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Surrey Lodge Group Practice Good

Inspection Summary

Overall summary & rating

Inspection areas



Updated 21 December 2018

We rated the practice as good for providing safe services.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse.

  • The practice had reviewed its recruitment procedure since the last inspection. They had implemented changes including ensuring job roles and job descriptions were up to date and reflected the actual jobs staff were employed to do. Records of immunology were now held for clinical staff and a plan was being implemented for checking non-clinical staff.
  • The practice had undertaken Disclosure and Barring Service (DBS) checks for all staff even for those staff members with a DBS check already in place. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • Staff had received training in health and safety and this included fire safety. There were designated leads for the building and fire safety. Risk assessment and regular monitoring checks on different aspects of the building were undertaken.
  • The lead for infection prevention and control had received training since the previous inspection and there was an effective system to manage infection prevention and control. This included audit supported by regular monthly checks.
  • Staff had received training and support through monthly full team training/meetings and formal appraisal.

Appropriate and safe use of medicines

The practice had improved systems to ensure emergency medicine and equipment were safe.

  • Since the last inspection emergency medicines had been reviewed and a risk assessment was in place for those not held with control measures recorded. Equipment included that used for emergencies were regularly checked to ensure expiry dates had not passed.
  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.

Lessons learned and improvements made

Since the previous inspection the practice had following review further developed their procedure and protocol for identifying and responding to significant events.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Other areas

The practice continued to implement their strategy to improve the culture to become more inclusive for all staff. Monthly full team training meetings were held where staff learned about a range of subjects around the management and delivery of a modern health care service. The practice was implementing a team structure that recognised staff members areas of expertise. For example, one staff member was now lead for data and data quality, another team member was lead for issues regarding the building including safety and aesthetics.

The practice had been proactive and responded to the areas identified at our previous inspection. For example, the carer’s register had increased from seven to 36 members. There was recognition that further work was required to improve this further. The practice patients had been canvassed regarding their understanding of a patient participation group (PPG) and from this seven patients had confirmed their interest and commitment to joining a PPG.

Please refer to the evidence tables for further information.



Updated 21 December 2018

We rated the practice as good for providing effective services to Working age people (including those recently retired and students)

Working age people (including those recently retired and students):

  • Up to date data since the last inspection in June 2018 for cervical was not available. The practice manager tried to access the database used by Public Health England to provide up to date data without success. However, the practice believed their overall achievement was improving and quality and outcomes framework data showed improvements.
  • The practice had continued implementing their strategy to improve their cervical screening. Since June 2018 the practice had introduced a number of measures to assist them to identify and support patients more effectively. These included; support from 'Jo's Cervical Cancer Trust’, the introduction of an additional computer software programme which flagged up patients who required screening, and extra monitoring checks on the accuracy of information recorded and coded on the practice patient records.

Please refer to the evidence tables for further information.






Checks on specific services

People with long term conditions


Families, children and young people


Older people


Working age people (including those recently retired and students)


People experiencing poor mental health (including people with dementia)


People whose circumstances may make them vulnerable