The Care Quality Commission
  • Doctor
  • GP practice

Boundary House Surgery

Overall: Good read more about inspection ratings

Forest Primary Care Centre, 308a Hertford Road, London, N9 7HD (020) 8344 3120

Provided and run by:
Dr Donna Marie Samuels

Important: The provider of this service changed - see old profile

All Inspections

01 December 2023

During an inspection looking at part of the service

We carried out an announced targeted assessment of the responsive key question at Boundary House Surgery on 1 December 2023. The assessment took place remotely. As part of the assessment we have reviewed the rating for the responsive key question. As a result, the responsive key question has been rated requires improvement.

Safe – not rated, the rating of good was carried over from the previous inspection.

Effective - not rated, the rating of good was carried over from the previous inspection.

Caring - not rated, the rating of good was carried over from the previous inspection.

Responsive – rated requires improvement, the overall rating will remain good.

Well-led - not rated, the rating of good was carried over from the previous inspection.

We previously inspected the service on September 2022, the practice was rated good in all five key questions, with an overall rating of good. The full reports for previous inspections can be found by selecting the ‘all reports’ link for Boundary House Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities to complete targeted assessments of the responsive key question to better understand the experience of patients and providers.

Outline focus of inspection to include:

  • Responsive Key question inspected

How we carried out the inspection

This assessment was completed remotely.

This included:

  • Conducting staff interviews using teleconferencing.
  • Requesting evidence from the provider.
  • Reviewing the data we hold on this provider.
  • Reviewing patient feedback reported directly to us, verified patient reviews and patient experience evidence supplied by 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 and
  • information from the provider, patients, the public and other organisations.

We found that:

  • Some patients could access care and treatment in a timely way.
  • Patient feedback for access was below local and national averages.
  • We found services were developed to respond to the needs of the local population.
  • We saw evidence the practice used complaints to drive improvement.

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

  • Continue to review and improve patient feedback.

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

20 September 2022

During a routine inspection

We carried out an announced inspection at Boundary House Surgery on 20 September 2022. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective – Good

Caring - Good

Responsive - Good

Well-led - Good

Why we carried out this inspection

This inspection was a comprehensive inspection as the practice had changed registration and the new provider had not been rated by the CQC. The practice’s previous provider was rated 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 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.
  • 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.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. 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:

  • Look at further ways to improve the uptake for the childhood immunisation programme;
  • Look at further ways to improve the uptake for the cervical screening programme;
  • Continue to update long term conditions medicine reviews.

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