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