The Care Quality Commission
  • Doctor
  • GP practice

Rutland House Surgery

Overall: Good read more about inspection ratings

40 Colney Hatch Lane, London, N10 1DU (020) 8883 8214

Provided and run by:
Rutland House Surgery

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

All Inspections

17-19 July 2023

During a routine inspection

We carried out an announced comprehensive inspection at Rutland House Surgery on 17-19 July 2023. Overall, the practice is rated as good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

During a routine inspection in May 2022, we rated the practice as requires improvement overall and issued a warning notice and requirement notice for regulation 12 and regulation 17. This was because of concerns regarding:

  • systems and processes for managing patients prescribed high-risk drugs and on long-term conditions.
  • the management of drug safety alerts.
  • the availability of emergency medication.
  • overdue risk assessments.
  • the temperature readings of the vaccine fridge in the branch site.

The warning notice provided the practice with three months to make improvements to the above concerns. We conducted a focused inspection in September 2022 to follow up on the warning notice and found the practice had made improvements in respect of the above concerns. Therefore, we were satisfied the practice had met the conditions of the warning notice. At this inspection, we found the practice continued to make improvements and we were able to rate the practice good overall and for all key questions.

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection.

Outline focus of inspection to include:

  • Key questions inspected
  • Areas followed up including any breaches of regulations or ‘shoulds’ identified in previous inspection
  • Any other areas reviewed

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 and
  • 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. This included the prescribing and monitoring of patients on high-risk drugs, the monitoring of drug safety alerts and maintaining infection prevention and control standards within the premises.
  • Patients received effective care and treatment that met their needs. We found patients with long-term conditions and medication reviews were being monitored appropriately.
  • 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.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

8 September 2022

During an inspection looking at part of the service

We previously carried out an announced comprehensive inspection of Rutland House Surgery between 9-11 May 2022. At the inspection, we found the practice was in breach of Regulation 12 Safe care and treatment of the Health and Social Care Act 2008. In line with the CQC’s enforcement process, we issued a warning notice which required Rutland House Surgery to comply with the regulations by 31 August 2022.

Rutland House Surgery is currently rated as required improvement overall (rated inadequate for the key question of safe, requires improvement for the key questions of effective and well-led, and good for the key questions of caring and responsive).

The full report of the practice’s previous inspection can be found by selecting the ‘all reports’ link for Rutland House Surgery on our website at www.cqc.org.uk.

We carried out this announced focused inspection of Rutland House Surgery on 7 and 8 September 2022 to check whether the provider had addressed the issues in the warning notice, and now met the legal requirements. At this inspection we found the breaches of regulation in our warning notice had now been complied with.

This report covers our findings in relation to those specific areas, is not rated, and does not change the current ratings held by the practice.

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.

Following our methodology, we have not rated or changed the rating as part of this inspection.

At this inspection we found the provider had taken effective actions to address the issues we identified at the previous inspection.

  • The practice had arranged appropriate monitoring of patients on high-risk medicines and reviews of patients whose diagnosis or treatment for long-term conditions required it.
  • The practice had reviewed patients on a number of medicines subject to safety alerts and made changes where appropriate to keep patients safe.
  • Staff told us about changes being made to systems and processes to ensure improvements were sustained and fully embedded.
  • The practice had reviewed its emergency medication list and had appropriate emergency medication stocked across both sites.
  • The practice had arranged for vaccines to be appropriately stored with its temperature recordings appropriately monitored.
  • The practice had carried out appropriate environmental risk assessments with recommended actions being carried out.
  • The practice had made arrangements to secure the security and premises of the building.

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

9-11 May 2022

During a routine inspection

We carried out an announced inspection at Rutland House Surgery on 11 May 2022. Overall, the practice is rated as requires improvement.

Safe - Inadequate

Effective – Requires improvement

Caring – Good

Responsive - Good

Well-led – Requires improvement

Why we carried out this inspection:

This was a comprehensive inspection as part of our inspection programme. This was our first inspection of this location since it had changed providers in August 2020.

How we carried out the inspection:

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections.

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.

We found that:

  • Patients on high risk medications were not always monitored appropriately.
  • The practice did not have an effective system to implement medication reviews and patient safety alerts. Some patients who had long term conditions had not received their blood tests and reviews in a timely manner.
  • There was no effective oversight of risks, such as protecting staff and patients from legionella and fire safety.
  • The practice did not stock all the required emergency medication.
  • The practice was not appropriately monitoring the temperature of the vaccine fridge in the branch site.
  • There were concerns regarding the security of the administrative office on the first floor, which had an unlocked door easily accessible by tenants in the building.
  • There were concerns regarding the infection prevention and control policy and the privacy screens in the branch site not being properly maintained.

The area where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the practice should make improvements are:

  • Improving efforts to increase uptake of childhood immunisations and cancer screening to meet World Health Organisation (WHO) and national targets.

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