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Review carried out on 6 September 2019

During an annual regulatory review

We reviewed the information available to us about Hawes Lane Surgery on 6 September 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 23 May 2018

During a routine inspection

Inspection carried out on 5 September 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

We previously inspected Hawes Lane Surgery on 19 March 2015; this inspection was carried out under the previous provider’s registration. As a result of the inspection visit, the practice was rated as requires improvement overall with a requires improvement rating for providing safe and well-led services; this was because we identified some areas where the provider must make improvements and some areas where the provider should make improvements. The practice was rated good for providing effective, caring and responsive services.

We carried out an announced inspection at Hawes Lane Surgery on 5 September 2017. This inspection was conducted as a comprehensive inspection, under the new provider’s registration.

Our key findings across all the areas we inspected were as follows:

  • Staff we spoke with during our inspection spoke positively about working at the practice. Most of the comments provided by patients during our inspection were positive, indicating that patients were satisfied with the care provided by the practice and that their dignity and privacy was respected.

  • Staff we spoke with were aware of their responsibilities to raise and report concerns, incidents and near misses. However during our inspection we found that the practices system for recording significant events needed improvement.

  • We found that in some areas clinical expertise and oversight was not always in place in order to operate well governed, safe systems and processes.

  • We saw that when alerts were received and disseminated, they were recorded on the system to monitor actions taken. However during our inspection we found that the practice was not signed up to receive all national safety alerts and as a result, the practice was unable to demonstrate that they had taken necessary action in response to specific safety alerts.

  • During our inspection we found that the practice did not have adequate patient specific directions (PSDs) in place to support health care assistant’s role when administering specific vaccinations, such as flu vaccines. PSDs are written instructions by a prescriber, for medicines to be supplied or administered to a named patient after the prescriber has assessed the patient on an individual basis.

  • Although prescription stationery was securely stored we found that the practice did not operate a system to monitor and track prescription stationery. In addition, we found that the practices system for managing uncollected prescriptions was not always effective.

  • We observed the premises to be visibly clean and tidy.

  • The results from the most recently 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 were yet to be able to demonstrate sustained improvement and improved satisfaction in this area.

We saw an area of outstanding practice during our inspection:

  • Winter bags had been set up during the winter months in 2016, to support their vulnerable patients; including vulnerable older patients and patients who were living in isolation. This idea was initiated in practice and the team put support bags together to give to vulnerable patients in the practice and during home visits. Each bag contained a hot water bottle, a blanket, a pair of gloves, a pair of socks, a hat, a torch and a thermos mug to help patients through the winter months. Approximately 35 bags were handed out to help patients, although outcomes were not recorded in the practice, staff expressed that patients responded very positively to this piece of work and that the practice was going to repeat the winter bag initiative this year.

However, there were areas of practice where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way to patients.

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvement are:

  • Continue to explore ways to improve satisfaction rates with regards to access.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice