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The Lordship Lane Surgery Requires improvement

Inspection Summary

Overall summary & rating

Requires improvement

Updated 10 April 2020

We carried out an inspection of The Lordship Lane Surgery on 11 February 2020 . The inspection of this service was prompted by our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a change to the quality of care provided since the last inspection.

This inspection focused on the following key questions: Safe, Effective and Well Led.

Because of the assurance received from our review of information we carried forward the ratings for the following key questions: Caring and Responsive

At this inspection we identified concerns around the management of medicines and low level risks associated with the premises. The practice had not met targets for childhood immunisations and certain types of screening and had above average exception reporting for patients with some long term conditions. There was also no system in place to monitor the professional registrations of clinical staff, training had not been completed for all staff and the practice had not followed their recruitment policy in respect of one new staff member recruited since our last inspection.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Requires Improvement overall and Inadequate for families children and young people, requires improvement for people experience poor mental health and working age people and good for all other population groups.

We rated the practice as requires improvement for providing safe services because:

  • The systems in place for managing patients prescribed medicines, including one high risk medicine did not ensure that all patients received timely monitoring in line with guidance to ensure that these medicines remained safe to prescribe. We found two patients who were not receiving appropriate monitoring and the rationale for continuing to prescribe medication in absence of monitoring was not documented in the patient’s notes.
  • Prescription numbers were not logged upon delivery to the practice although they were stored securely and there were systems to monitor prescriptions when they were distributed to clinical rooms.
  • The prescribing of controlled medicines had not been audited to ensure that prescribing was appropriate and safe.
  • One member of staff had been recruited since our last inspection and most appropriate recruitment checks had been completed for this staff member. However there was no system in place to periodically monitor the professional registrations of clinical staff.
  • The practice had safeguarding systems in place.
  • Risks associated with the premises had been assessed however the practice had not taken adequate action to address low level risks associate with legionella bacteria.
  • There were systems in place to report significant events and we saw evidence of discussion of events in practice meetings and changes made to prevent similar incident occurring in the future.
  • The provider had adequate arrangements in place to respond to emergencies including patients who presented with symptoms of sepsis.

We rated the practice as requires improvement for providing effective services because:

  • Patients were receiving regular reviews and the treatment provided was in line with current guidelines this was reflected in comparable or above average levels of achievement against most local and national targets. However, performance against targets for childhood immunisations were significantly below the World Health Organisation Targets, performance for cervical screening was below the Public Health England target and the rate of exception reporting for patients with some conditions was above local and national averages.
  • There was evidence of quality improvement activity.
  • Staff were receiving regular appraisals but some training had not been completed by all staff including equality and diversity, mental capacity act and information governance.
  • We saw examples of effective joint working with other organisations.

We rated the practice as requires improvement for providing well-led services because:

  • There were effective governance arrangements in many areas. However some aspects of the systems for the management of medicines were not sufficient and the provider had no system to monitor the professional registrations of clinical staff.
  • Information that highlighted risk around the prescribing of one high risk medicine had not been acted upon to fully mitigate the risk identified.
  • The practice had not undertaken adequate analysis or made sufficient improvements in respect of targets for childhood immunisations and certain cancer screening. The provider was also unaware of certain above average rates of exception reporting for some long term conditions.
  • The provider had adequate systems in place to assess, monitor and address risk in most areas although some low-level risks related to legionella had not been addressed.
  • The provider had an active patient participation group who met regularly and felt able to raise concerns and contribute ideas regarding the operation of the service. We saw evidence that the provider considered suggestions.
  • There was some evidence of continuous improvement or innovation.
  • Staff provided positive feedback about working at the practice which indicated that there was a good working culture.

The areas 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

  • Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out their duties

The areas where the provider should make improvements are:

  • Consider having external assessments for risk associated with the practice premises.
  • Undertake an audit of controlled medicines prescribing.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Please refer to the detailed report and the evidence tables for further information.

Inspection areas


Requires improvement


Requires improvement






Requires improvement
Checks on specific services

People with long term conditions


Families, children and young people


Older people


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