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Inspection Summary


Overall summary & rating

Updated 22 May 2018

We carried out an announced comprehensive inspection on 5 April 2018 to ask the service the following key questions; Are services safe, effective, caring, responsive and well-led?

Our findings were:

Are services safe?

We found that this service was providing safe care in accordance with the relevant regulations.

Are services effective?

We found that this service was providing effective care in accordance with the relevant regulations.

Are services caring?

We found that this service was providing caring services in accordance with the relevant regulations.

Are services responsive?

We found that this service was providing responsive care in accordance with the relevant regulations.

Are services well-led?

We found that this service was providing well-led care in accordance with the relevant regulations.

We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the practice was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

The services inspected included provision of travel immunisations and private GP consultations for people who either sought a second opinion or access to an immediate appointment. Some patients also used the service to obtain a private health assessment. There was also a system in place for parents of patients aged under 16 to confirm their identity when these younger patients attended for travel immunisations.

This service is registered with 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 service and these are set out in Schedule 2 of The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. At The Lanes Medical Practice services are provided to patients under arrangements made by their employer and a government department. These types of arrangements are exempt by law from CQC regulation. Therefore, at The Lanes Medical Practice, we were only able to inspect the services which are not arranged for patients by their employers and government departments.

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

Prior to the inspection we asked for feedback from patients by providing CQC comment cards to the practice four weeks in advance. We received 17 completed CQC feedback cards. All the patients who provided feedback were positive about the service they received. Patients described the service as caring, personalised and professional.

Our key findings were:

  • Systems were in place to protect people from avoidable harm and abuse.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Information about the service and how to complain was available.
  • There was a clear leadership structure and staff felt supported by the provider and worked very well together as a team. The provider was aware of the Duty of Candour.
  • The premises were appropriate to the service delivered and were accessible to clients with mobility difficulties.
  • There were appropriate arrangements in place to share information with the patients’ registered GPs.
  • There was an effective system to deal with blood samples and test results.
  • The system in place to receive feedback from patients did not include those patients receiving services subject to regulation.

There were areas where the provider should make improvements and should:

  • Review and improve the process in place in relation to the use of patient group directions for administration of vaccines to ensure this is in line with National Institute for Health and Care Excellence (NICE) guidance.
  • Improve quality improvement methods to carry out medicines audits to include antibiotics and hypnotics.
  • Monitor the effectiveness and sustainability of the changes made to procedures at the time of, and immediately following, inspection.
  • Review the processes in place to obtain and act upon patient feedback from patients receiving services subject to regulation.
Inspection areas

Safe

Updated 22 May 2018

We found that this service was providing safe care in accordance with the relevant regulations.

  • The service had clearly defined systems, processes and practices in place to keep people safe and safeguarded from abuse.

  • There was an effective system in place for reporting and recording significant events. However, no incidents relating to the services inspected had occurred.
  • There was a system in place to enable lessons to be shared to make sure action was taken to improve safety in the clinic.
  • There were arrangements in place for the management of vaccines and medicines. At the time of inspection there were some concerns identified but these were all rectified within two days of the inspection being completed.
  • The service offered a wide range of travel immunisations. This included administration of yellow fever immunisations for which the practice was registered and staff trained appropriately to administer these.
  • The service reviewed the arrangements in place to respond to medical and other emergencies. Within two days of inspection there were appropriate arrangements in place to deal with such emergencies.

Effective

Updated 22 May 2018

We found that this service was providing effective care in accordance with the relevant regulations.

  • Staff assessed client needs and delivered care in line with current evidence based guidance.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Staff informed us that they had regular appraisals and personal development plans for all staff were completed annually.
  • There were limited processes in place to drive quality improvement. For example, an audit programme was not in place.

Caring

Updated 22 May 2018

We found that this service was providing caring services in accordance with the relevant regulations.

  • Information for clients about the services available was easy to understand and accessible.
  • Information from CQC comment cards and feedback received by the service highlighted that staff treated clients with kindness and respect, and that clients were involved in decisions about their care and treatment.

Responsive

Updated 22 May 2018

We found that this service was providing responsive care in accordance with the relevant regulations.

  • The service offered a flexible appointment system.
  • Information about how to complain was available and easy to understand. However, we were informed that no complaints had been received within the last three years.
  • The service was located at ground floor level and could be accessed by patients with mobility problems. Translation services were available but had not been required.
  • The systems in place to receive and act upon patient feedback were limited and did not include feedback from patients receiving services subject to regulation

Well-led

Updated 22 May 2018

We found that this service was providing well-led care in accordance with the relevant regulations.

  • The service had a clear vision and strategy to deliver high quality care and promote good outcomes for patients.
  • There was a clear leadership structure and staff felt supported by the provider.
  • The service had a number of policies and procedures to govern activity and held regular staff meetings.
  • The service had systems in place for notifiable safety incidents.
  • Opportunities for continuous learning and improvement were appropriate for the level of service provided.
  • The service sought feedback from patients and stakeholders. However, the processes to obtain feedback did not extend to all patients.