The Care Quality Commission
  • Doctor
  • GP practice

Birchdale Road Medical Centre

Overall: Good read more about inspection ratings

2 Birchdale Road, London, E7 8AR (020) 8472 1600

Provided and run by:
Dr Mohamed Shaffi Omar Esmail

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Birchdale Road Medical Centre on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Birchdale Road Medical Centre, you can give feedback on this service.

29 September and 04 October 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Birchdale Road Medical Centre on 29 September 2022.

We previously carried out an announced inspection at Birchdale Road Medical Centre on 4 June 2019, when the practice was rated as good overall, for all key questions and areas except for caring and the practice was rated as requires improvement in this area.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Birchdale Road Medical Centre on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused inspection to review the rating for the key question of:

  • Caring

How we carried out the inspection/review

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

This inspection was carried out in a way which enabled us to complete this off-site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Speaking with staff using video conferencing.
  • Requesting evidence from the provider.

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.

This practice remains as good overall.

We have rated the key question for caring as good because the practice had:

The provider had undertaken work to improve the achievement rates in the National GP Patient Survey. They had:

  • Increased the rate of carers who had been identified and registered at the practice.
  • Developed caring services for patients regarding preventative health services.
  • Improved the practice emergency plan to incorporate planning in the circumstances of Pandemic Influenza and Coronavirus.
  • Amended and improved the practice Mission Statement.
  • Developing a five-year Business Plan with a focus on providing a compassionate caring service for patients.
  • Developing caring services for patients regarding cancer screening services.
  • We have not reviewed childhood immunisations achievement rates as this comes within the key question for providing effective care and treatment. However, we have reviewed the practice for providing caring preventative health services.
  • Joining the Safe Surgeries initiative to enable practice staff to gain a better understand of the challenges faced by migrants.

Whilst we found no breaches of regulations, the provider should:

  • Continue to improve patient satisfaction achievement rates in the National GP Patient Survey (GPPS).

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

4 June 2019

During a routine inspection

We carried out an announced comprehensive inspection at Birchdale Road Medical Centre on 4 June 2019 as part of our inspection programme for practices rated inadequate in one or more key questions at our last inspection of the practice.

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 good overall, with requires improvement for providing caring services.

We rated the practice requires improvement for caring services because:-

  • Whilst the practice had scored well in some areas of the most recent published National GP Survey, the practice scored lower than both the local clinical commissioning group (CCG) and the national averages regarding their interaction with patients at the practice.

We rated the practice good for safe, effective, responsive and well-led services because

  • The practice conducted clinical audits and could show improvement in patient care because of audits.
  • The practice has clear systems, practice and process which kept patients safe.
  • The practice acted on significant events and shared the learning amongst staff.
  • Complaints were dealt with in line with recognised guidance.
  • The practice had scored well in some areas of the National GP Patient survey relating to access to services at the practice.
  • Staff had the skills, knowledge and experience to carry out their roles.
  • The practice engaged with internal stakeholders including the practice participation group (PPG) to ensure that service provided met the needs of the practice population.

We have rated the practice as good for all the population groups for the key questions of effective and responsive.

The areas where the provider should make improvements are:

  • Review the service and care provided by staff in relation to low patient satisfaction scores.
  • Continue with efforts to improve practice uptake of screening for bowel cancer.
  • Review internal recall process for cervical screening.
  • Re-assess the practice business plan to show how the practice aims to achieve objectives identified. Focus should be paid to the strategy for identifying for potential risks to the service and how to address them.

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

7 February 2019

During an inspection looking at part of the service

We previously carried out an announced comprehensive inspection of Birchdale Road Medical Centre on 3 October 2018 and found that the practice was in breach of Regulation 12: ‘Safe care and treatment’ of the Health and Social Care Act 2008. In line with the Care Quality Commission’s (CQC) enforcement processes, we issued a warning notice which required Birchdale Road Medical Centre to comply with the Regulations by 17 January 2019. The full report of the 3 October 2018 inspection can be found by selecting the ‘all reports’ link for Birchdale Road Medical Centre on our website at .

We carried out this announced focused inspection on 7 February 2019 to check whether the practice had addressed the issues in the warning notice and now met the legal requirements. This report covers our findings in relation to those requirements and will not change the current ratings held by the practice.

At the inspection on 7 February 2019 we found the provider had acted to address all the requirements of the Regulation 12 warning notice.

Our key findings were as follows:

  • Individual care records and referral letters were written and managed in line with relevant guidance and legislation and referrals were made in a timely way.
  • Blank prescriptions were kept securely, and their use monitored.
  • Safety alerts were received, cascaded and acted on.
  • The lead GP had implemented systems to gain oversight of long term locum GPs clinical care.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and evidence table for further information.

3 October 2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous rating August 2017– Requires Improvement)

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Requires Improvement

Are services caring? – Requires Improvement

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at Birchdale Road Medical Centre on 3 October 2018. This inspection was undertaken in line with our inspection programme of re-inspecting practices where a breach or breaches of regulations was identified at our previous inspection.

At this inspection we found:

  • The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice did not always review the effectiveness and appropriateness of the care it provided. There was evidence that care and treatment was not always delivered according to evidence-based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patient consultation notes did not always have sufficient detail explaining patient symptom(s), discussion, diagnosis and proposed treatment.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Recent patient safety alerts had not been acted on by the practice.
  • The practice had systems in place to manage infection prevention and control, as well as ensuring facilities and equipment were safe and in good working order.
  • There was no evidence that staff at the practice had undergone sepsis training. Clinical staff we spoke with could tell us the indicators of a potential sepsis diagnosis.
  • The practice and PPG worked together to ensure that care was delivered and could be accessed easily at the practice.
  • There was no clinical oversight of the consultations by locum GP clinical staff at the practice.

The areas where the provider must make improvements as they are in breach of regulations 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 provider should make improvements are:

  • Inform patients what services the practice provides for recently bereaved patients.
  • Obtain a paediatric oximeter to assist with the diagnosis of illness such as sepsis in children.
  • Review recent National GP Survey data with a view to addressing mixed patient satisfaction levels.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

25 August 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Birchdale Road Medical Centre on 25 August 2017. Overall the practice is rated as requires improvement.

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

  • There were weaknesses in systems for identifying and managing significant events.
  • Arrangements to minimise risks to patient and staff safety were not always effective including safety alerts, and fire and equipment safety.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were above average or comparable for responsive services such as patient access but below average for caring services.
  • Information about services and how to complain was available but complaints and trends in complaints were not sufficiently well managed.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had facilities including disabled access and was equipped to treat patients and meet their needs.
  • There was a leadership structure and staff felt supported by management. The practice proactively sought feedback from PPG members, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed where significant events were identified showed the practice complied with these requirements.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure that any complaint received is investigated and any proportionate action is taken in response to any failure identified by the complaint or investigation.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition the provider should:

  • Improve arrangements for patient’s breastfeeding and access to information and services online.
  • Formalise and embed arrangements for staff induction.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice