We carried out an announced comprehensive inspection at The Willesden Medical Centre on 27 October 2015. The overall rating for the practice was Good, with a rating of Requires Improvement in the Safe domain. The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for The Willesden Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced desk-based review carried out on 31 January 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 27 October 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

At this inspection, we found that the practice arrangements in relation to medicines management had improved. Consequently, the practice is now rated as good for providing safe services.

Our key findings were as follows:

• The practice had implemented a system to monitor the expiry dates.

• The practice had implemented a system to ensure that all fridge temperatures in the practice were checked; however, there were gaps in record books provided.

• The practice had implemented a standard training record system which recorded all staff training.

• The practice had reviewed arrangements for patients to access appointments. Patients could now book appointments via Patient Access, an online service where they could book appointments. They also offered extended hours twice a week and patients could also attend booked appointments at their local HUB service.

• The practice used an interpreting service available to all patients who required it.

• The practice had reviewed and updated their recruitment policy to include a checklist to ensure all recruitment checks adhered to the recruitment policy.

The areas where the provider should make improvements are:

• Review the newly implemented system of fridge temperature checks to ensure there are no gaps in monitoring.

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 Willesden Medical Centre on 27 October 2015. 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.
• Most risks to patients were assessed and well managed. Except, in relation to medicines management and staff training records not being complete.
• 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. However, training records did not identify all the training staff had undertaken or needed to complete.
• 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.

• Results from the GP survey showed that

• On the day of the inspection we observed that there was a queue of patients waiting for approximately thirty minutes to access the practice at 8.30am.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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 areas where the provider must make improvements:

• Ensure systems for checking expiry dates of medicines is suitable

• The areas where the provider should make improvements:

• Ensure staff recruitment checks adhere to the recruitment policy.

• Ensure a standardised system for training records that show completed or outstanding training.

• Review arrangements for patients to access appointments

• Review the information provided at the surgery regarding access to translators

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice