The Care Quality Commission
  • Doctor
  • GP practice

Pearl Medical Practice

Overall: Good read more about inspection ratings

116 Chaplin Road, Wembley, Middlesex, HA0 4UZ (020) 3837 9960

Provided and run by:
Dr Parita Amish Mehta

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

All Inspections

During an assessment under our new approach

Date of assessment: 7 August to 13 August 2024. Pearl Medical Practice provides primary care services from purpose-built premises located in the Wembley Centre for Health and Care, 116 Chaplin Road, Wembley, London HA0 4UZ. There were approximately 5,250 people registered with the service at the time of our assessment. Published demographic data shows that the practice population has a higher proportion of young people and a lower proportion of patients aged over 55 than the English average. Levels of income deprivation are in line with the English average however there is a relatively high prevalence of some longer-term conditions such as diabetes mellitus. We conducted this assessment to follow-up on a previous breach of regulations and covered the key questions of effective and well-led. We found that the provider had addressed the issues identified at our previous inspection. We also covered 4 quality statements from the safe key question and 1 quality statement from the responsive key question and combined the scores for these areas with the scores from the last inspection for the quality statement areas we did not assess this time. The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. The facilities and equipment met the needs of people, were clean and well-maintained and any risks mitigated. Staff managed medicines well and involved people in planning any changes. People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people took decisions in people’s best interest

15 September 2021

During an inspection looking at part of the service

We carried out an announced focused inspection at Pearl Medical Practice on 15 September 2021. Overall, the practice is rated as Requires Improvement.

Safe - Good

Effective - Requires Improvement

Well-led - Requires Improvement

Following our previous inspection on 18 February 2020, the practice was rated Requires Improvement overall and for key questions safe and well led, and good for providing effective, caring and responsive services.

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

Why we carried out this inspection

This inspection focused inspection to follow up on breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance. At the previous inspection we found:

  • The provider had not undertaken risk assessments to ensure the health and safety of staff and people using the service.
  • Systems and processes to ensure good governance in accordance with the fundamental standards of care required had not always identified the shortfalls within the service.

We also followed up on areas we identified the practice should improve at the last inspection. Specifically:

  • Continue to review and improve the uptake of cervical screening and the childhood immunisation programme.
  • Review staff’s understanding of the duty of candour.

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

We have rated this practice as Requires Improvement overall and RI for all population groups.

We found that:

  • Policies were monitored, reviewed and updated.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
  • Staff dealt with patients with kindness and respect.
  • The practice proactively sought feedback from patients, which it acted on.
  • There was evidence of quality improvement activity.

We found a breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We also found the provider should:

  • Continue to consider ways to improve uptake for cervical screening and childhood immunisations.
  • Ensure that all staff are aware of who their Freedom to Speak Up Guardian is and how they can be contacted.
  • Continue to consider ways to improve data not consistent with national targets, including diabetes and antibiotic prescribing.

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

18 February 2020

During a routine inspection

We carried out an announced comprehensive inspection at Pearl Medical Practice (Dr Parita Mehta) on 18 February 2020 as part of our inspection programme.

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 and requires improvement for safe and well-led. We rated the practice good for effective, caring and responsive and in all the population groups.

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

  • The provider had not undertaken risk assessments to ensure the health and safety of staff and people using the service.
  • Systems and processes to ensure good governance in accordance with the fundamental standards of care required had not always identified the shortfalls within the service.

We rated the practice as good for providing effective, caring and responsive services because:

  • 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.
  • There was a clear leadership structure and staff felt supported by management.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way for patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Continue to review and improve the uptake of cervical screening and the childhood immunisation programme.
  • Review staff’s understanding of the duty of candour.

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