The Care Quality Commission
  • Doctor
  • GP practice

Park Lane Surgery

Overall: Requires improvement read more about inspection ratings

8 Park Lane, Broxbourne, Hertfordshire, EN10 7NQ (01992) 465555

Provided and run by:
Park Lane Surgery

Important: We are carrying out a review of quality at Park Lane Surgery. We will publish a report when our review is complete. Find out more about our inspection reports.

All Inspections

24 October 2023

During a routine inspection

We carried out an announced comprehensive at Park Lane Surgery on 24 October 2023. Overall, the practice is rated as requires improvement.

Safe – Inadequate

Effective - requires improvement.

Caring - Good

Responsive - requires improvement.

Well-led - requires improvement.

Following our previous inspection on 1 December 2016, 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 Park Lane Surgery on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

This was a comprehensive inspection to review the following domains:

  • Safe
  • Effective
  • Caring
  • Responsive
  • Well Led

How we carried out the inspection/review

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
  • 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.
  • Reviewing patient feedback.

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:

  • There were safeguarding processes to keep people safe from abuse, however not all staff were trained to the appropriate levels of their role.
  • There was an absence of appropriate staff recruitment checks to ensure safety and checks of staff immunisation status or appropriate risk assessments had not been completed for all staff.
  • Patients care, needs and assessment for treatment were not always delivered in line with national and recommended guidance.
  • The building and premises required upgrading to meet health and safety requirements; the practice had works booked for repair.
  • The provider did not always review or keep up to date risk assessments and action plans.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Ensure all premises and equipment used by the service provider is fit for use.
  • Complete a risk assessment on the surgical clinical room.

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

  • Take action to complete mandatory training for staff employed at the practice.
  • Take action to implement a strengthened process for reviewing coding of patients with a misdiagnosis.
  • Take action to audit and monitor non-medical prescribing staff.
  • Take action to review and update all risk assessments and action plans.
  • Take action to maintain childhood immunisation uptake.
  • Take steps to increase patient satisfaction in line with the national GP patient survey.

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

8 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Park Lane Surgery on 8 September 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.
  • The practice held regular staff and clinical meetings where learning was shared from significant events and complaints.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • All patients had a usual GP providing continuity of care. Urgent appointments were available on 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 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.
  • The practice sought the views of their patients through the patient participation group, surveys and the friends and family test.

The areas where the provider should make improvement are:

  • Implement a system to monitor the use of blank prescription forms and pads in the practice.

  • Continue to monitor and ensure improvement to national patient survey results in relation to accessing appointments

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

3 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced inspection of Park Lane Surgery on 3 June 2015. This was a comprehensive inspection under Section 60 of the Health and Social Care Act (2008) as part of our regulatory functions. The practice achieved an overall rating of requires improvement. Specifically, we found the practice to be good for providing effective, caring and responsive services. We found it to be requiring improvement for safe and well-led. Consequently, it requires improvement for providing services for older people; people with long-term conditions; families, children and young people; working age people; people whose circumstances may make them vulnerable and people experiencing poor mental health.

Our key findings were as follows:

  • Systems were in place to identify and respond to concerns about the safeguarding of adults and children.
  • We saw patients receiving respectful treatment from staff. Patients felt they were seen by supportive and helpful staff. Patients reported feeling satisfied with the care and treatment they received.
  • The practice offered a number of services designed to promote patients’ health and wellbeing and prevent the onset of illness.
  • The practice acted upon best practice guidance to further improve patient care.
  • The management and meeting structure ensured that appropriate clinical decisions were reached and action was taken.
  • Some systems designed to assess the risk of and to prevent, detect and control the spread of infection were lacking or not fully implemented.
  • Adequate recruitment procedures including completing the required background checks on staff were lacking.

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

Importantly, the provider must:

  • Ensure that systems designed to assess the risk of and to prevent, detect and control the spread of infection are fully implemented and audited and that a Legionella risk assessment is completed and available.
  • Ensure adequate recruitment procedures are in place including completing the required background checks on staff and that the required information is available in respect of each person employed.

In addition the provider should:

  • Ensure that patient privacy is maintained at reception.
  • Ensure the practice and the services available are fully accessible to those patients who may find attending in working hours difficult.
  • Ensure the recording of stock of controlled drugs is completed properly.
  • Ensure that suitable arrangements are in place for the testing of all electrical equipment.
  • Ensure there is a recurring programme of clinical audit.
  • Ensure that all staff are supported by receiving appropriate supervision and appraisal and complete the training relevant to their roles.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice