We carried out an announced comprehensive inspection at The Light on 11 August 2022. Following this inspection, we rated the location as Good and the following for each key question:
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 15 February 2019, the practice was rated Good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for The Light on our website at www.cqc.org.uk
Why we carried out this inspection
This comprehensive inspection was undertaken as a result of identified risk; as indicated by CQC data analyst systems.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site as possible. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Requesting evidence from the provider.
- Conducting some staff interviews via telephone and teleconferencing.
- Practice staff completing questionnaires.
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
- Reviewing patient records to identify issues and clarify actions taken by the provider
- A site visit.
Our findings
We based our judgement of the quality of care at this service 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.
We have rated this practice as Good overall
We found that:
- There were systems in place to safeguard children and vulnerable adults from abuse and staff knew how to identify and report safeguarding concerns.
- Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
- The practice had adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- Staff had the skills, knowledge and experience to deliver effective care.
- The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Whilst we found no breaches of regulations, the provider should:
- Summarise any outstanding patient records to ensure that all information is available for the delivery of safe patient care and treatment.
- Continue to look at ways of improving uptake rates for childhood immunisations and cancer screening of breast, bowel and cervical.
- Continue to review and improve patient satisfaction, particularly relating to access.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services