Lodge Surgery

We carried out an announced comprehensive inspection at Lodge Surgery on 9 and 10 November 2023. Overall, the practice is rated as good.

Safe - Requires Improvement

Effective - Good

Caring - Good

Responsive – Good

Well-led – Good

Following our previous inspection on 5 March 2015 of the Lodge Surgery and its branch, Highfield Surgery, the practice was rated good overall and for all key questions.

The Lodge Surgery merged with Redbourn Health Centre (also known as, Dr Baguant and Partners), in 2018. Redbourn Health Centre was inspected on 7 December 2016. The overall rating for the practice was good. However, we identified a breach of legal requirements. Improvements were needed to systems, processes, and procedures to ensure the practice provided safe services. Consequently the practice was rated as requires improvement for providing safe services. A subsequent focused inspection on 2 August 2017 found that the practice had made improvements since our previous inspection and were now meeting the regulation that had previously been breached. The practice was now rated as good for providing safe services.

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

Archived reports for previous inspections of Dr Baguant and Partners (also known as, Redbourn Health Centre) can be found here: https://www.cqc.org.uk/location/1-539585446

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

How we carried out the inspection/review

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

This included:

• Conducting staff interviews using video conferencing.
• 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 to all 3 of the practice’s sites: Lodge Surgery, Highfield Surgery and Redbourn Health Centre.

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 have rated this practice as Good overall.

We have rated the practice as Requires Improvement for providing safe services because:

• Some non-clinical staff had not undertaken safeguarding children level 2 training, in line with national guidance.
• The practice had test results and documents that had not been fully processed.
• Prescription stationery was not always secured in line with guidance and there was no system in place that recorded details of what blank prescriptions were kept and where, across all 3 sites.
• The recording of Patient Group Directions (PGDs) required improvement.
• While there was a process for monitoring patients’ health in relation to the use of medicines including medicines that require monitoring, not all patients had had the necessary checks.
• Although there was a system for checking emergency equipment and medicines, we found 2 vaccines that were past their expiry date in the fridge, at the Redbourn Health Centre site.
• While the practice had a system for recording and acting on safety alerts, not all patients affected by them had been protected from avoidable harm.

We also found that:

• In most cases, the practice had clear systems, practices, and processes to keep people safe and safeguarded from abuse.
• Recruitment checks were carried out by the practice in accordance with regulations, including locum staff.
• The practice maintained and responded to concerns relating to their premises, such as fire safety and health and safety matters.
• We saw that appropriate standards of cleanliness and hygiene were met, across the 3 sites.
• There were adequate systems in place to assess, monitor and manage risks to patient safety
• The practice monitored and regularly reviewed the clinical practices and prescribing competencies of non-medical prescribers.
• The practice learned and made improvements in response to significant events.
• Patients received effective care and treatment that met their needs.
• We saw staff demonstrated the values of the practice and dealt with patients with kindness, respect, and compassion.
• The practice organised and delivered services to meet patients’ needs.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

Whilst we found no breaches of regulations, the provider should:

• Embed identified improvements in keeping non-clinical staff up to date with safeguarding children level 2 training, in line with national guidance.
• Embed identified improvements in processes for assessing and monitoring patients and medicines, including test results and documents, monitoring patients’ health in relation to the use of medicines, safety alerts and long term conditions, in line with guidance.
• Embed identified improvements in processes for the secure storage and management of blank prescriptions and vaccines and review of patient group directions (PGDs), in line with guidance.
• Continue to take actions to improve child immunisation and cervical screening uptake.
• Continue to embed processes and systems to improve patient access, monitoring and reviewing these appropriately.

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 Health Care