Archived: Lakeside Healthcare Stamford

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Sheepmarket Surgery on 2 February 2015 followed by a further comprehensive inspection on 6 April 2017.

The overall rating for the practice was Good but we rated the Safe domain as requires improvement. The full comprehensive report from 2 February 2015 and focussed follow-up inspection from 6 April 2017 can be found by selecting the ‘all reports’ link for The Sheepmarket Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection on 19 September 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspections of 2 February 2015 and 6 April 2017. This report covers our findings in relation to those requirements.

The rating for the Safe Domain is good and the overall rating for the practice remains as Good.

Our key findings were as follows:

• We found that the practice had made considerable improvements since the last inspection.

• An effective system was in place for safeguarding service users from abuse.

• We found the practice had made significant improvements to its system for significant events, near misses and incidents. Some further improvement was required to ensure that all events were captured and investigations were detailed and actions identified and implemented.
• The practice now had systems in place to minimise risks to patient safety which included fire safety and monitoring of Disclosure and Barring Checks for all staff including the medicine delivery drivers.

• A review of some of the processes in the dispensary had taken place to minimise the risk to patients. For example, regular checks to ensure that dispensary stock is within expiry date and maintain appropriate records and implemented a system to ensure dispensary fridge temperatures were recorded daily in line with national guidance.

• Quality Improvement had taken place but in relation to clinical audit, further information was required to evidence the actions, outcomes and shared learning achieved as a result of the audits.

• We saw a more formalised process had been put in place for meetings that took place in the practice. Most minutes of meetings we reviewed were structured and followed a fixed agenda.

• The practice now had a governance framework in place which supported the delivery of their strategy and good quality care.

The provider should:

• Continue to review the system in place for significant events to ensure all events are captured , investigations are detailed, actions are identified and implemented

• To strengthen the system for clinical audits to demonstrate the evidence, actions, outcomes and shared learning achieved.

• Review the process in place for prescriptions that remain uncollected in the dispensary to ensure patient safety.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We previously carried out an announced comprehensive inspection at The Sheepmarket Surgery on 2 February 2015. The overall rating for the practice was requires improvement. The full comprehensive report on the 2 February 2015 report can be found by selecting the ‘all reports’ link for The Sheepmarket Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 6 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 2 February 2015. This report will cover all the five key questions and include our findings in relation to those requirements and additional improvements made since our last inspection.

Following the most recent inspection the practice is rated as Good. Safe remains as requires improvement and well-led has improved from requires improvement to good. The overall rating for all the population groups is good.

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

• We found that the system in place for significant event system had been reviewed since the last inspection. Some further improvement was required to ensure that the investigations were detailed and actions were identified and implemented.
• The practice had systems in place to minimise risks to patient safety with the exception of Disclosure and Barring Checks for medicine delivery drivers.
• 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.
• Clinical audits had been carried out but further information was required to evidence the improvements to patient outcomes and shared learning with the practice team.
• 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.
• 95% of patients who responded to the July 2016 patient GP survey said they found the receptionists at the practice helpful compared to the CCG average of 89% and the national average of 87%. Comment cards we reviewed aligned with these views.

• Comments cards we reviewed told us that the appointment systems were working well. They found it easy to make an appointment with a named GP and urgent appointments were 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. 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.

• The practice had a formalised process for the recording of minutes of meetings but the meeting minutes still required more detail.

The areas where the provider must make improvement are:

• Continue to embed the new system for significant events to ensure investigations are detailed, actions are identified and implemented and meetings minutes represent the discussion that takes place.

• Ensure the safeguarding registers are reviewed and updated.

• Continue to embed the system in place for quality improvement activates such as clinical audits and ensure that any actions and learning outcomes are recorded and reviewed to ensure improvements have been achieved.

• Review the processes in the dispensary to minimise the risk to patients. For example, the process for regular monitoring of prescriptions that have not been collected, regular checks  to ensure that dispensary stock is within expiry date and maintain appropriate records and implement a system to ensure dispensary fridge temperatures are recorded daily in line with national guidance.

The areas where the provider should make improvement are:

• Review the policy for fire safety and ensure that the practice have fire wardens trained and in place.

• Complete the disclosure and barring service (DBS) check for medicine delivery drivers.

• Review meeting minutes to ensure that more detail is documented and include set agenda items such as safeguarding, NICE guidance.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice