The Care Quality Commission
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  • GP practice

Hendford Lodge Medical Centre

Overall: Requires improvement read more about inspection ratings

74 Hendford, Yeovil, Somerset, BA20 1UJ (01935) 470200

Provided and run by:
Hendford Lodge Medical Centre

All Inspections

09 November 2023

During a routine inspection

We carried out an announced focused inspection at Hendford Lodge Medical Centre on 9 November 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement

Effective - requires improvement

Caring - not inspected, rating of good carried forward from previous inspection

Responsive - requires improvement

Well-led - requires improvement

During the inspection process, the practice highlighted efforts they are making to improve outcomes and treatment for their population. These had only recently been implemented so there is not yet verified evidence to show they were working. For example, changes to systems to improve access for patients to the service. As such, the ratings for this inspection have not been impacted. However, we continue to monitor the data and where we see potential changes, we will follow these up with the practice.

We recognise the pressure that practices are currently experiencing and the efforts staff are making to maintain levels of access for their patients. At the same time, our strategy commits to delivering regulation driven by people’s needs and experiences of care. Although we saw the practice was attempting to improve access, this was not yet reflected in the GP patient survey data or other sources of patient feedback. Therefore, the rating is requires improvement, as ratings depend on evidence of impact and must reflect the lived experience that people were reporting at the time of inspection.

Following our previous inspection in October 2019, the practice was rated good overall and for all key questions.

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

Why we carried out this inspection

We carried out this inspection to follow up concerns reported to us.

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:

  • 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 short 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 not consistently provided care in a way that kept patients safe and protected them from avoidable harm. For example, more work was required to ensure all aspects of medicine management were safe.
  • Patients’ needs were assessed and the care and treatment provided were delivered in line with current legislation, standards and evidence-based guidance although not all patients had access to health checks.
  • The practice could not fully demonstrate that all staff had the skills, knowledge and experience to carry out their roles.
  • The number of cervical screenings carried out in the practice had not met the national targets.
  • Patients could not always access care and treatment in a timely way.
  • The way the practice was led and managed did not always promote the delivery of high-quality, person-centre care due to a lack of consistent oversight of all systems and processes.

We found 1 breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Additionally, the provider should:

  • continue to develop and embed systems to enable patients to access relevant health checks and carry out appropriate monitoring for their long-term conditions.
  • continue to take action to increase the cervical screening carried out at the practice.
  • Continue to embed systems to review safeguarding concerns within the practice. For example, reinstating and holding regular safeguarding review meetings.

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

30 Oct to 30 Oct 2019

During an inspection looking at part of the service

We have rated this practice as good overall and good for all population groups.

The key questions are rated as:

Are services effective? Good

Are services well-led? Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Requires improvement.

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) – Good

We rated the population group working age people as requires improvement due to the verified data for cervical smears showing below the national Public Health England target.

We carried out an announced focused inspection at Hendford Lodge Medical Centre on 30 October 2019. We carried out an inspection of this service following 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: Effective and well-led.

Because of the assurance received from our review of information we carried forward the ratings for the following key questions: Safe, caring and responsive.

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 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 systems and processes in place for managing risks, issues and performance.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice listened to staff and patients, acting on issues to improve the service.
  • 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:

  • Review and improve uptake rates for cervical smear screening.
  • Complete annual appraisals for all staff in line with practice policy.
  • Continue to implement measures to improve patient access via the telephone and access to appointments.
  • Improve the recording of quality measurement outcomes for patients with long-term conditions.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

11 November 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Hendford Lodge Medical Centre was inspected on Tuesday 11 November 2014. This was a comprehensive inspection.

Hendford Lodge Medical Centre provides primary medical services to people living in the town of Yeovil, Somerset. The practice provides services to a mixed population group and is situated near the town centre.

Hendford Lodge Medical Centre also has a branch in Abbey Manor, Yeovil. The two practices were run by the same management group and owned by the same company Diamond Health Care.

At the time of our inspection there were 11,639 patients registered at Hendford Lodge with a team of 10 GPs, two trainee GPs, a practice manager, seven nurses, six health care assistants and approximately 24 administrative staff. GP partners held managerial and financial responsibility for running the business.

Patients who use the practice have access to community staff including district nurses, community psychiatric nurses, health visitors, physiotherapists, mental health staff, counsellors, chiropodist and midwives. The practice also runs specialist orthopaedic services and a leg ulcer service.

We rated this practice as good.

Our key findings were as follows:

Patient feedback about care and treatment was positive. The practice had a patient centred culture. Practice staff were well trained and experienced. Staff provided compassionate care to their patients. External stakeholders were positive about the practice.

Hendford Lodge Medical Centre was well organised, clean and tidy. The practice had well maintained facilities and was well equipped to treat patients. There were effective infection control procedures in place. Patients experienced relatively easy access to appointments at the practice. Patients had a named GP which improved their continuity of care.

The practice had a clear leadership structure in place and was well led. Systems were in place to monitor quality of care and to identify risk and manage emergencies.

Patients’ needs were assessed and care planned and delivered in line with current legislation. This includes assessment of the patient’s capacity to make informed choices about their care and treatment, and the promotion of good health.

Recruitment, pre-employment checks, induction and appraisal processes were robust. Staff had received appropriate training for their roles and additional training needs had been identified and planned.

Information about the practice provided evidence that the practice performed comparatively with other practices within the clinical commissioning group (CCG) area.

Patients told us that they felt safe with the practice staff and confident in clinical decisions made. There were safeguarding procedures in place. Significant events, complaints and incidents were investigated. Improvements made following these events had been discussed and communicated with staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice