way.

We carried out an unrated follow-up inspection in October 2022 and found that the practice had improved and was meeting the required standards at that time.

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

Why we carried out this inspection

We carried out this inspection to follow-up on previous breaches of regulations and to assess whether improvements noted at the focused follow-up visit in October 2022 had been sustained. We carried out a comprehensive inspection covering all key questions.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • 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.
  • Information from the provider, patients, the public and other organisations.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm. The practice had sustained the improvements to safety noted at our previous follow-up inspection.
  • 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.
  • Patients could access care and treatment in a timely way. However, improvements to the appointment system were not yet reflected in patient feedback and the practice’s National GP Patient Survey results were below average.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

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

  • Take action to improve the documentation of medicines reviews so these more consistently include all required information.
  • Follow up patients who have been prescribed oral steroids for an acute exacerbation of asthma in line with current clinical guidelines.
  • Take action to increase the participation of eligible patients in cancer screening programmes and increase uptake of childhood immunisations.
  • Evaluate patient experience of the appointment system including the experience of patients without online access to identify any areas for improvement.
  • Engage with the patient participation group and include them in planning future meetings and group activity.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

25 October 2022

During an inspection looking at part of the service

We carried out an announced focused inspection of Roxbourne Medical Centre on 25 October 2022.

Following our previous inspection on 14 April 2022, the practice was rated requires improvement overall. It was rated inadequate for providing safe services and requires improvement for providing effective services and well-led services. It had been rated as good for providing caring and responsive services at a previous inspection on 4 December 2019 and the ratings for these key questions were carried forward.

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

Why we carried out this inspection

We carried out this inspection to follow up a breach of regulations from a previous inspection. We did not rate any key questions at this inspection.

At this inspection we focused on the immediate concerns identified at the previous inspection, that is:

  • unsafe prescribing of higher risk medicines
  • unsafe medicines usage for asthma
  • potential missed diagnoses of diabetes
  • incomplete implementation of national patient safety alerts
  • incomplete monitoring for diabetes and hypothyroidism.

How we carried out the inspection

This inspection was carried out remotely. This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.

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 found that:

The practice had addressed the immediate concerns identified at the previous inspection. In relation to the areas focused on at this inspection:

  • 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.
  • The way the practice was led and managed promoted improvement.

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

  • Arrange the provision of steroid emergency cards to relevant patients in line with national guidelines and document that this has been done in the patient record.
  • Document in the patient record the discussion and information provided to patients about the risks of teratogenic medicines and pregnancy at the time of prescribing. (Teratogenic medicines are medicines that increase the risk of foetal abnormality during pregnancy)

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

14 April 2022

During an inspection looking at part of the service

We carried out an announced inspection at Roxbourne Medical Centre on 6 and 14 April 2022. Overall, the practice is rated as requires improvement.

Set out the ratings for each key question

Safe - inadequate

Effective – requires improvement

Well-led – requires improvement

Following our previous inspection on 4 December 2019, the practice was rated Good overall and for all key questions.

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

Why we carried out this inspection

This inspection was a focused inspection to follow up on:

  • Specific concerns reported by members of the public

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 found that:

  • The practice had good systems in place to safeguard patients from abuse or harm.
  • Staff recruitment and training files were not always complete, in particular vaccination records and prioritising mandatory training such as infection prevention and control.
  • A significant number of documents were found on the digital patient records system awaiting review, coding and filing.
  • Clinical searches found a number of patients on repeat and/or high-risk medicines who had not had reviews and monitoring in a timely manner.
  • Two suggested emergency medicines were not found on the day of inspection. There was no formal risk assessment for the omission of these medicines. This was implemented immediately after the inspection.
  • Patients with long term conditions did not always receive monitoring in a timely manner.
  • Leaders did not always recognise the challenges to providing care to their practice population.
  • The practice did not have a comprehensive succession plan in place.
  • The practice had a vision; however, staff did not have a good awareness of it to apply to their daily job roles.
  • Comprehensive policies were in place, but these were not sufficiently embedded to ensure that there were no gaps in care and treatment.
  • The practice did not provide adequate access to all patients throughout the pandemic and leaders did not show that patient needs and concerns around access had been appropriately considered.
  • Staff were very happy working at the practice and told us that leaders were friendly and approachable.

We found three breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The provider should:

  • Implement quality improvement processes for example in-house two-cycle audits to monitor quality of care and improve the quality of care provided at the practice.
  • Investigate, respond, and utilise information to improve, when patients provide suggestions, feedback or voice concerns. Consider ways to improve access to care for all groups of patients, especially on site where doors were locked despite COVID restrictions easing, and alternative means to book appointments besides online-only.
  • Develop appropriate succession planning.
  • Continue work to improve rates of childhood immunisation and cancer screening.
  • Modify existing induction systems to allow for new recruits to complete mandatory training in a timely manner to ensure patient safety.

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