The Lakeside Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

People were involved in the assessment of their needs and in decisions about their care and treatment. However, administrative systems for reviewing assessments were not always failsafe, and there was limited assurance that patients received continuity of care. The provider promoted healthier lives through screening, immunisations and health promotion initiatives. However, long-term condition management was variable, administrative gaps delayed patient reviews, and governance audits failed to improve clinical outcomes.

We looked for evidence that staff involved people in decisions about their care and treatment. Staff said they reviewed people's care and worked with other services to achieve this. Whilst inspectors found examples of collaborative working with partner organisations, the provider could not consistently demonstrate through records and governance systems how this was monitored, embedded and reviewed. At our last inspection, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

This service scored 58 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The provider safely used Artificial Intelligence systems to register new patients, and transfer records. We identified examples of appropriate clinical decision making during the assessment, and staff told us patients received assessments based on their presenting needs. This was reflected in the National GP Patient Survey, where 83% of respondents said their needs were met during their last appointment, compared to the local result of 91% and the national result of 90%. However, clinical searches demonstrated that ongoing assessment, review and follow-up were not consistently undertaken in a timely manner or in line with national guidance. Call and recall systems did not ensure that all patients received appropriate follow up treatment.

Clinical searches undertaken during the assessment identified patients with long-term conditions who had not received timely reviews following abnormal clinical findings. This included patients with raised diabetes indicator results, hypothyroidism and asthma, where appropriate assessment, review and follow-up had not been completed within expected timescales. We also identified opportunities where potential diagnoses had not been recognised or appropriately coded, which may have delayed further assessment, treatment and ongoing management.

The provider planned and delivered care and treatment in line with current legislation, national guidance and evidence-based practice. Clinicians had access to relevant guidance, including National Institute for Health and Care Excellence (NICE) guidance and local clinical pathways, which informed decision-making and supported the delivery of evidence-based care.Staff described using clinical decision support systems and evidence-based guidance when assessing, diagnosing and treating patients. Patients were involved in decisions about their care and treatment and were offered treatment options appropriate to their individual needs and clinical circumstances.Clinical searches undertaken during the assessment identified a few examples where follow-up, monitoring and prescribing processes were not consistently effective. 

The provider worked collaboratively with external organisations, including the Primary Care Network (PCN), and staff attended a range of external meetings and forums, including safeguarding, nursing and practice manager meetings. However, the provider could not demonstrate that information, learning or agreed actions arising from these meetings were consistently communicated to the wider practice team or embedded into day-to-day practice.There were no formal internal multidisciplinary or whole-practice meetings to support the routine sharing of information, learning or service developments. Staff described daily clinical huddles; however, these were informal, focused primarily on immediate clinical issues and were not documented. The practice manager did not routinely attend these meetings and leaders could not provide assurance that important information was consistently communicated across the practice.Staff had access to the information required to assess, plan and deliver people's care and treatment. However, governance arrangements were ineffective in ensuring that policies, procedures and clinical guidance were reviewed and kept up to date. As a result, leaders could not provide assurance that staff were consistently working from accurate and current information.The provider demonstrated collaborative working with partner organisations where required, including participation in Gold Standards Framework (GSF) multidisciplinary meetings to support people receiving end-of-life care. However, there was limited evidence of wider multidisciplinary working within the practice, including formal safeguarding discussions, to support coordinated care, shared learning and service improvement.Whilst staff described positive working relationships, we found that communication processes within the practice were ineffective. Staff were not always clear about the roles and responsibilities of colleagues, and leaders could not demonstrate effective systems to ensure information was consistently shared, understood and acted on across the organisation.

The provider supported people to live healthier lives by promoting health, preventing ill health and encouraging people to take an active role in managing their own health and wellbeing. Staff used opportunities during consultations to provide personalised advice and signpost patients to appropriate health promotion and support services.

Patients were encouraged to attend national screening programmes and routine immunisation appointments.

Systems were in place to identify patients who may benefit from additional support, including people living with long-term conditions, carers and those at risk of developing chronic disease. Where appropriate, patients were referred to other health and social care services to support their health and wellbeing.

The provider worked with local services, including the PCN, to improve access to health promotion initiatives and support patients to access services such as social prescribing, smoking cessation, weight management and lifestyle advice where appropriate.

Information to support healthier lifestyles was available to patients, and clinicians discussed prevention, self-management and risk reduction as part of routine consultations. Overall, the provider promoted healthier living and supported patients to make informed choices about their health and wellbeing.

The provider had systems in place to monitor and improve patient outcomes and demonstrated examples of proactive work to support population health. This included initiatives to reduce health inequalities, targeted reviews of patients with chronic obstructive pulmonary disease (COPD), learning disability health checks, NHS Health Checks, opportunistic screening and collaborative working with specialist services to optimise patient care. The provider also promoted national health initiatives, including falls prevention, healthy lifestyle programmes and lung cancer screening.

Staff described a range of processes to support the ongoing review of patients with long-term conditions and to involve patients and, where appropriate, those lawfully acting on their behalf in planning and reviewing care.

Overall, the provider demonstrated a commitment to improving population health and supporting positive outcomes for patients. However, weaknesses in clinical monitoring, follow-up and governance meant that opportunities to identify deteriorating health, optimise treatment and improve patient outcomes were not always acted on in a timely manner.

Staff demonstrated an understanding of the principles of obtaining consent and told us that patients who lacked capacity were supported in line with the Mental Capacity Act 2005. Best interest decisions were discussed with family members, carers and other professionals where appropriate, and staff described how people lawfully acting on a patient's behalf were involved in planning and reviewing care.

However, the provider could not demonstrate that all staff had received appropriate training in the Mental Capacity Act 2005 and consent to care and treatment. Leaders were therefore unable to provide assurance that staff had the knowledge and skills required to consistently apply the legislation and associated guidance in practice.

We also identified concerns regarding the management of documentation relating to Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions. DNACPR documentation was not consistently maintained within patients' clinical records in accordance with national guidance. This meant the provider could not provide assurance that important information relating to patients' wishes and clinical decisions would always be readily available to staff involved in their care.