Archived: Lever Chambers 2

We inspected Lever Chambers 2 on 7 November 2016 as part of our inspection programme. The practice was given an overall rating of Good with the following key question ratings:

Safe – Good

Effective – Good

Caring – Good

Responsive – Good

Well-led – Good

We undertook an annual regulatory review of the practice on 2 July 2019 and a comprehensive inspection was agreed.

We undertook a comprehensive inspection of Lever Chambers 2 on 10 October 2019 to review the key questions Safe, Effective, Caring, Responsive and Well Led.

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 have rated this practice as requires improvement for providing safe services because:

• The practice did not have clear systems and processes to keep patients safe.
• The practice did not have appropriate systems in place for the safe management of medicines.
• The practice did not always learn and make improvements when things went wrong, they did not involve the relevant person or offer an apology.
• There was inconsistency in clinical documentation, specifically around the recording of medicine reviews.
• There were gaps in the recruitment checks for newly appointed staff.

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

• Some performance data was significantly below local and national averages

We have rated this practice as requires improvement for providing a well led service because:

• Leaders could not demonstrate that they had the capacity and skills to deliver high quality sustainable care.
• The practice culture did not effectively support high quality sustainable care.
• The practice did not have clear and effective processes for managing risks, issues and performance
• The practice did not always act on appropriate and accurate information.
• There was little evidence of systems and processes for learning, continuous improvement and innovation.

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

• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• The practice had a number of new staff including the practice manager and practice nurse who had recently introduced new policies, procedures and risk assessments.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Ensure that all staff complete their mandatory training in a timely manner
• Ensure that there is a central record of all clinicians training

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