Archived: Great Lever One

We carried out an announced inspection at Great Lever One on 11 May 2021. Overall, the practice is rated as good.

Safe - good.

Effective – good

Caring – good

Responsive – good

Well-led – good

Why we carried out this inspection.

This inspection was the first comprehensive inspection of the service since it was registered in August 2019.

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 good overall. We rated the population groups as follows:

Older people: good.

People with long-term conditions: good.

Families, children and young people: good.

Working age people (including those recently retired and students): requires improvement.

People whose circumstances may make them vulnerable: good.

People experiencing poor mental health (including people with dementia): good.

We rated the practice good for providing safe services.

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.

We rated the practice good for providing effective services.

• Patients receive effective care and treatment that met their needs.
• Data for cervical screening was below the local and national average. Measures had been put in place by the practice but were not yet demonstrating improvement

We rated the practice good for providing caring services.

• Staff dealt with patients with kindness and respect.

We rated the practice good for providing responsive services.

• Patients’ views of the service were mixed. Data shows patients’ satisfaction rates in some areas were below local and national average.
• 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.

We rated the practice good for providing well led services.

• The way the practice was led and managed promoted the delivery of a good person-centred care.

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

• Record the decisions made in relation to a patient’s care plan when they receive end of life care and will not be resuscitated at the end of their life.
• Improve data relating to cervical screening and childhood immunisations.
• Improve data relating to patient satisfaction rates in relation to the care and treatment they receive.

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