The Bacon Lane Surgery

Updated 3 November 2023

The Bacon Lane Surgery is located in the Harrow area in West London at:

11 Bacon Lane

Edgware

Middlesex

HA8 5AT

We visited this location as part of this inspection activity. The practice is located in a converted property.

The provider is registered with CQC to deliver the Regulated Activities: diagnostic and screening procedures; family planning; maternity and midwifery services; and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the North West London Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 9,570. This is part of a contract held with NHS England.

The practice is part of the Harrow East Primary Care Network (PCN).

Information published by the Office for Health Improvement and Disparities rates the deprivation within the practice population groups as seven, on a scale of one to ten. Level one represents the highest level of deprivation and ten the lowest.

According to the latest available data, the ethnic make-up of the practice is 42.2% White, 40.5% Asian, 9.9% Black, 3.7% Mixed and 3.7% Other ethnic groups. The practice has a higher than average population of older patients compared to other practices in Harrow.

There are three GP partners, a pharmacist partner and an accountant partner. There are three locum GPs and two trainee GPs. Six GPs are female and 2 are male. The practice employs a practice nurse, two clinical pharmacists, a physiotherapist (musculoskeletal specialist) and two health care assistants. The partners are supported by an operational manager, a practice supervisor and a team of administrative and reception staff.

The practice is open from 8am to 6.30pm Monday to Friday. The practice offers a range of appointment types.

Extended access is provided locally by the PCN, where late evening and weekend appointments are available. Out of hours services are provided by Practice Plus.

Updated 3 November 2023

We carried out an announced focused inspection at The Bacon Lane Surgery on 4 and 5 July 2023. Overall, the practice is rated as Requires Improvement.

Set out the ratings for each key question:

Safe - Requires improvement.

Effective - Requires improvement.

Caring - not inspected, rating of Good carried forward from the previous inspection.

Responsive - Requires improvement.

Well-led - Requires improvement.

Following our previous inspection in April 2022, the practice was rated requires improvement overall and for the safe, effective and well-led key questions. It was rated good for caring and the responsive key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Bacon Lane Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on breaches of regulations from a previous inspection.

This was a focused inspection. At this inspection, we covered the following key questions:

• Are services safe?
• Are services effective?
• Are services responsive?
• Are services well-led?

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• 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 found that:

• The practice had demonstrated some improvements in areas of concern identified during the previous inspection. However, we found additional concerns during this inspection.
• There was a lack of good governance in some areas.
• Our clinical records searches showed that the practice did not always have an effective process for monitoring patients’ health in relation to the use of medicines including medicines that require ongoing monitoring.
• Risks to patients were not assessed and well managed in relation to some medication reviews, some emergency medicines, the fire evacuation plan and the implementation of national patient safety and medicines alerts.
• Recruitment checks including Disclosure and Barring Service (DBS) were not always carried out in accordance with regulations and some records were not kept in staff files.
• There was a system in place to monitor the use of blank prescription forms and pads. However, it did not work as intended.
• There was a system for recording and acting on significant events.
• There was an infection prevention and control policy and procedures were in place to reduce the risk and spread of infection.
• There was evidence of quality improvement activity. Clinical audits were carried out.
• Patients were not able to access care and treatment in a timely way.
• Staff had received training relevant to their role.
• Annual appraisals were carried out in a timely manner.
• Feedback from patients was positive about the way staff treated people.
• The practice had systems to manage and learn from complaints.
• The Patient Participation Group (PPG) was active.

We found two breaches of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The provider should:

• Continue to encourage the patient for cervical cancer screening and childhood immunisation uptake.

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 Health Care