Kensington Road surgery

Updated 22 January 2024

Kensington Road Surgery provides a range of primary medical services to people living in the surrounding area, including two local care homes.

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 delivers General Medical Services (GMS) to a patient population of about 5950. This is part of a contract held with NHS England.

The practice population is predominantly white (83.3%) and asian (11.3%) patients. Information published by Public Health England shows that deprivation within the practice population group is in the third from highest decile (8 out of 10). The lower the decile, the more deprived the practice population is relative to others.

The practice is led by one GP. There is 1 salaried GP and locum GPs. The practice has an advanced nurse practitioner (ANP), prescribing paramedic and 2 practice nurses. There is a practice manager, a deputy practice manager and a team of administration staff. Also, there are pharmacists, a physiotherapist, midwife, care coordinators and social prescribers working for partner organisations.

The practice is open 8am to 6.30pm Monday to Wednesday, 8am to 1pm on Thursday and 8am to 6.30pm on Friday. The practice is closed at weekends.

When the practice is closed out of hours services are provided by the NHS 111 service.

Updated 22 January 2024

We carried out an announced inspection at Kensington Road Surgery on 9 October 2023.

Overall, the practice is rated as Requires improvement.

The ratings for each key question:

Safe – Requires improvement.

Effective – Good.

Caring – Requires improvement.

Responsive – Requires improvement.

Well-led – Good.

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 in person and on the phone
• 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 found that:

• The practice had a backlog of medicine monitoring and reviews for patients prescribed certain high risk medicines and patients prescribed medicines to treat specific long term conditions. Processes to identify patients that needed a new course of treatment for a long term condition, such as diabetes, were not always effective. Although the practice had identified the issues and had a plan in place, plans were ongoing. Actions were in their infancy and were yet to be embedded.
• The practice had a plan to address a backlog of summarisation of new patient notes but this work was ongoing.
• The practice had improved access and the overall experience for patients, but there was limited evidence on the positive impact on patient experience.

However we also found that:

• There was an effective system to identify and safeguard people from abuse. Clinical staff received regular updates, training and took steps to ensure they were familiar with the most recent clinical guidelines.
• We observed staff dealt with patients with kindness and respect.
• Patients could access care and treatment in a timely way.
• There was a clear leadership structure and staff felt supported by management.
• The practice team demonstrated a commitment to learning and improvement at all levels of the organisation.

The provider MUST:

• Ensure care and treatment is provided in a safe way to patients.

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