Lathom House Surgery

Updated 24 June 2022

Lathom House surgery is now situated in Burscough Health Centre in Lord Street, Ormskirk, L40 4LA.

The building is a purpose-built health centre. It consists of two floors and all patient facilities are located on the ground floor. The practice provides level access for patients to the building with disabled facilities available.

There is limited parking provided for patients in the practice car park and the practice is close to public transport.

The practice is part of the NHS West Lancashire Clinical Commissioning Group (CCG) and services are provided under a General Medical Services Contract (GMS) with NHS England.

The provider is a partnership of three GPs (two males and one female) supported by three salaried GPs (two female & one male); assisted by an Advanced Clinical Practitioner (ACP), Practice Nurses (RPN), a Healthcare Assistant (HCA), a clinical Pharmacist, a Paramedic and a Physiotherapist. The rest of the team consists of two business managers, an administrative manager, a reception supervisor five additional administrative and reception staff. The practice is also able to use the services of a number of other healthcare professionals that are employed by the Primary Care Network (PCN) and local CCG for additional support.

The practice is open from Monday to Friday from 8am to 6.30pm and extended hours appointments are available weekday evenings and weekends at various locations run by the PCN. Appointments are offered from 8am to 6.20pm on weekdays at the practice and extended hours appointments were booked through the practice reception. Weekend times varied and practice staff were able to give patients these details.

When the practice is closed, patients are able to access out of hours services offered locally by contacting NHS 111.

The practice provides services to 4397 patients. Information published by Public Health England rates the level of deprivation within the practice population group as nine on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest. Life expectancy for females is 83 years and 80 years for males. This compares to the national overall average of 81.65 years.

The practice population is 98.3% white and 1.7% non-white ethnic groups.

Updated 24 June 2022

We carried out an announced inspection at Lathom House Surgery on 3 & 5 May 2022. Overall, the practice is rated as good. We inspected;

Safe -Good

Effective -Good

Caring – Good

Responsive – Good

Well-led -Good

The previous provider of this service was inspected on 1 May 2019 and was rated good overall and for all key questions. A new provider was registered in March 2020 and the previous report and provider profile was archived in July 2020.

Why we carried out this inspection

This inspection was a fully comprehensive inspection to give a rating to the new provider of the service.

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 included:

• Conducting staff interviews using video conferencing and face to face;
• 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 and reviewing evidence from 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;
• information from the provider, patients, the public and other organisations.

We have rated this practice as Good overall

We found that:

• The practice demonstrated that systems and processes were in place to protect patients and staff from harm in all areas of service delivery. There were areas that the practice acknowledged would benefit from strengthening and they took or were taking action immediately to address these areas.
• Effective staffing arrangements were in place and patients with long-term conditions and all other clinical areas received care and treatment in line with best practice.
• Patient feedback in relation to being treated with kindness, respect and dignity, as well as being involved in their care and treatment was in line with local and national averages.
• Feedback was generally positive in relation to access to care and treatment. We found that practice services were planned to meet patient needs and the practice was aware of areas that continued to need improvement and was addressing them.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic and continued to follow government guidance to mitigate the risk of this virus.
• Governance arrangements were in place and working to facilitate the services offered to the practice population. They demonstrated that these systems and processes were embedded and able to adapt to challenges; supporting the practice to be responsive to quality improvement activity.

We found no breaches of regulations however, the provider should:

• Embed all safeguarding systems onto the central clinical system to ensure consistency.
• Work to complete backlogs in relation to monitoring, heart failure and COPD reviews.
• Bring cervical screening uptake to expected targets.
• Review Do not attempt Cardiorespiratory resuscitation (DNACPR) systems to ensure that mental capacity is assessed, and 12-month reviews are effective.
• Set out plans to increase the number of identified carers within the practice population in order to facilitate access to support.

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