The Lordship Lane Surgery

Updated 20 July 2023

The Lordship Lane Surgery in London at:

417 Lordship Lane

East Dulwich

London

SE22 8JN

The provider is registered with CQC to deliver the Regulated Activities, diagnostic and screening procedures, family planning, maternity and midwifery services, treatment of disease, and disorder or injury.

The practice offers services from a single location.

The practice is situated within the South East London Integrated Care Board (ICB) and delivers Primary Medical Services (PMS) to a patient population of 5310. This is part of a contract held with NHS England.

The practice is part of Dulwich Primary Care Network which includes four other neighbouring GP practices.

Information published by Public Health England report deprivation within the practice population group as 6 on a scale of 1 to 10. Level 1 represents the highest levels of deprivation and level 10 the lowest.

The practice has a higher percentage of unemployed people compared to the national average (13% compared to 4%).

The average male and female life expectancy for the ICB area and the practice is in line with the national average for both males and females. The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.

The staff team at the practice consists of two full time male GPs, one female GP, a male practice manager, two-part time female practice nurses, two administrators/receptionists. The service is provided from this location only.

Updated 20 July 2023

We carried out an announced comprehensive at The Lordship Lane Surgery on 17 May 2023. Overall, the practice is rated as requires improvement.

Safe - Requires improvement.

Effective - Requires Improvement.

Caring - Good

Responsive - Good

Well-led - Requires improvement.

Following our previous inspection on 19 April 2021, the practice was rated Requires Improvement overall and Good for the Caring and Responsive key questions:

The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Lordship Lane Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection to follow up on the warning notice and requirement notice, which had been issued during our inspection in April 2021. We looked at the Safe, Effective, Caring, Responsive and Well-led key questions and followed up on breaches of regulation 17 (Good governance) and 18 (Staffing).

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A site visit.

Our findings

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 found that:

• The practice had addressed some of the concerns raised at the last inspection, for example, they now had baby changing facilities available to service users.
• They had undertaken risk assessments for emergency medicines considered not to be required.
• We saw the practice had introduced a cleaning schedule detailing which areas of the practice had been cleaned.
• The practice had improved the up take for childhood immunisations.
• Patients were not always monitored effectively.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm in most cases.
• Patients received effective care and treatment that met their needs in most cases.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care in most cases.

The areas where the provider must make improvements as they are in breach of regulations 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 provider should:

• Continue to monitor and improve cervical screening uptake to bring in line with the England average.
• Work on ways to redevelop the practice Patient Participation Group.
• Take action to undertake a patient survey.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services