You are here

The Lanes Medical Practice Good

Inspection Summary


Overall summary & rating

Good

Updated 22 November 2019

This service is rated as Good overall.

The previous inspection was in April 2018.

The inspection report for the previous inspection can be found by selecting the ‘all services’ link for The Lanes Medical Practice on our website at www.cqc.org.uk.

Since the April 2018 inspection, our methodology to regulate independent doctors and clinics providing primary care services has changed, the October 2019 inspection was therefore a rated inspection and the key questions are rated as:

•Are services safe? – Good

•Are services effective? – Good

•Are services caring? – Good

•Are services responsive? – Good

•Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at The Lanes Medical Practice in Stoke Poges, Buckinghamshire on 2 October 2019.

This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The Lanes Medical Practice is registered with Care Quality Commission (CQC) under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some exemptions from regulation by CQC which relate to particular types of regulated activities and services and these are set out in Schedule 1 and Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

Some of the services available at The Lanes Medical Practice, for example private GP service provision to patients under arrangements made by their employer and a government department, are exempt by law from CQC regulation.

Therefore, we were only able to inspect the services (private GP service and travel health services) which are not arranged for patients by their employers and government departments as part of this inspection.

The provider is an individual registered with CQC to manage the service. Individuals registered have legal responsibility for meeting the legal requirements in the Health and Social Care Act 2008 and associated regulations about how the service is run.

As part of our inspection we asked for CQC comment cards to be completed by patients prior to our inspection, we received four completed comment cards which were all positive about the standard of care they received. The service advised due to the limited range of services (approximately 90% of the services provided are exempt from CQC regulation), the number of completed cards aligned to the size of the services we inspected.

All the comment cards were positive, further comments highlighted patients were satisfied with the standard of care received and thought the GPs and nurse were approachable, committed and caring. Several comments highlighted the wealth of knowledge within the travel health clinic which was easily accessible.

Our key findings were:

  • The service had clear systems to keep people safe and safeguarded from abuse. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.
  • Patients received effective care and treatment that met their needs.
  • The way in which care was delivered was reviewed to ensure it was delivered according to best practice guidance.
  • For patients accessing the travel health clinic, the GPs and nurse recorded accurate travel plans including destinations, timescales and the reason for travel.
  • All patient feedback was overwhelmingly positive, this included archived patient feedback recorded by the service included a variety of patient testimonials.
  • Both the private GP services and travel health services were tailored to meet the needs of individual patients. They were delivered in a flexible way that ensured choice and continuity of care.
  • There were clear responsibilities, roles and systems to support good governance and management. However, the governance arrangements and supporting processes to verify patient identity required improvement.

The area where the provider must make improvements as there was a breach of regulations is:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care. (Please see the specific details on action required at the end of this report).

In addition, the provider should:

  • Complete the planned training programme to ensure all members of staff are trained to the correct level of safeguarding training (in line with current safeguarding intercollegiate requirements) for their role and responsibilities.
  • Continue quality improvement activity for services subject to CQC regulation. This activity should include data evidencing improvement.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 22 November 2019

We rated safe as Good because:

  • There were systems to assess, monitor and manage risks to patient safety. The service learned when things went wrong and took steps to prevent incidents from reoccurring. The service had processes and systems in place to keep patients safe.

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider worked with external specialists and conducted safety risk assessments. It had appropriate safety policies, which were regularly reviewed and communicated to staff. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • Both the GP service and travel health service saw children under the age of 18. We saw there was a system in place to assure that an adult accompanying a child had parental authority. Staff had a clear awareness of destinations where female genital mutilation was a high-risk (FGM) and aware of their responsibilities to report concerns.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • Most staff had received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. The lead GP within the service was the safeguarding lead and had been trained in safeguarding adults and children up to level three and told us what action they would take in the event of a safeguarding concern. We saw the other clinicians (GP and nurse) had also received appropriate safeguarding training. However, we saw the non-clinical members of staff (three admin/reception staff) involved in the provision of regulated services did not have the correct level of safeguarding training for their role and responsibilities, this was not in line with current safeguarding intercollegiate requirements.
  • There was a chaperone policy and procedure available and promoted within the clinic. Chaperone duties would be undertaken by either the nurse or the second GP.

  • The service maintained appropriate standards of cleanliness and hygiene. We saw there was an effective system to manage infection prevention and control. This included a variety of infection prevention and control measures and supporting procedures. The most recent review highlighted no concerns. There was a variety of other risk assessments in place to monitor safety of the premises such as a legionella risk assessment. (Legionella is a term for a bacterium which can contaminate water systems in buildings).
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. This included annual service testing and calibration of equipment. There was a system for safely managing healthcare waste including management of used needles, predominantly used within the travel health clinic.
  • The provider carried out appropriate environmental risk assessments, which took into account the profile of people using the service and those who may be accompanying them.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly. Following the April 2018 inspection, the service had reviewed national guidance regarding the management of emergencies and recommended emergency medicines to determine which medicines to store. This review then led to a risk assessment which recorded the rationale and assessments for what medicines were stored. Although the likelihood was rare, the service also decided to hold emergency medicines which could be used in the event of a medical emergency for patients receiving travel immunisations at the travel health clinic.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • There were appropriate indemnity arrangements in place.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • When a patient arrived for their appointment, they were asked for their name, but no formal identity checks took place to confirm these details correlated with the original contact information supplied. We highlighted this concern to the service and the provider instigated a review immediately. We noted, this concern was only applicable to patients accessing the GP service, as photographic identify checks were undertaken for the travel health clinic and the unregulated services.

  • The patient records reviewed by the Care Quality Commission GP advisor to corroborate evidence contained appropriate levels of detail. For example, past medical history, medication and allergies were routinely recorded. The records of patient management were in line with good medical practice. There was evidence of appropriate communications with consultants and GP colleagues as a result of consultations.
  • Patients accessing the travel health service were asked to provide basic travel information when booking their appointment. As part of the consultation a travel questionnaire was completed with the patient and risks identified.
  • The service had a system in place to retain medical records in line with Department of Health and Social Care (DHSC) guidance in the event that they cease trading.
  • Although the occurrence of a referral was rare, the GPs had tools to make appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines, including vaccines, controlled drugs, emergency medicines and equipment minimised risks. The service kept prescription stationery securely and monitored its use.
  • Following the April 2018 inspection, the service used a toolkit from the Royal College of General Practitioners to support the GPs and patients’ responsible antibiotic use. This was also used to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. Processes were in place for checking medicines and staff kept accurate records of medicines. Where there was a different approach taken from national guidance there was a clear rationale for this that protected patient safety.
  • The service did not prescribe Schedule 2, 3, 4 or 5 controlled drugs (medicines that have the highest level of control due to their risk of misuse and dependence).

Track record on safety and incidents

The service had a good safety record.

  • There were risk assessments in relation to safety issues.
  • The service monitored and reviewed activity and developments within private GP services and travel health. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned, and improvements made

The service had mechanisms to learn and make improvements if things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses.
  • The service had not reported any serious incident relevant to the services we inspected since our April 2018 inspection. At that inspection, we saw lessons were shared to make sure action was taken to improve safety in the service. For example, following an incident related to the administration of a travel immunisation. We also noted that the incident had been reported to the appropriate external organisation. At this inspection (October 2019) we were therefore unable to test whether the system was applied as intended. Given the low numbers of incidents, the service did not use standardised template for the recording of significant events. However, staff we spoke with were aware of the requirement to communicate the incidents and accurately record information pertinent to the event. Staff told us they would have no hesitation in raising and reporting an adverse incident.
  • Staff we spoke with were aware of and complied with the requirements of the Duty of Candour. The lead GP encouraged a culture of openness and honesty.
  • The service had systems in place for knowing about notifiable safety incidents.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The service had an effective mechanism in place to disseminate alerts to all appropriate members of the team.

Effective

Good

Updated 22 November 2019

We rated effective as Good because:

  • The service had systems to keep staff up to date with current evidence-based guidance including specific travel health guidance. Staff had the skills, knowledge and experience to carry out their roles. The service monitored performance and had commenced activity to make quality improvements where possible. Where appropriate, the staff gave self-care advice including post vaccination after care advice.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to the GP service and travel health clinic).

  • The service assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines. The service monitored that these guidelines were followed through an up-to-date medical history, a clinical assessment and recording of consent to treatment. For patients accessing the travel health clinic, we saw the service accessed travel health guidance from National Travel Health Network and Centre (NaTHNaC) travel guidance.
  • The provider maintained awareness of best practice guidelines through membership of three professional bodies. These included the Independent Doctors Federation (IDF).
  • The GPs had enough information to make or confirm a diagnosis. For patients accessing the travel health clinic, a comprehensive travel assessment was undertaken prior to recommending or administering treatments.
  • We saw no evidence of discrimination when making care and treatment decisions.

Monitoring care and treatment

Following the April 2018 inspection, the service had begun quality improvement activity.

  • The service used information about care and treatment to make improvements. For example, the lead GP monitored care and treatment through random sampling of patient records. We also saw they reviewed the consultation notes of the salaried GP after every clinical session.
  • The small range of services offered resulted in limited opportunity for clinical audit. We saw the service had begun to audit prescribing habits, this included antibiotic prescribing and hypnotic prescribing. However, the first cycles of both prescribing audits were qualitative audits as opposed quantitative audits and contained limited numerical data. Therefore identifying quality improvements was limited. We highlighted this to the provider, they advised they would add numerical data to the audits and add to future cycles of audits.
  • Other quality improvement activities included a cholesterol audit (36 patients) which monitored cholesterol levels and included a review of risk factors, a risk calculation and actions discussed. We also saw the service had adapted a national Yellow Fever immunisation audit tool to include additional service specific information. This was a three-month audit which begun in October 2019.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. All members of staff were long standing team members, the provider advised if required there would be an induction/shadow programme for any newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council (NMC) and were up to date with revalidation.

  • The provider understood the learning needs of staff and provided protected time and training to meet them. We saw the service had accessed a training package from an independent training provider to widen the range of training staff received.
  • Staff whose role included travel immunisations had received specific training in providing travel health advice and vaccinations and could demonstrate how they stayed up to date.
  • The GPs were up to date with their yearly continuing professional development requirements. We saw records which demonstrated that the GPs attended various training updates.

Coordinating patient care and information sharing

Within the scope of the service, we saw staff worked together, and worked well with other organisations, to deliver effective care and treatment.

  • Patients received coordinated and person-centred care and treatment. Staff referred to, and communicated effectively with, other services when appropriate.
  • The service did not aspire to be a patient’s primary care provider or a patient’s first line GP. For the majority of patients their first line GP was their NHS GP.
  • The registration form included details of the patients registered GP. Our review of a sample of notes showed that communication with registered GPs took place when the patient gave consent for such information to be shared.
  • Before providing treatment, the GPs and nurse ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment. For patients accessing the travel health clinic, the GPs and nurse recorded accurate travel plans including destinations, timescales and the reason for travel.
  • All patients were asked for consent to share details of their consultation and any medicines prescribed with their registered GP on each occasion they used the service.
  • The provider had risk assessed the different treatments they offered. For example, individual risk assessments for patients accessing one of the travel vaccinations via an accelerated schedule (if there is insufficient time before travel to complete the course).
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services.

Supporting patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • Where appropriate, the GPs gave people advice, so they could self-care. For example, the cholesterol audit highlighted when dietary advice and smoking cessation advice was provided.
  • Patients accessing the travel health clinic were assessed and given individually tailored advice, to support them to remain healthy whilst abroad.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • The reception and waiting area within the service had a full range of leaflets providing information on various conditions, health promotion, support organisations and alternative care providers. Information leaflets were themed and aligned with national awareness programmes. During the October 2019 inspection, we saw patient information and reading materials about influenza and winter illness.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance.

  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.
  • The service displayed full, clear and detailed information about the cost of consultations and treatments, including tests and further appointments. This was displayed on the website and in the reception area and was included in all patient literature information packs. This information clearly outlined what was and what wasn’t included in the treatment costs. For example, if a prescription was required following a nurse consultation there was an additional cost.

Caring

Good

Updated 22 November 2019

We rated caring as Good because:

  • Staff treated patients with kindness, respect and compassion. Patients were involved in decisions about their care. Staff respected patients’ privacy and dignity. Written feedback from patients told us they had very positive experiences of both the GP service and travel health service.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received.
  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • As part of our inspection we asked for Care Quality Commission (CQC) comment cards to be completed by patients prior to our inspection, we received four completed comment cards which were all positive about the standard of care they received. The service advised due to the limited range of services (approximately 90% of the services provided are exempt from CQC regulation), the number of completed cards aligned to the size of the services we inspected. All the comment cards were positive, further comments highlighted patients were satisfied with the standard of care received and thought the GPs and nurse were approachable, committed and caring.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • There was clear information on the service’s website with regards to how the service worked, a frequently asked question section and a section which listed each cost that applied to the services. The website had details on how the patient could contact the service with any enquiries.
  • The service told us they had never needed to provide interpretation services for patients who did not have English as a first language. However, staff were clear on how such services could be obtained.
  • Staff introduced themselves by name to the patient and relatives.
  • Staff communicated with people in a way that they could understand.

Privacy and dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of patients’ dignity and respect and the service complied with the revised Data Protection Act (2018) and General Data Protection Regulations.
  • All confidential information was stored securely.
  • Appointments for all services provided by Lanes Medical Practice were coordinated and scheduled to avoid a busy reception area and strengthen existing privacy and dignity arrangements.
  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.

Responsive

Good

Updated 22 November 2019

We rated responsive as Good because:

  • Patients had timely access to services. Where appropriate, patients who accessed the travel health clinic could book their consultations and vaccinations as part of a planned programme. The service took account of patient’s needs and concerns were taken seriously. Feedback from patients was positive with regards to booking appointments, access to care and the timeliness of the services provided.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • Access to the service was on a planned basis with appointments booked in advance. People wishing to book an appointment for either a private GP consultation or for travel advice and immunisations were able to do so by contacting the practice by phone, e-mail or in person.
  • The provider understood the needs of their patients and improved services in response to those needs. For example, same day appointments were available for those with urgent travel needs.
  • The service was designated as a yellow fever centre, which meant it was able to accommodate people’s needs around the demand for this vaccine. The lead GP and practice nurse had been trained to administer yellow fever immunisations and the practice was appropriately registered to provide the service.
  • The facilities and premises were appropriate for the services delivered which included a large designated car park, with parking and level access.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately. The waiting time for appointments was no more than three working days for either GP consultation or travel advice. However, if there was an emergency, cancellations or other exceptional circumstances, patients could be seen at much shorter notice.
  • Patients with the most urgent needs had their care and treatment prioritised. Dependent on travel plans, patients could access travel vaccinations via an accelerated schedule, if there was insufficient time before travel to complete the course.
  • Patient feedback highlighted the appointment system was easy to use. Where appropriate, patients who accessed the travel health clinic could book their consultations and vaccinations as part of a planned programme.
  • This service was not required to offer an out of hours service. Patients who needed medical assistance out of corporate operating hours were requested to seek assistance from alternative services. This was detailed in patient literature supplied by the service and on the website.

Listening and learning from concerns and complaints

The service had a system to take complaints and concerns seriously and if required responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available.
  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The lead GP was the designated responsible person who handled all complaints in the service. We were told, any complaints which required a second opinion, or second review would be reviewed by the other GP.
  • All patient satisfaction was overwhelmingly positive, this included archived patient feedback recorded by the service including a variety of patient testimonials. As a result, there had been no complaints reported related to the service we inspected in the last five years. We were therefore unable to test whether the complaint process system was applied as intended. However, staff we spoke with were aware of how to handle complaints.

Well-led

Requires improvement

Updated 22 November 2019

We rated well-led as Requires improvement because:

  • The governance arrangements and supporting processes to verify patient identity for patients accessing the private GP service required improvement.

Leadership capacity and capability

Staff had the capacity and skills to deliver high-quality, sustainable care.

  • Although a small team, there was a clear staffing structure and staff were aware of their own roles and responsibilities. All staff were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges within private GP service and travel health and were addressing them.
  • Staff told us the provider, (also the lead GP) was visible and approachable. The limited provision of service enabled prompt communication between the provider of the service and the staff involved in delivering the registered service inspected.

Vision, strategy and culture

The service had a clear vision and credible strategy to provide accessible high-quality care, promote good outcomes for patients and deliver high quality travel health in a professional and safe manner.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The provider had a strategy to maintain the provision of those services subject to regulation. In addition, the provider continued to seek additional contracts from private organisations for services that were not regulated by Care Quality Commission (CQC).
  • The culture of the service encouraged candour, openness and honesty. Staff we spoke with told us the service had a ‘no blame’ culture and that they would have no hesitation in bringing any errors or near misses to the attention of either GP or external bodies. None of the staff we spoke with recalled any instances of poor practice that they had needed to report.
  • There were processes for providing all staff with the development they need. Staff received regular appraisals and were supported to meet the requirements of professional revalidation where necessary. The lead GP had trained the practice nurse to deliver yellow fever immunisations and the nurse would hold the yellow fever vaccination certificate when it was next renewed.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • The governance arrangements were evidenced based and appropriate to the limited range of services provided and the small team delivering these services. Staff had prompt access to provider and arrangements were in place if the provider was not immediately available.
  • There were clear responsibilities, roles and systems to support good governance and management. However, the governance arrangements and supporting processes to verify patient identity required improvement.
  • There were a range of policies and procedure relevant to the management of the services and these were kept up to date by an annual review.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety. The service was aware of national and local challenges, including the changing demand on GP services and increased national activity in private GP services - there was a strategy to manage these challenges. The service also monitored and had a clear understanding of global risks and changes within travel health, for example latest disease outbreaks.
  • The provider had tools to support an oversight of safety alerts, incidents, and complaints.
  • We saw, despite a limited opportunity for quality improvement activity within services subject to this inspection, clinical audits had begun in both the private GP service and the travel health service.
  • The provider had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance.
  • The information used to monitor performance and the delivery of quality care was accurate and useful.
  • The service submitted data or notifications to external organisations as required.
  • There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

Due to the small range of services offered and the immediate nature of the services accessed there wasn’t a structured programme of seeking patient feedback. The majority of patients attended for a single consultation or short series of travel vaccinations. However, we saw the service had commenced engagement with patients and external partners, for example:

  • Following the April 2018 inspection, we saw a patient survey with 31 responses had been completed. The results, comments and feedback had been analysed and were documented. Survey results were positive, comments highlighted high levels of care, respect and compassion. Furthermore, all patients commented they would recommend the Lanes Medical Practice.
  • Other feedback we saw was in relation to the services not subject to CQC regulation which formed the largest sector of the services work.
  • As part of the prescribing review, we saw the service encouraged and heard views from external partners, notably the local pharmacy (which dispensed 95% of prescriptions issued) and acted on their views to shape services.
  • Similarly, formal engagement with external bodies was limited to private companies and government bodies outside of the scope of CQC registration.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation. The majority of this was linked to work outside of the scope of CQC registration.

  • There was a focus on continuous learning and improvement. For example, the practice had purchased a training package from an independent training provider to widen the range of training staff received.
  • The service had the ability and tools to make use of internal and external reviews of incidents and complaints.
  • The provider demonstrated their commitment to improve and acted upon previous inspection feedback. For example, a formal review of emergency medicines, audit activity for prescribing had begun and strengthened engagement with patients and stakeholders.