Lyndhurst Medical Centre

We carried out an announced inspection at Lyndhurst Medical Centre (the practice) on 30 September 2021. Overall, the practice is rated as “Good”.

The ratings for each key question were rated as:

Safe - Good

Effective - Good

Well-led - Good

We previously inspected the practice on 8 March 2019, when we rated it “Requires improvement” overall and for the key questions “Safe” and “Well-led”. The practice was rated “Good” for “Effective”, “Caring” and “Responsive”.

The reports of previous inspections can be found by selecting the ‘all reports’ link for Lyndhurst Medical Centre on our website at https://www.cqc.org.uk/location/1-547765682.

Why we carried out this inspection

This focused inspection was carried out to follow up on the issues noted previously, when we found the practice did not have effective systems and processes to ensure:

• Care and treatment were being provided in a safe way.
• Good governance, in accordance with the fundamental standards of care.

How we carried out the inspection

Throughout the pandemic, the Care Quality Commission (CQC) has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system and discussing findings with the practice.
• Reviewing patient records to identify issues and clarify actions taken by the practice.
• Requesting evidence submitted by the practice.
• 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 practice, patients, the public and other organisations.

We have rated the practice as Good overall.

The population groups are rated as follows:

Older people – Good

People with long term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students) – Good

People whose circumstances may make them vulnerable – Good

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

We found that:

• The practice was monitoring patients effectively who were prescribed high risk medicines.
• Prescribers had an understanding of the repeat prescribing policy and all staff interviewed were able to describe how they would access this.
• The practice had implemented a system to monitor the tracking of blank prescription pads, ensuring each clinician was accountable for their own documentation.
• Actions in response to safety alerts were recorded.
• The practice had completed hand hygiene and personal protective equipment (PPE) audits, and all staff interviewed were able to name who the responsible infection prevention and control lead was.
• A legionella risk assessment had been completed by an external contractor and an action plan was completed in response to this. The practice informed us that they no longer used liquid nitrogen, so the need for this risk assessment was no longer required.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• Staff interviewed felt supported by management and reported leaders in the practice were approachable.

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