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Inspection Summary

Overall summary & rating


Updated 14 June 2019

We carried out an announced focused inspection at Lingfield Surgery on 24 April 2019 as part of our inspection programme.

At the last inspection in May 2018 we rated the practice as requires improvement for providing safe services because:

  • Safety alerts were not always documented, discussed and lessons learnt.
  • The risks to vulnerable patients registered at the practice were not always recorded, monitored and actioned.
  • The systems and processes to monitor, maintain and dispose of medical and cleaning supplies were not always effective.
  • There was a risk of electrical supply failure to the vaccine refrigerator and the maintenance of equipment used for checking the temperature was not in line with guidance.
  • Not all staff roles were covered for periods of absence, including holidays, sickness and busy periods.

We also found areas where the provider should make improvements:

  • Strengthen the guidance provided for reception staff to include identification of symptoms for potentially seriously ill patients, such as sepsis.
  • Strengthen the guidance provided to all clinical staff to include information on the location of care plans on the practice computer system.
  • Review the facilities provided and ensure all reasonable adjustments are made, including that all patients can raise an alarm if they require assistance.

We based our judgement of the quality of care at this service is 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.

Overall the practice continues to be rated as good and is now good in the safe domain.

Details of our findings

At this inspection we found:

  • There were processes to identify, understand, monitor and address current and future risks including risks to patient safety. The practice fully recorded, investigated and acted on safety alerts. Actions were taken to improve safety and lessons were learned.
  • The practice had processes in place to make sure vulnerable patients were monitored, and appropriate actions were completed as a result of any concerns.
  • The practice had systems to monitor, maintain and dispose of medical and cleaning supplies. They had developed a room-specific recording log for every clinical room, to ensure the correct supplies were available to clinicians.
  • Vaccines were appropriately stored and monitored to ensure they remained safe and effective.
  • Additional staff were being or had been trained for roles to make sure they were covered for periods of absence. Staff were consistently positive about the changes to their roles and responsibilities.
  • The practice had resolved concerns relating to the guidance provided to staff. An emergency assistance alarm had also been installed.

Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Inspection areas










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