Sudbury and Alperton Medical Centre

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We assessed all the quality statements from this key question. Our rating for this key question is good. We found the provider had systems in place to identify and learn from incidents, alerts and complaints. Staff were appropriately qualified and up to date with required training relevant to their roles. The provider was managing medicines safely and this had improved since our previous inspection. However, we found occasional gaps in the documented follow-up with people with chronic kidney disease. The service was provided in an environment that was generally safe and clean, but the sinks in the clinical rooms were not compliant with current guidelines and the practice had not assessed and mitigated the associated risks.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

We received feedback from a representative of the patient participation group who spoke positively about how the practice responded to patient feedback.

Staff understood how to raise concerns when things went wrong. The team discussed and learnt from safety issues in their regular meetings. Staff reported that there was a learning culture in relation to safety incidents and the provider was open with people who use the service.

The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints. Learning from incidents and complaints resulted in changes that improved care for others.

People did not raise any specific concerns about safe systems, pathways and transitions.

Staff were knowledgeable about local clinical pathways and support networks in the area. They reported good working relationships with the local community teams to support people with more complex needs.

We did not speak with representatives from partner agencies as part of the inspection.

The provider had processes in place to work with other health and social care professionals and agencies, for example, to reduce the risk of avoidable hospital admissions. There were effective systems in place to track urgent referrals for suspected cancer. People using the service had access to a ‘social prescriber’ at the practice who could advise on available local resources to help with wider issues affecting people’s health and wellbeing, for example, housing problems.

People did not raise any specific concerns about safeguarding.

Leaders were able to demonstrate how safeguarding was managed in the practice. There were discussions with other health and social care professionals when needed, to support and protect adults and children at risk of significant harm. Staff were trained to the appropriate levels for their role.

We did not speak with representatives from partner agencies as part of the inspection.

The provider had policies and processes in place to safeguard people. They maintained registers of people at particular risk of abuse for regular review, including children, adults in vulnerable circumstances and people affected by (or at risk of) female genital mutilation. We saw evidence of cross agency coordination in relation to a recent child safeguarding concern. Safeguarding issues were discussed at the regular practice meeting to which the whole team was invited.

The most recent National GP Patient Survey results (2024) showed that 96% of respondents said they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment at Sudbury and Alperton Medical Centre. (Other practices in Brent scored 89% on average for this indicator.)

Staff and clinicians told us they discussed relevant risks with people and updated their records with this information.

We carried out a series of standardised searches of the clinical records. This showed that the clinicians were actively diagnosing potential cases of diabetes. However, we found 3 cases where people’s test results indicated chronic kidney disease (stage 3-5) without a coded diagnosis. The diagnosis did not seem to have been discussed with these patients. In 2 of these cases, the practice had initiated the appropriate diagnostic investigations, but people had not subsequently been followed-up in line with guidelines.

Leaders were confident that the service was provided in a safe environment. Staff confirmed us that they had no concerns about the environment and facilities.

We observed the premises at both the main and branch surgeries to be safe. The clinical and public areas were clearly signposted, and all areas were clear of clutter. The equipment we inspected had been appropriately checked and serviced to ensure it was safe to use. The practice was equipped for medical emergencies. Emergency equipment, including emergency oxygen and an automated external defibrillator (AED) were checked by staff to ensure they were safely stored and fit for use.

The provider had comprehensive policies and risk assessments in place to assure itself that the environment was safe including water temperature monitoring, fire alarm testing and electrical safety. The provider had completed all higher risk recommendations from the fire safety risk assessment and was in the process of addressing lower risk and longer-term actions. A risk to the water supply in the staff kitchen had been identified during routine water testing (as part of the Legionella risk assessment) and the provider had notified the relevant authorities and taken remedial action to change the affected piping system. The provider implemented measures to minimise the risk to staff as they awaited further maintenance work and repeat water testing.

We received feedback from a representative of the patient participation group who spoke positively about staffing at the service.

Leaders and staff told us they had a stable team and enough staff in various roles to provide an accessible service and meet people’s needs. The leaders were making use of associated staff funded by the primary care network, for example, a clinical pharmacist and a social prescriber.

Recruitment checks were carried out in accordance with regulations. Staff had access to regular appraisals. Staff were appropriately qualified and up to date with required training. The lead GP provided clinical oversight and supervision for clinical staff and associated clinical staff. At least one GP was present at each site during opening hours.

We received feedback from a representative of the patient participation group, who informed us that they did not have any concerns regarding infection prevention and control at the practice. In their experience, clinical staff observed infection control protocols to provide a clean and safe working environment.

Staff confirmed they received effective training and updates on infection prevention and control and had access to relevant policies and guidelines and sufficient supplies of personal protective equipment.

During our site visit, we observed that the flooring, the sinks and splashback areas in clinical rooms were not fully compliant with current infection prevention and control guidelines making cleaning difficult. We raised this as an issue at the previous inspection. The practice did not have a plan in place to make improvements at the time of this visit.

Infection prevention and control audits were carried out and the provider was acting on issues identified in the most recent audit and some recommendations from our previous inspection (for example to monitor water temperatures). The audits had not identified the problems that we observed at this assessment in relation to non-compliant sinks and flooring. Otherwise, there were effective infection prevention and control processes in place, for example to safely receive biological specimens and dispose of clinical waste.

People did not raise any specific concerns about their experience of medicines optimisation at the practice.

Staff understood the systems in place for the safe ordering, storage, and administration of medicines, including vaccinations. Clinical staff and leaders explained the protocols in place to ensure medicines were prescribed safely and in line with national guidelines. The practice had access to clinical pharmacist resource through the primary care network. The clinical pharmacists supported the practice for example, in auditing prescribing against guidelines and carrying out structured medication reviews with patients.

The practice stored blank prescriptions securely and their use was monitored in line with national guidance. The practice held appropriate emergency medicines safely and monitored stock levels and expiry dates. Vaccines were appropriately stored, monitored and transported in line with guidance to ensure they remained safe and effective.

The provider had effective systems to manage and respond to safety alerts and medicine recalls. Staff followed established processes to ensure people prescribed medicines with specific risks received recommended monitoring.

Staff took steps to ensure they prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, the rate of hypnotic prescribing by the provider was lower than local and national averages.