We carried out an announced comprehensive inspection at Colney Hatch Lane Surgery on 2 August 2017. The overall rating for the practice was requires improvement. The full comprehensive report on 2 August 2017 inspection can be found by selecting the ‘all reports’ link for Colney Hatch Lane Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused follow up inspection carried out on 20 February 2018 to confirm that the practice had carried out their plan to correct the issues that we identified in relation to identifying, monitoring and mitigating risks, knowledge of national guidelines incident reporting, quality improvement, involvement in multidisciplinary meetings, inadequate cytology rates and governance structure in our previous inspection on 2 August 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• Although the practice now documented internal clinical meetings, there was no participation in multidisciplinary meetings.

• The practice had a good system of dealing with complaints, but did not discuss the learning and outcomes of complaints at relevant practice meetings.

• There was no system to identify vulnerable patients and there was no child safeguarding register.

• The practice vision and strategy with associated business plans were not formally documented and discussed.

• There was an open and transparent approach to safety and effective systems in place for recording and reporting significant events.

• The practice carried out risk assessments, including health and safety and fire safety.

• There was a process to review Quality Outcomes Framework (QOF) exception reporting rates where the practice was now achieving below the CCG and national averages.

• The practice had a system in place to monitor, review and improve inadequate cytology rates.

• There was evidence of quality improvement and the practice made good use of clinical audits.

• Clinical guidelines and patient safety alerts were discussed in clinical meetings where learning was shared.

• Blank prescriptions were secured and there use was effectively monitored.

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However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider should:

• Continue to work to improve inadequate cytology rates.

• Consider a system for multidisciplinary meeting involvement.

• Continue to monitor and review the child protection register.

• Review how vulnerable patients are highlighted on the clinical system.

• Ensure the system to discuss learning from complaints is implemented.

• Formalise the practice vision and strategy.

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 Colney Hatch Lane Surgery on 2 August 2017. Overall the practice is rated as requires improvement.

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

• Staff did not always understand and fulfil their responsibilities to raise concerns, and to report incidents and near misses. Reviews and investigations were not thorough enough.
• Risks to patients were not always well managed, for example those relating to fire, health and safety.
• Staff were not always aware of current evidence based guidance. Consequently, there was limited evidence of how these had been used to deliver effective care and treatment.
• Data showed patient outcomes were improving to the national average. Although some audits had been carried out, we saw limited evidence that audits were driving improvements to patient outcomes.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.

• Patients were positive about their interactions with staff and said they were treated with compassion and dignity.

• Patients we spoke with said they were able to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

• There was a clear leadership structure and staff felt supported by management. However, there were limited formal governance arrangements were in place.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. Introduce reliable processes for reporting, recording, acting on and monitoring significant events and for assessing and monitoring risks and the quality of the service provision Address identified concerns with fire, safety and health and safety practice. Ensure the practice’s quality improvement process takes account of national guidelines and can demonstrate improved patient outcomes.

In addition the provider should

• Review arrangements for monitoring the use of blank prescription forms and pads.

• Consider ways to improve cervical screening rates specifically in relation to inadequacy results.

• Consider a consent audit to review the effectiveness of how consent is obtained from patients in line with practice’s protocols.

• Review the practice’s approach to analysing practice complaints to include both verbal and written complaints to demonstrate consideration of how actions taken have resulted in improved outcomes for patients.

• Assess the practice’s strategy and consider developing supporting business plans to assist the practice in achieving its vision.

• Review processes in regard to the duty of candour to record all verbal as well as written interactions.

• Review the practice’s approach to multi-disciplinary discussions in order to better meet the needs of its most vulnerable patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice