Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 16 February 2016 where breaches of legal requirements were found. After the inspection, the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12 Safe care and treatment of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

We undertook this desk-based focussed inspection on 27 September 2016 to check that the practice had followed their plan to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where additional improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Kilburn Park Medical Centre on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing safe services.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 8.30am on 16 February 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed, however they were not in all instances well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Patients said there was continuity of care, with routine and urgent appointments available the same day. However, patients reported that it was difficult to get through on the phone and therefore had to come in to the practice in order to get same day appointments.In addition appointments with a preferred GP could take up to three weeks.
• The practice facilities were clean and equipped to treat patients and meet their needs, however the premises was in need of repair/upgrade.
• There was a clear leadership structure and staff felt supported by management. The practice proactively 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 areas where the provider must make improvements are:

• Implement the recommendations from the legionella risk assessment (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
• Complete the infection control audit started in December 2015.
• Take appropriate steps to assure the risk of fire evacuation is assessed.

In addition the provider should:

• Improve telephone access to appointments.
• Take action to improve Quality Outcomes and Framework (QOF) exception reporting rate.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Patients who used the service received appropriate care and support that met their individual needs and were treated with dignity and respect.

There were processes in place to protect patients who used the service from harm. The staff had received training to recognise the signs of abuse and to report concerns in accordance with the practice procedures.

The premises were clean and hygienic and staff had been trained in infection control.

Patients were cared for and supported by suitably qualified, skilled and experienced staff.

The practice had an effective system to regularly assess and monitor the quality of service that patients received and to identify, assess and manage risks to the health, safety and welfare of patients who used the service.

We reviewed the information available to us about Kilburn Park Medical Centre on 8 June 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.