This practice is rated as requires improvement overall.

The key questions are rated as:

Are services safe? - Requires improvement

Are services effective? - Good

Are services caring? - Good

Are services responsive? - Good

Are services well-led? - Requires improvement

We carried out an announced comprehensive inspection at The Pinner Road Surgery on 14 May 2018. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether The Pinner Road Surgery was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

• We noted the current provider had inherited the number of challenges when they took over the practice in August 2017. We found the practice had implemented the number of measures to mitigate the challenges.
• There was a lack of good governance in some areas.
• Risks to patients were assessed and well managed in some areas, with the exception of those relating to fire safety, staff vaccination and management of blank prescription forms.
• The practice was unable to provide documentary evidence to demonstrate that all staff had received training relevant to their role.
• The practice was unable to demonstrate that all appropriate recruitment checks had been undertaken prior to employment.
• The practice had not provided curtains in all consulting/ treatment rooms to maintain patients’ privacy and dignity during examinations, investigations and treatments.
• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• Information about services and how to complain were available and easy to understand.
• The practice was aware of and complied with the requirements of the Duty of Candour.
• Staff we spoke with informed us the management was approachable and always took time to listen to all members of staff.

The areas where the provider must make improvements are:

• 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 areas where the provider should make improvements are:

• Review the management and security of blank prescription forms, to ensure this is in accordance with national guidance.
• Implement a system to ensure the effective monitoring of uncollected prescriptions.
• Ensure all staff have received formal training relevant to their role including sepsis awareness training.
• Ensure all actions required in response to legionella risk assessment are completed in a timely manner.
• Ensure information about a translation service is displayed in the reception area informing patients this service is available. Ensure information posters and leaflets are available in multiple languages.
• Ensure curtains are provided in all consulting and treatment rooms to maintain patients’ privacy and dignity during examinations, investigations and treatments.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice