Ludlow - Portcullis

We carried out an announced inspection at Ludlow-Portcullis Surgery on 27 April 2022. Overall, the practice is rated as Good.

The ratings for each key question are:

Safe - Good

Effective – Good

Caring – Good

Responsive – Outstanding

Well-led – Good

Why we carried out this inspection

This comprehensive inspection was carried out following changes to provider registration and legal entity of the practice. This was the first inspection since this change.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Ludlow-Portcullis on our website at www.cqc.org.uk

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
• 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 from the provider
• A site visit
• Staff feedback questionnaires

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:

• 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.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care. Patient feedback was very positive about the care received.
• 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.
• The practice demonstrated a strong focus on continuous learning, improvement, innovation and research.
• We identified shortfalls in way the practice had obtained satisfactory evidence of staff conduct in previous employment.

We rated the practice as outstanding for providing a responsive service because:

• The practice had responded to the needs of its population by delivering services differently. For example, virtual education meetings had been arranged to provide information about Covid-19 and vaccines for patients.
• Weekly virtual education sessions had also been arranged for students aged 13 to 19 years old during the lockdown period January to April 2021. The practice offered work experience placements.
• The two practice funded counsellors volunteered extra hours during the pandemic to provide extra support for patients affected by the lockdowns. Virtual specialist group counselling sessions had also been set up to meet the needs of patients.
• Patients were very positive about access to appointments at the practice. All four indicators from the national GP survey were above the local and national averages with 88% of respondents stating they were satisfied with the appointment offered and 93% stating it was easy to get through to the GP practice on the telephone.
• The registered manager worked with local councillors and led on the creation of a community initiative, which was known as “Pulling Together Ludlow”.
• The practice launched a campaign to identify patients who needed prioritising to ensure that their waiting times for secondary care was minimised.

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

• Obtain satisfactory evidence of conduct in previous employment and full employment history, with a satisfactory written explanation of any gaps in employment, prior to staff commencing employment.

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