- GP practice
Archived: Lilford Park Surgery
All Inspections
25 April 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out our first announced comprehensive inspection at Lilford Park Surgery on 30 September 2016 when the practice was rated as requires improvement overall. The areas where the provider was required to make improvements related to the safe, effective and well led domains. The full comprehensive report following that inspection can be found by selecting the ‘all reports’ link for Lilford Park Surgery on our website at www.cqc.org.uk.
We carried out this announced comprehensive inspection at Lilford Park Surgery on 25 April 2017 to check that the practice had made improvement. Improvements were demonstrated in all areas. The practice had taken action on each and every point highlighted at the inspection of 30 September 2016 and had introduced robust systems to address the concerns.
Overall the practice is now rated Good.
Our key findings across all the areas we inspected were as follows:
- The practice had introduced and embedded a number of systems to minimise risks to patients and staff since our inspection in September 2016. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
- The systems to manage risks and issues, introduced following our inspection in September 2016, demonstrated that people would be protected by a strong comprehensive safety system with a focus on openness, transparency and learning when things went wrong.
- Risks to patients were well assessed in particular those relating to medicines management, infection control, medical emergencies and staff training which had been highlighted as requiring improvement at the last inspection.
- Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment and training was regularly monitored and updated.
- Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
- Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
- Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with open access between 9.00am and 11.30am each 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
30 September 2016
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Lilford Park Surgery on 30 September 2016. Overall the practice is rated as Requires Improvement.
- We saw a number of significant events recorded that were dealt with appropriately with lessons learned to prevent reoccurrence. However, not all staff fully understood their responsibilities to raise concerns, and did not always report incidents and near misses. Those that were reported were not always dealt with in a timely manner.
- Risks to patients were assessed, but those relating to medicines management, infection control, medical emergencies, and staff training were not adequately managed.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Although training was provided not all members of staff were up to date with mandatory training, such as safeguarding and basic life support.
- 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. Improvements were made to the quality of care as a result of complaints and concerns.
- Patients said they found it easy to make an appointment with a named GP and 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 management. However, where staff worked in isolation there was no formal mentorship process in place.
- 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 found areas where the provider must make improvements. The provider must :
- Ensure the process for reporting, recording, acting on and monitoring significant events, incidents and near misses is followed by all staff.
- Ensure that protocols and guidance are available and followed for all staff to manage their responsibilities in a safe and effective way.
- Ensure that systems to address and manage risks are sufficiently implemented in relation to medicines, training, staff, unforeseen circumstances, infection control and dealing with emergencies.
- Ensure that staff are aware of their roles and responsibilities and assess that they are working within their competencies.
We found areas where the provider should make improvements. The provider should :
- Review the process to communicate patient safety alerts and other guidance.
- Introduce temporary signage for the practice until permanent changes can be achieved.
- Have a formal process in place to review and assess positive DBS checks.
- Follow best practice when managing and prescribing medicines.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice