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Archived: Belsize Priory Medical Practice

Overall: Good read more about inspection ratings

208 Belsize Road, London, NW6 4DX (020) 7326 8200

Provided and run by:
Dr Nabila Muslem Abdulsahib Hanosh

Important: The provider of this service changed. See old profile
Important: This service is now registered at a different address - see new profile

All Inspections

27 June 2022

During an inspection looking at part of the service

Why we carried out this inspection

We carried out an announced focussed inspection at Belsize Priory Medical Practice between 22nd-27th June 2022.

We carried out this inspection to follow up on the previous inspection carried out in September 2021 where the practice received a requires improvement rating for the safe, effective and well domains. We also issued requirement notices for breaches of Regulation 15 HSCA (RA) Regulations 2014 Premise and Equipment and Regulation 12 HSCA (RA) Regulations 2014 Safe care and Treatment.

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

At this inspection we were satisfied all previous concerns had been rectified and the requirement notices had been met.

The following ratings have been applied at this inspection:

Safe - Good

Effective - Good

Caring - Good (carried over from previous inspection)

Responsive – Good (carried over from previous inspection)

Well-led – Good

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, considering 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 spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit

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 and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Continue with efforts to improve the uptake of cervical screening and childhood immunisations.

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

8th September 2021

During a routine inspection

We carried out an announced comprehensive inspection at Belsize Priory Medical Practice between 6th -8th September 2021. Overall, the practice is rated as requires improvement.

Why we carried out this inspection

We carried out an inspection to follow up on the previous inspection carried out in January 2019 where the practice received a requires improvement rating for the responsive domain. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Belsize Priory Medical Practice on our website at www.cqc.org.uk.

How we carried out the inspection

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 spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system and discussing. findings with the provider.
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider.
  • A site visit.

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 and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as requires improvement overall.

We rated the practice as requires improvement for providing safe services because:

  • We had concerns regarding the actioning of a drug safety alert, the cleanliness of the public toilets, the lack of posters stating what to do in the event of a sharp’s injury and safe disposal of sharps bins.

We rated the practice as requires improvement for providing effective services because:

  • The practice’s uptake for childhood immunisation was below the national targets.

  • The practice’s uptake for cervical screening was below the national targets.

We rated the practice as good for providing caring services because:

  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We re-rated the practice as good for providing responsive services because:

  • We were now satisfied the practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

We rated the practice as requires improvement for providing well-led services because:

  • We were not assured there was appropriate processes in place for actioning all drug safety alerts; disposing of sharps bins; and to maintain standards of hygiene appropriate for the purposes for which the premises were being used.

Population Groups

  • We rated older people and people whose circumstances may make them vulnerable as good.

  • We rated people with long-term conditions as good.

  • We rated families, children and young people as requires improvement because the practice has not met the WHO based national target of 95% (the recommended standard for achieving herd immunity) for five of five childhood immunisation uptake indicators.

  • We rated working age people as requires improvement as the practice had not met the 80% national uptake target for cervical screening.

  • We rated people experiencing poor mental health (including people with dementia) as good.

We found two breaches of regulations. The provider must:

  • Ensure that care and treatment is provided in a safe way (Please see the specific details on action required at the end of this report).
  • Maintain appropriate standards of hygiene for premises and equipment (Please see the specific details on action required at the end of this report).

The provider should:

  • Continue with efforts to improve the uptake of cervical screening and childhood immunisations.
  • Consider increasing nursing staff and/or nursing working hours.
  • Ensure sharps bins are disposed and replaced as per best practice guidelines.
  • Ensure sharps injury posters are displayed in all consultation rooms.

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

30 January 2019

During a routine inspection

We carried out an announced comprehensive inspection at Belsize Priory Medical Practice on 30 January 2019 as part of our inspection programme.

The practice was previously inspected in December 2017 and rated as good overall.

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 rated this practice as good overall but requires improvement for providing responsive services. We rated the practice requires improvement for responsive because:

  • Patient satisfaction with telephone access and making and accessing appointments was consistently lower than average compared to other GP practices. Although the practice had introduced improvements, the practice had not yet assessed the effectiveness of actions taken and could not demonstrate changes made had been fully embedded and were sustainable.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Continue to improve the uptake for childhood immunisations to achieve the national target of 90% or above in all four indicators.
  • Continue with efforts to recruit a qualified sample taker to improve cervical screening rates and to improve the uptake for cervical screening to achieve the national target of 80%.
  • Follow through with plans to assess the impact of changes made to services and continue to consider where further improvements could be made with a view to improving patient satisfaction levels.

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

4 December 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive focused inspection at Belsize Priory Medical Practice on 4 December 2017. This inspection was carried out as part of our inspection programme. There was a new provider, Dr Nabila Muslem Abdulsahib Hanosh, who took over the running of the practice in 2016. This was the first, comprehensive inspection for the new provider.

At this inspection we found:

  • The practice had clear 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 provider was aware of, and complied with, the requirements of the duty of candour.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided.

  • Care and treatment was delivered according to evidence- based guidelines.

  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • The leadership team were committed to service development and were working to improve the quality of the service.

  • The practice proactively sought, and acted on, feedback from staff and patients.

However,

  • Patients found that there were long waiting times for appointments.

  • The GP Patient survey suggests had not always involved patients in their care.

  • The practice had good facilities; however the lift to the first floor remains out of use.
  • Staff had relevant training for the role, but the practice had not always identified and monitored where staff may need additional training, such as in the requirements of the Mental Capacity Act (2005) or in fire safety.

The areas where the provider should make improvements are:

  • Implement strategies to improve cervical screening uptake among women attending the practice.

  • Staff should take action to involve patients in their care and consistently treat patients with kindness and respect.

  • Continue to review patient feedback and take action to improve in areas where patients indicate that they are not satisfied with the service provided.

  • Take action to satisfy themselves the premises and equipment used by the service are properly maintained.

  • Review actions already taken to improve waiting times to assess the impact of these, and the sustainability of any reductions in waiting times.

  • Review protocols for risk assessing staff that do not require a Disclosure and Barring Service (DBS) check to carry out their role.

  • Assess staff training requirements in relation to fire safety and the requirements of the Mental Capacity Act (2005).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice