The Care Quality Commission
  • Doctor
  • GP practice

Lightwater Surgery

Overall: Good read more about inspection ratings

39 All Saints Road, Lightwater, Surrey, GU18 5SQ 0844 815 1127

Provided and run by:
Lightwater Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Lightwater Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Lightwater Surgery, you can give feedback on this service.

15 November 2019

During an annual regulatory review

We reviewed the information available to us about Lightwater Surgery on 15 November 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

During a routine inspection

We carried out an announced comprehensive inspection at Lightwater Surgery on 19 December 2018 as part of our inspection programme. We had inspected the practice previously, in February 2016, where the practice had also been rated as Good.

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 and good for all population groups.

We found that:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • 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 organised and delivered services to meet patients’ needs. 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.
  • Feedback from all 28 patient comment cards was continuously positive about the way staff treated them. Staff were said to go the extra mile and were patient focussed in all aspects of care.
  • There was a strong ethos within the practice for community development and engagement work. The practice had arranged local talks for their patients and those people living in the vicinity.

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

  • Improve the identification of carers to enable this group of patients to access the care and support they need.
  • Review and continue to monitor cervical smear screening to meet Public Health England screening rates.

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

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

9 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lightwater Surgery on 9 February 2016. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice participated in multidisciplinary telephone meetings with the integrated care team to improve communication between different services for patients.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw areas of outstanding practice:

  • The practice engaged with the community by helping to arrange local talks. There was a strong ethos within the practice for community development and engagement work. The practice had arranged local talks for their patients and those people living in the vicinity. For example, post-natal depression focus group, dementia workshop, a carers event, the role of the modern pharmacist and Sunday afternoon tea get together for its older patients. We received feedback from PPG members and the pharmacist explaining how these talks had been invaluable and how they believed there had been a positive impact on patients.

We also saw areas where the provider should make an improvement:

  • Review the low number of patients currently registered as a carer at the practice

  • Review the exceptional reporting rate as higher than the local and national average percentage

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice