Updated 19 June 2025
Date of Assessment: 24 July 2025 to 30 July 2025.
Lytham Road Surgery is a GP practice that delivers service to 13416 under a contract held with NHS England. The National General Practice Profiles states that 75% of the practice population is White, 19% Asian, 2% Mixed 2% Black and 2% Other. Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 8th decile (8 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
SAFE: Recruitment procedures were not safe; the provider did not carry out all the required checks or hold the required information. Staff did not always demonstrate they understood and managed risks fully. Managers did not always make sure staff received regular supervision and monitoring to ensure high-quality care. Staff did not always manage medicines well and involve people in planning any changes. However, the provider 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 identified were mitigated.
EFFECTIVE: Care was not always carried out in line with latest evidence and good practice. Staff did not always ensure people understood their care and treatment nor enabled them to give informed consent. Staff did not evidence they involved those important to people to take decisions in people’s best interests where they did not have capacity. It was not always evident that people were involved in assessments of their needs. However, staff reviewed assessments taking account of people’s communication, personal and health needs. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services.
CARING: People were treated with kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
RESPONSIVE: People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood options around choosing to withdraw or not receive care.
WELL-LED: There was not an embedded culture of continuous improvement and quality assurance. The practice did not have effective systems to assess, monitor and improve the quality and safety of the services they provided. They did not have systems and processes that enabled them to identify and assess risks to the health and safety of people who used the service. However, leaders and staff had a shared vision and culture based on listening, learning and trust and were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas.
We found breaches of regulation in relation to safe care and treatment and good governance. We have asked the provider for an action plan in response to the concerns found at this assessment.