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Lilyville @ Parsons Green Requires improvement

This service was previously registered at a different address - see old profile

Reports


Inspection carried out on 19 December 2019

During a routine inspection

We carried out an announced comprehensive inspection at Lillyville at Parsons Green on 19 December 2019 as part of our inspection programme.

We inspected this practice on one previous occasion, on 19 April 2016, as The Lilyville Surgery, and the practice was rated as good overall, in all domains and in all patient population groups.

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 systems and processes to keep patients safe.
  • Receptionists had been given guidance on identifying deteriorating or acutely unwell patients. They were aware of actions to take in respect of such patients.
  • The practice learnt and make improvements when things went wrong.

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

  • There were some gaps in regular training for clinical and non-clinical staff.
  • Some performance data was significantly below local and national averages.

We rated the practice as requires improvement for providing well-led services because:

  • While the practice had a clear vision and that vision was supported by a credible strategy.
  • Some governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not have an appropriate fail-safe system in place for the safe management of patients who had been referred via the two-week wait urgent referral system.
  • The practice did not have an appropriate fail-safe system in place to monitor and manage cervical screening for female patients.

These areas affected all population groups so we rated all population groups as requires improvement.

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

Staff dealt with patients with kindness and respect and involved them in decisions about their care.

  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

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

(Please see the specific details on action required at the end of this report).

The areas where the provider should make improvements are:

  • The provider should consider reviewing its complaints system to ensure all relevant information is documented.
  • The provider should consider implementing a system to ensure practice policies are regularly reviewed to ensure all relevant information is documented.
  • The provider should consider additional strategies to enable them to identify carers within their patient community.
  • The provider should continue to work towards improving achievement rates regarding childhood immunisations.
  • The provider should continue to work towards improving achievement rates regarding 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