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Lakeside Healthcare at Headlands Good

Reports


Inspection carried out on 01 September 2021

During an inspection looking at part of the service

We carried out an announced inspection at Lakeside Healthcare at Headlands on 1 September 2021. Overall, the practice is rated as Good.

Set out the ratings for each key question

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Good

Following our previous inspection published in March 2020, the practice was rated Requires Improvement overall. We rated the practice as Requires Improvement for providing Effective and Well-led services; and as Good for providing Safe, Caring, and Responsive services.

The full report for the previous inspection can be found by selecting the ‘all reports’ link for Lakeside Healthcare at Headlands on our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was a comprehensive, follow-up inspection, to review breaches of regulations identified at our previous inspection, and to ensure required actions had been taken.

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. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing and telephone calls.
  • 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.
  • Requesting evidence, data and information from the provider.
  • Carrying out desktop reviews of documentary evidence, including policies and procedures.
  • Reviewing information from stakeholders.
  • A short 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.
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall and Good for all population groups.

We found that:

  • Effective and well-led care was delivered to patients. The practice had made and sustained the improvements required to address the concerns identified at our last inspection.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • The practice had clear and effective systems to ensure patients on medicines received regular monitoring in a timely way.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

We found an example of outstanding practice:

  • The practice had a social prescriber who was embedded and integrated into the practice’s ways of working. They supported the practice to provide a holistic approach to people’s health, wellbeing and social welfare by supporting and signposting people to local support groups. We evidence of sustained positive outcomes for service users, for example patients being involved in the maintenance of a local community allotment before and after COVID-19 lockdown restrictions. We saw evidence of how around 70 patients had experienced improvements in their circumstances in the last 12 months as a result of this work.

Whilst we found no breaches of regulations, the provider should:

  • Continue to take action to further increase the uptake of cervical screening.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 6 February 2020

During a routine inspection

Lakeside Healthcare at Headlands, formally known as Headlands Surgery, is located at 20 Headlands, Kettering, Northamptonshire, NN15 7HP. The surgery is one of eight locations of Lakeside Healthcare Partnership, a partnership of GPs and others which provides primary medical services to approximately 180,000 patients across Northamptonshire, Lincolnshire, Cambridgeshire and Peterborough.

We carried out an announced comprehensive inspection at Lakeside Healthcare at Headlands on 6th February 2020 as part of our inspection programme.

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 Requires Improvement overall.

We rated the practice as good for providing safe services because:-

  • The practice had most systems, practices and processes in place to keep people safe and safeguarded from abuse.
  • The practice had systems for the appropriate and safe use of medicines including medicines optimisation.
  • Patients’ health was monitored in a timely manner to ensure medicines were being used safely and followed up on appropriately.
  • The practice learnt and made improvements when things went wrong.

We rated the practice as requires improvement for providing an effective service because:

The populations groups of older people, people with long term conditions, working age people (including those recently retired and students), people whose circumstances make them vulnerable and people who because the population groups of long term conditions and working age people (including those recently retired and students) and people experiencing poor mental health (including people with dementia) were rated as Requires Improvement. Families, children and young people were rated as Good. :-

  • The practice did not have a proactive team approach to the shared care of frail elderly people with multiple co-morbidities which included cancer and frailty.
  • Palliative care meetings were not held and there were no personalised care plans in place.
  • The practice were not able to demonstrate that they used a clinical tool to identify older patients who were living with moderate or severe frailty.
  • The percentage of women eligible for cervical screening was below the national average of 80%.
  • Exception reporting for patients with long term conditions was above the CCG and national averages.

We have rated the practice as good for providing caring and responsive services because:-

•Staff treated patients with kindness, respect and compassion. Feedback from patients were positive about the way staff treated people.

The practice organised and delivered services to meet patients’ needs

We have rated the practice as requires improvement for providing a well-led service because:-

•Not all governance systems in place were effective

•Not all the processes for managing risks, issues and performance were effective.

•The practice did not always act on appropriate and accurate information.

The areas where the provider must:

•Ensure care and treatment is appropriate, meets their needs and reflects their preferences.

•Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should:

•Improve the privacy at the main reception desk.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care