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Inspection Summary

Overall summary & rating

Inspection areas



Updated 23 July 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • Staff provided support and advice to vulnerable patients such as those recently bereaved and patients living in vulnerable circumstances.

Involvement in decisions about care and treatment

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

  • Staff communicated with people in a way that they could understand, for example, communication aids, Interpretation services were available for patients who did not have English as a first language.
  • Staff helped patients and their carers find further information and access community and advocacy services.
  • The practice proactively identified carers and supported them.
  • The practice sent birthday cards to patients aged 75 and over.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • Reception staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect.

Please refer to the Evidence Tables for further information.


Requires improvement

Updated 23 July 2018

We previously carried out an announced comprehensive inspection at Hawes Lane Surgery on 5 September 2017. At the time the practice was rated requires improvement for providing responsive services. The results from the most recent published national GP patient survey highlighted that some responses were below local and national averages in relation to access. Although we found that the practice had made some changes to improve access, at the point of our inspection the practice was unable to demonstrate sustained improvement and improved satisfaction in this area.

During this inspection we rated the practice as requires improvement for providing responsive services. The concerns which led to this rating apply to everyone using the practice, including all of the population groups which were rated as requires improvement.

Responding to and meeting people’s needs

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

  • The practice understood the needs of its population and tailored services in response to those needs. For example, the practice held coffee mornings on Tuesdays and Thursdays for patients who may be socially isolated.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • There were facilities in place for people with disabilities and those with mobility difficulties. The practice was in the early stages of moving to a new purpose-built building which would improve facilities for patients and enable the practice to expand services
  • Reasonable adjustments were made when patients found it hard to access services such as home visits.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.
  • The practice offered an in-house phlebotomy service and diabetes clinic with specialist nurses.

Older people:

  • Patients over the age of 75 had a named GP and a care co-ordinator in place at the practice.
  • The practice was responsive to the needs of older patients, and offered urgent appointments for those with enhanced needs.
  • The GP, practice nurse and healthcare assistant accommodated home visits for those who had difficulties getting to the practice. This included visits for blood tests and to administer the flu and shingles vaccines.
  • The practice held a coffee morning every Tuesday and Thursday for patients to attend the aim was to benefit patients who may be socially isolated.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met.
  • The practice operated a joint diabetic specialist clinic (DICE) every eight weeks with a hospital diabetic specialist nurse and with the practice nurse for their diabetic patients with complex needs.
  • Patients receiving end of life care were discussed at multi-disciplinary team meetings so that information was shared in a timely manner.

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

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

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, the practice had developed joint working in conjunction with six other general practices. This was part of a local federation. This enabled patients to access appointments across the six practices seven days a week which included weekday evenings and weekend mornings.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode. Evidence seen that a vulnerable person with no fixed address was able to register at the practice.

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

  • The practice worked with other health and social care organisations in the case management of people experiencing poor mental health, including those with dementia.
  • Patients with complex needs and patients experiencing poor mental health were regularly discussed during MDT meetings.
  • Performance for dementia related indicators for 2016/17 was 100%. No patients had been exception reported.
  • Performance for overall mental health related indicators for 2016/17 was comparable to other practices nationally.

Timely access to care and treatment

During the previous inspection in September 2017, the results from the national GP patient survey published in July 2017, highlighted the practice was below local and national averages in relation to access and needed to explore ways to improve.At this inspection it was clear that the practice had made changes improve access for patients by implementing a number of actions. For example, the practice had developed joint working in conjunction with six other general practices as part of a local federation. This enabled patients to access appointments across six neighbouring practices seven days a week which included weekday evenings and weekend mornings. Staff told us of plans to install a new telephone system at the end of May 2018.This would enable staff to manage demand and monitor call waiting times to improve efficiency. More telephone lines would be made available to reduce the time patients were waiting to get through to the practice by phone. However, some of the feedback from patients at this inspection indicated that access was still an area for improvement. At the time of the inspection there was insufficient evidence to suggest that all areas of the national GP patient survey which required improvement had been fully addressed. The actions taken to date by the practice would need further analysis to assess the impact on the ability of patients to access care and treatment in a timely manner and ensure long term sustainability.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care. For example, following a complaint about a delay in a report for a patient. The practice had written and apologised to the patient and made changes to ensure such reports were completed in a timely manner

Please refer to the Evidence Tables for further information.



Updated 23 July 2018

We previously carried out an announced comprehensive inspection at Hawes Lane Surgery on 5 September 2017. At the time the practice was rated requires improvement for providing well led services. There was a lack of clinical oversight in some areas and a lack of evidence to support shared learning from significant events and complaints.

During this inspection we rated the practice as good for providing a well-led service.

Leadership capacity and capability

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

  • They were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. This included the need for permanent GP’s.
  • The manager and GP’s were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future and ensuring sustainable clinical leadership.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care.

  • There was a clear vision and set of values, the management and staff were passionate about the care they provided and took pride in being a caring compassionate practice.
  • The practice had a realistic strategy and supporting business plans to achieve priorities this included the need for social prescribing and the need for a purpose-built premise.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The practice planned its services to meet the needs of the practice population.


The practice had a culture of high-quality sustainable care.

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • The practice focused on the needs of patients.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Although some of the clinical staff worked as locum, they were considered valued members of the practice team. They were given protected time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

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

  • Systems and processes had been developed to support good governance and effective management. This included clinical leadership provided by one of the long-term locum. The practice manager who was also the provider had overall responsibility and oversight of the governance arrangements within the practice.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control
  • Overall the practice had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

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 practice had processes to manage current and future performance. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Practice leaders had oversight of national and local safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice implemented service developments to improve efficiency.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care for example, implementing a new telephone system.
  • The practice submitted data or notifications to external organisations as required.
  • There were arrangements in place 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

The practice involved patients, staff and external partners to support high-quality sustainable services.

  • Patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to improve the service.
  • There was an active patient participation group (PPG).The PPG worked alongside the practice to develop an in-house patient survey in response to results of the national GP survey. An action plan was developed and improvements made to help increase access for patients.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The practice made use of internal and external reviews of incidents and complaints.
  • Learning was shared and used to make improvements.
  • The practice demonstrated proactive and innovative in ways to support vulnerable patients.

Please refer to the Evidence Tables for further information.

Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement