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Archived: Lordswood House Group Good

The provider of this service changed - see new profile


Inspection carried out on 29 June 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out focussed inspection at Lordswood House Group on 29 June 2016. The practice had previously been inspected in September 2015 and was rated as requires improvement for providing safe services. The practice was found to be in breach of regulation 19 and schedule 3 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Recruitment records seen did not demonstrate that appropriate checks had been undertaken to ensure fit and proper persons were employed at the practice. Following the inspection the practice sent us an action plan detailing the action they were going to take to improve.

We returned to the practice to consider whether improvements had been made in response to the breach in regulations. We found the practice had made improvements and is now rated as good for providing safe services. This report should be read in conjunction with our previous inspection report for the practice.

Our findings were as follows:

  • Appropriate pre-employment checks were carried out to ensure new staff were suitable to carry out regulated activities and work with vulnerable persons in order to keep patients safe

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 11 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lordswood House Group on 11 September 2015. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • There were systems in place to manage risks to patients who used the services but these were not well implemented in all areas. For example, staff recruitment, equipment and fire safety. However, following the inspection the practice responded swiftly to rectify these issues.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

  • Patients were positive about the care and treatment they received. They said they were treated with dignity and respect and were involved in their care and decisions about their treatment.
  • Information about how to complain was available and easy to understand.
  • Patients were satisfied that they were able to obtain 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.
  • There was a clear leadership structure and staff felt supported by senior staff and partners at the practice. The practice proactively sought feedback from staff and patients, which it acted on.

However there were areas of practice where the provider needs to make improvements.

The areas where the provider must make improvements are:

  • Ensure that the recruitment process includes all necessary pre-employment checks for staff.

The areas of practice where the provider should make improvements are:

  • Ensure fire risk assessments and any associated actions are kept up to date.
  • Ensure audits complete their full audit cycle in order to demonstrate improvements made to practice.
  • Maintain accurate records for the recording of activities completed such as staff training, appraisals and fire drills so that the practice can be assured that they have been completed and are up to date.
  • Develop systems for recording verbal and informal complaints in order to identify themes and trends and to support learning.
  • Ensure policies and procedures used by staff are clear about when they were last reviewed so that staff can be assured they are using the most up to date guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice