We carried out a review of the data available to us about Sutherland Lodge Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Sutherland Lodge Surgery, you can give feedback on this service.
We carried out an announced comprehensive inspection at Sutherland Lodge Surgery on 7 October 2019 as part of our inspection programme.
At this inspection, we followed up on breaches of regulations identified at a previous inspection on 13 November 2018, when we rated the practice as requires improvement overall. Specifically we rated safe, effective and well-led as requires improvement with caring and responsive rated as good.
Prior to the inspection of November 2018, we inspected the practice in December 2017 and rated the practice as inadequate overall. They were placed in special measures for a period of six months.
We based our judgement of the quality of care at this service on a combination of:
We have rated this practice as good overall.
We rated the practice as requires improvement for providing caring services because:
We rated the practice as good for providing safe, effective, responsive and well-led services because:
The areas where the provider should make improvements are:
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care
This practice is rated as requires improvement overall. (Previous rating December 2017 – Inadequate)
Sutherland Lodge Surgery was previously inspected in December 2017 and received a rating of inadequate overall. We found the practice was inadequate for providing safe, effective, responsive and well-led services. As a result of the risk identified at this inspection, we asked the provider to take immediate action to mitigate the risks. We then carried out a focused inspection on 10 January to check whether the provider had taken appropriate action to lower the risk. We found that they had done so. We then issued a warning notice for regulation 17, good governance, to ensure the practice made appropriate improvements.
We reviewed the areas covered within the warning notice during an unrated focused inspection in July 2018 and found that they had complied with the warning notice.
We carried out an announced comprehensive inspection at Sutherland Lodge Surgery on 13 November 2018 to follow up on breaches of regulation.
The key questions at this inspection are rated as:
Are services safe? – Requires improvement
Are services effective? – Requires improvement (for patients with long-term conditions, those experiencing poor mental health and those who were vulnerable)
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Requires improvement
At this inspection we found:
We saw one area of outstanding practice:
The practice had gained funding from the provider to create ‘positivity packs’ which were designed to help vulnerable patients such as those with mental health conditions and the homeless. Staff at the practice were proud of the work they had achieved and had received feedback from patients that the packs had helped them through vulnerable situations.
The areas where the provider must make improvements are:
The areas where the provider should make improvements are:
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.
Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.
Sutherland Lodge Surgery was previously inspected in December 2017 and received a rating of inadequate overall. We found the practice was inadequate for providing safe, effective, responsive and well-led services. As a result, we issued a warning notice for regulation 17, good governance, to ensure the practice made appropriate improvements.
We carried out an announced focused inspection at Sutherland Lodge Surgery on 04 July 2018. The focused inspection was to review whether the provider had made improvements and was compliant with the warning notice. We also looked at the governance arrangements and the leadership of the practice. The practice was not rated at this inspection.
At this inspection we found:
The areas where the provider should make improvements are:
The practice had made effective improvements and had complied with the warning notice.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
Please refer to the detailed report and the evidence tables for further information.
We carried out an announced, comprehensive inspection of Sutherland Lodge on 7 December 2017. At this inspection, we found a number of areas of serious concern relating to risk management and patient safety. We spoke with the provider about our findings and asked them to send us an action plan to assure us that the areas of high risk that we found on inspection were being managed effectively and the risks to patients reduced.
As a result of the action plan sent to us on 22 December 2017, we found that the provider had identified measures to reduce the risks to patients.
We then carried out an unannounced focused inspection on 10 January 2018 to check whether the service had implemented their action plan effectively and made sufficient progress to reduce the risk to patients, since the last inspection on 7 December 2017 and to enable us to assess the level of enforcement action we needed to take. This report covers our findings.
The practice was not rated as part of this inspection and we only looked at areas where risk was assessed as high, as a result of the last inspection.
Our key findings were as follows:
We were satisfied that the findings at this inspection reduced the risk to patients to a level where significant enforcement action was not required. The provider was continuing to make improvements as identified in their action plan.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
This practice is rated as inadequate overall.
The key questions are rated as:
Are services safe? – Inadequate
Are services effective? – Inadequate
Are services caring? – Requires improvement
Are services responsive? – Inadequate
Are services well-led? - Inadequate
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Inadequate
People with long-term conditions – Inadequate
Families, children and young people – Inadequate
Working age people (including those recently retired and students – Inadequate
People whose circumstances may make them vulnerable – Inadequate
People experiencing poor mental health (including people with dementia) - Inadequate
We carried out an announced comprehensive inspection at Sutherland Lodge on 7 December 2017, as part of our inspection programme and in response to concerns, raised directly with us relating to patient access, the quality of treatment, the management of prescriptions and delays in referrals.
As a result of the findings at this inspection, we asked the provider to take action to reduce the more concerning risks by 22 December 2017 and we then carried out a further focused inspection on 10 January 2018, to check whether the risks to patients had been reduced. We found that they had. The report of this inspection has not yet been completed at the time of writing this report, but it will be published on our website in due course.
Our key findings at the inspection on 7 December 2017 across all the areas we inspected were as follows:
Systems, processes and practices to keep people safe and safeguarded from abuse were unreliable. Clinical staff were not trained to the correct level recommended by guidance.
Also clinical staff did not always adhere to or have sufficient knowledge of the Mental Health Act Code of Practice.
Some of the key requirements from the Health and Social Care Act 2008 Code of Practice on the prevention and control of infection were not being met.
Risks to patients were not being appropriately assessed, or their safety monitored and managed so they were supported to stay safe. There was a lack of clinical oversite to ensure information received regarding new diagnosis and medicine changes were not completed in a timely way.
Staff were aware of their responsibilities to manage emergencies on the premises and they had up to date information on how to identify and manage patients with severe infections, for example, sepsis.
Medicines and associated equipment were not always in date or stored at the correct temperature and nursing staff tasked with monitoring did not take action when temperatures were above recommended levels.
Arrangements in place to receive and comply with patient safety alerts, recalls and rapid response reports were ineffective. There was no process to ensure safety alerts were actioned and patients informed if they were at risk.
There had been no significant events identified therefore there was no evidence of learning from incidents to improve quality. Opportunities to analysis, action change and share outcomes were missed.
Patients with complex needs for example learning disabilities and older patients were not receiving their care in line with guidance. For example care plan reviews and health checks.
Medicine reviews were not always taking place. There were inconsistent reviews of high-risk medicines and action to address risks was not always in line with national guidance.
There was a corporate system for the handling of complaints. However, this did not include cascading the learning to staff working at the practice or ongoing monitoring. Action was not always taken to improve the quality of care as a result.
Some outcomes for patients were below local and national averages. Participation in audits and quality assurance processes was limited.
Patients reported there was a lack of continuity of care and we saw that this had a detrimental impact on the quality of patient treatment and care.
Services were not always planned or delivered in a way that met patient’s needs. There was no evidence the service took account of patient preferences.
Appointment systems were not working well so patients did not receive timely care when they needed it, particularly in relation to GP home visits. Patient survey results and CQC comment cards identified patients had concerns about access to GP appointments and getting through to the practice by phone.
The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.
Risks within the practice were not effectively managed and risk assessments were either unavailable or insufficient. Staff responsible for the management of risks and health and safety were not aware of the scope of these responsibilities.
Policies and procedures were not always accessible, clear or up to date.
There was uncertainty amongst staff due to unclear changes in relation to the registered provider and a subsequent impact on the staffing structure within the practice.
There were accessible facilities, which included a hearing loop, and interpretation services available.
The areas where the provider must make improvements are:
Ensure there are systems to assess, monitor, manage and mitigate risks to the health and safety of patients who use services.
Ensure that persons providing care or treatment to service users have the qualifications, competence, skills and experience to do so safely.
Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Ensure the proper and safe management of prescribing medicines. This is to include repeat prescribing and monitoring of high-risk medicines.
The areas where the provider should make improvements are:
Ensure there were systems for assessing the risk of, and preventing, detecting and controlling the spread of infections. Monitor and schedule cleaning of areas where debris collects.
Continue to review how the practice could proactively identify carers in order to offer them support where appropriate.
Review the current processes for engaging with the practice population to encourage patients to feedback on services.
The provider should actively seek the views of a wide range of stakeholders, including people who used the service. The provider did not analyse patient feedback or made improvements.
Ensure that equipment used by the service provider for providing care or treatment to a service user was safe for such use. Checks for out of date equipment should be made frequently.
I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.
The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration.
Special measures will give people who use the service the reassurance that the care they get should improve.’
Chief Inspector of General Practice