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Surrey Lodge Group Practice Good


Review carried out on 13 September 2019

During an annual regulatory review

We reviewed the information available to us about Surrey Lodge Group Practice on 13 September 2019. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

Inspection carried out on 27/11/2018

During an inspection looking at part of the service

Inspection carried out on 06 June 2018

During a routine inspection

This practice is rated as good overall. (Previous rating August 2015 -Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Surrey Lodge Group Practice on 6 June 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

  • The practice had experienced a change in leadership within the last two years. The practice recruited a new practice manager in August 2017 to lead and support the team to provide a safe and effective service.
  • The new management team identified several areas of improvement and implemented a comprehensive plan to improve and develop the practice and service delivery.
  • This inspection identified many areas where changes had been implemented and a plan was in place to continue with the implementation of improvements.
  • Areas requiring further development including implementing health and safety risk assessments and systems of staff training and support.
  • The practice had clear systems to manage safety incidents. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they could access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Continue to identify and support patients who are also carers.
  • Review the reception area to seek solutions to improve patient privacy.
  • Continue with the planned programme to establish the patient participation programme.
  • Continue to implement the strategy to improve achievement in cervical cytology.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 05/08/2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Surrey Lodge Group Practice on 5 August 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing, effective, caring, responsive and safe services. It was also good for providing services for the populations groups we rate. We found however the service required improvement in well led.

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.
  • Risks to patients were assessed and well managed.
  • 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 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.
  • Patients feedback on accessing appointments with GPs and nurses was positive.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had a clear vision which had quality and safety as its top priority. High standards were promoted and owned by all practice staff with evidence of team working across all roles; however the practice would benefit from clearer leadership in some clinical areas and meeting the needs of vulnerable patients.

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

Importantly the provider should

  • Ensure checks are carried out on portable electrical equipment
  • Ensure where required clear staff leads are in place and this is clearly communicated to all staff.
  • Ensure where required patients are provided with written management plans to support them in self managing conditions such as asthma and COPD.
  • Ensure the staff appraisal plan is fully implemented, and appraisals for nurses are supported with clinical input.
  • Ensure systems are in place to provide staff with up to date guidance on available internal and external health promotion services such as counselling and smoking cessation, and to ensure patients have access to support in a timely manner.
  • Enable all clinical staff to have access to practice meetings.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice