The Care Quality Commission
  • Doctor
  • GP practice

Archived: Landywood Lane Surgery

Overall: Inadequate read more about inspection ratings

Great Wyrley Health Centre, Landywood Lane, Great Wyrley, Walsall, West Midlands, WS6 6JD (01922) 414315

Provided and run by:
Landywood Lane Surgery

All Inspections

22 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Landywood Lane Surgery on 22 September 2016. Overall the practice is rated as inadequate.

Following the inspection we sent a letter to the provider, which required them to provide the Care Quality Commission with information under Section 65 of the Health and Social Care Act 2008 and Regulation 10 Care Quality Commission (Registration) Regulations 2009. This related to the rationale behind prescribing subcutaneous fluids to patients in care homes without visiting them to carry out a clinical review or access to recent blood results. We also requested information on the action the provider was going to take to ensure that the clinical care of these patients was safe. We received a response from the practice to our Section 65 letter.

Our key findings were as follows:

  • Patients told us during the inspection that they were treated with compassion, dignity and respect and that they were involved in their care and decisions about their treatment. However, the GP survey results did not reflect these findings.
  • Patients told us that they were able to get appointments when they needed them.
  • Patients were not protected from risks because the GPs prescribed fluids for a number of patients without a clinical assessment, including recent blood monitoring.
  • There was an inconsistent approach to risk management. For example, Disclosure and Barring Service checks hadn’t been obtained, safety checks on electrical equipment hadn’t been completed and there was a lack of planning and monitoring of staff numbers to meet the needs of patients.
  • The practice had no clear leadership structure, insufficient leadership capacity and limited formal governance arrangements.

The areas where the provider must make improvements are:

  • Ensure that there is an effective process in place to guide staff on the reporting, recording and managing of significant events.
  • Ensure that there is access to all the recruitment information required under Schedule 3 of the regulations when recruiting staff, including locum GPs.
  • Access whether there is a risk to patients of being cared for or treated by members of staff without Disclosure and Barring Service checks.
  • Ensure that all electrical equipment and clinical equipment is safe to use and/or calibrated.
  • Assess the risks of not keeping a full range of emergency medicines at the practice and mitigate the risks to patients.
  • Provide appropriate sharps bins for the disposal of sharps contaminated with s
  • The practice must ensure there are adequate numbers of appropriately skilled staff to cover sickness and absence.
  • Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision.
  • Develop a clear leadership structure, including designated roles and responsibilities for staff.

In addition the provider should:

  • Introduce a system which demonstrates that medicines and equipment alerts issued by external agencies are acted upon.
  • Implement a system to monitor the use of prescription stationery.
  • Introduce effective systems for monitoring the collection of prescriptions.
  • Provide written evidence to demonstrate that all new staff are provided with, and complete an induction programme.
  • Evaluate the reasons for poor performance in the national GP patient survey regarding patient satisfaction with their interactions with GPs and nurses in respect of their involvement in planning and making decisions about their care and treatment.
  • Make information about how to make a complaint more accessible to patients.
  • Review and update all policies and procedures.

On the basis of the ratings given to this practice at this inspection I am placing the provider into special measures. This will be for a period of six months. We will inspect the practice again in six months to consider whether sufficient improvements have been made. If we find that the provider is still providing inadequate care we will take steps to cancel its registration with CQC.

Services placed in special measures will be inspected again within six months. If, after re-inspection, the service has failed to make sufficient improvement, and is still rated as inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During a check to make sure that the improvements required had been made

We previously inspected Landywood Lane Surgery on 8 April 2014. At this inspection we saw that improvements were needed to protect patients from the risks of unsafe or inappropriate care and treatment because accurate records were not always maintained.

Following the inspection, the provider submitted an action plan setting out how they would address the issues. They confirmed that all the issues had been addressed. We asked the provider to send information to us to show that all the required improvements had been made. We checked this evidence and saw that systems to ensure accurate care records were maintained had been put in place.

8 April 2014

During an inspection looking at part of the service

At our previous inspection on 19 December 2013, we saw that patients' privacy and dignity were not always respected. At this inspection we saw that staff were aware of how to maintain patients' privacy and dignity.

At our previous inspection we saw that arrangements were not in place to deal with foreseeable emergencies. At this inspection we saw that the provider had taken reasonable steps to keep patients safe during a medical emergency.

At our previous inspection we saw that the provider did not have systems in place to ensure patients were cared for by suitably trained staff. Some staff had not received training in safeguarding children. Staff were not always aware of the appropriate agencies to refer safeguarding concerns to. At this inspection we saw that staff had received appropriate training and were aware of who to report concerns to. This meant that patients were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent it from happening.

At our previous inspection we saw that the provider did not have effective systems in place to identify, assess and manage risks to the health, safety and welfare of patients who used the service. At this inspection we saw that the provider had taken steps to address these issues.

At this inspection we saw that patients were not protected from the risks of unsafe or inappropriate care and treatment because accurate care records were not maintained.

19 December 2013

During a routine inspection

On the day of our inspection we spoke with seven patients, the provider and four members of staff. One patient told us, "The practice is local and handy. The new nurse is very good". Another patient told us, "The practice is very friendly and the staff are approachable. Generally I get an appointment quite quickly but emergency appointments can be quite difficult to get".

We saw that patients' privacy and dignity was not always respected. Patients we spoke with told us they were happy with the care and treatment they had received but the appointment system did not always meet their needs. We saw that care and treatment was not always planned and delivered in a way that was intended to ensure patients' safety and welfare.

We saw that the provider did not have systems in place to ensure patients were cared for by suitably trained staff. Some staff had not received training in safeguarding children. Staff were not always aware of the appropriate agencies to refer safeguarding concerns to. This meant that patients were not protected from the risk of abuse because the provider had not taken reasonable steps to identify the possibility of abuse and prevent it from happening.

The provider did not have an effective system in place to identify, assess and manage risks to the health, safety and welfare of patients who used the service.