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Inspection Summary


Overall summary & rating

Good

Updated 17 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lincoln House Surgery on 5 April 2016. The overall rating for the practice was requires improvement. The full comprehensive report from the 5 April 2016 inspection can be found by selecting the ‘all reports’ link for Lincoln House Surgery on our website at www.cqc.org.uk.

After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

  • Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 - safe care and treatment.
  • Regulation 17 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 - good governance.
  • Regulation 18 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014 - staffing.

The areas identified as requiring improvement during our inspection in April 2016 were as follows:

  • Ensure an appropriate system was in place for the safe use and management of medicines, medical consumables and prescriptions, including those used in an emergency.
  • Ensure a plan of action to control and resolve risks identified by the Legionella risk assessment was completed. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • Ensure that a comprehensive business continuity plan was in place so that a service could be maintained in the event of a major incident.
  • Ensure that staff who act as chaperones were appropriately trained.
  • Ensure that all staff employed were receiving appropriate supervision and appraisal.

In addition, we told the provider they should:

  • Ensure that all staff completed a formal programme of infection control training.
  • Take steps to ensure that in future National GP Patient Surveys the practice’s areas of below local and national average performance were improved.
  • Take steps to improve access to the practice by telephone.
  • Continue to identify and support carers in its patient population.

We carried out an announced focused inspection on 14 December 2016 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 5 April 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key finding on this focused inspection was that the practice had made improvements since our previous inspection and were now meeting regulations that had previously been breached.

Overall the practice is now rated as good.

On this inspection we found:

  • There were appropriate arrangements in place for the safe use and management of medicines, including emergency medicines, vaccines and medical consumables.
  • Blank prescription forms and pads were securely stored and there were systems in place to monitor their use.
  • Appropriate Legionella management processes were in place.
  • Arrangements were in place to respond to emergencies and major incidents.
  • Staff who acted as chaperones were appropriately trained for the role.
  • A programme was in place to ensure all staff received an appraisal on an annual basis.

Additionally where we previously told the practice they should make improvements our key findings were as follows:

  • A programme of infection control training was in place and all staff had completed this.
  • The practice discussed their below average satisfaction scores from the National GP Patient Survey published in January 2016. They demonstrated they had taken action to improve these including reducing the administration and managerial workload of the GPs and increasing the amount of patients accessing their online facilities such as appointment booking. The results from the National GP Patient Survey published in July 2016 showed improvement in all the areas previously of concern. The practice was now mostly performing in line with local and national averages. Senior staff at the practice were aware of any current areas of below average satisfaction scores and could demonstrate they were responding to it.
  • Through additional training for some staff and a targeted approach the practice had increased the amount of carers identified in its patient population. As of December 2016 the practice had identified 145 patients on the practice list as carers. This was approximately 1.2% of the practice’s patient list and was an increase of around 48% from our inspection in April 2016.

Following our inspection on 14 December 2016 the area where the provider should continue to make improvement is:

  • Ensure that all non-clinical staff are supported by receiving appropriate supervision and appraisal.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 17 March 2017

At our comprehensive inspection on 5 April 2016, we identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided safe services. During our focused inspection on 14 December 2016 we found the provider had taken action to improve and the practice is rated as good for providing safe services.

  • Staff who acted as chaperones were appropriately trained for the role.

  • A programme of infection control training was in place and all staff had completed this.

  • There were appropriate arrangements in place for the safe use and management of medicines, including emergency medicines, vaccines and medical consumables.

  • Blank prescription forms and pads were securely stored and there were systems in place to monitor their use.

  • Appropriate Legionella management processes were in place. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).

  • Arrangements were in place to respond to emergencies and major incidents.

Effective

Good

Updated 17 March 2017

At our comprehensive inspection on 5 April 2016, we identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided effective services. During our focused inspection on 14 December 2016 we found the provider had taken action to improve and the practice is rated as good for providing effective services.

  • A programme was in place to ensure all staff received an appraisal on an annual basis. At the time of our inspection the first annual programme of non-clinical staff appraisals was not fully completed. However, there were more than three months of the programme left and all staff had dates scheduled for their appraisals to be completed.

Caring

Good

Updated 17 March 2017

Responsive

Good

Updated 17 March 2017

Well-led

Good

Updated 17 March 2017

At our comprehensive inspection on 5 April 2016, we identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided well-led services. During our focused inspection on 14 December 2016 we found the provider had taken action to improve and the practice is rated as good for providing well-led services.

  • The governance framework in place ensured the implementation of and adherence to the practice’s systems, processes and procedures.
Checks on specific services

People with long term conditions

Good

Updated 17 March 2017

At our focused inspection on 14 December 2016 we found the provider had resolved the concerns we identified under safe, effective and well-led services at our comprehensive inspection on 5 April 2016. This applied to everyone using the practice, including this population group. The population group ratings have been updated to reflect this.

Families, children and young people

Good

Updated 17 March 2017

At our focused inspection on 14 December 2016 we found the provider had resolved the concerns we identified under safe, effective and well-led services at our comprehensive inspection on 5 April 2016. This applied to everyone using the practice, including this population group. The population group ratings have been updated to reflect this.

Older people

Good

Updated 17 March 2017

At our focused inspection on 14 December 2016 we found the provider had resolved the concerns we identified under safe, effective and well-led services at our comprehensive inspection on 5 April 2016. This applied to everyone using the practice, including this population group. The population group ratings have been updated to reflect this.

Working age people (including those recently retired and students)

Good

Updated 17 March 2017

At our focused inspection on 14 December 2016 we found the provider had resolved the concerns we identified under safe, effective and well-led services at our comprehensive inspection on 5 April 2016. This applied to everyone using the practice, including this population group. The population group ratings have been updated to reflect this.

People experiencing poor mental health (including people with dementia)

Good

Updated 17 March 2017

At our focused inspection on 14 December 2016 we found the provider had resolved the concerns we identified under safe, effective and well-led services at our comprehensive inspection on 5 April 2016. This applied to everyone using the practice, including this population group. The population group ratings have been updated to reflect this.

People whose circumstances may make them vulnerable

Good

Updated 17 March 2017

At our focused inspection on 14 December 2016 we found the provider had resolved the concerns we identified under safe, effective and well-led services at our comprehensive inspection on 5 April 2016. This applied to everyone using the practice, including this population group. The population group ratings have been updated to reflect this.