The Lyndhurst Surgery

Background to this inspection

Updated 22 May 2017

The Lyndhurst Surgery operates from 53 Lyndhurst Drive, Leyton, London, E10 6JB. The practice provides NHS primary medical services through a General Medical Services (GMS) contract (a contract between NHS England and general practices for delivering general medical services and is the commonest form of GP contract) to approximately 3,500 patients in the Leyton area. The practice is part of the Waltham Forest Clinical Commissioning Group (CCG).

The practice has a higher than average percentage of patients between the 45-49 year age group and a higher proportion of unemployed patients than the CCG and national average with the practice having 13% compared to the CCG average of 7% and the national average of 4%.

The practice has a male and a female GP partner who carry out a total of 17 sessions per week, and a female practice nurse who carries out two sessions per week. There is a practice manager, four reception staff and one practice secretary.

The practice is open Monday to Friday between 8:45am and 6:30pm except for Thursdays when it closes at 1pm. Phone lines are answered from 9am to 12:30pm and 2:30pm to 6:30pm and appointment times are as follows:

Monday 9am to 11:30am and 4:30pm to 6:20pm
Tuesday 9am to 11:30am and 4:30pm to 7pm
Wednesday 9am to 11:30am and 4:30pm to 7pm
Thursday 9am to 11:30am
Friday 9am to 11:30am and 4:30pm to 6:30pm

Telephone consultations are carried out every day between 12pm and 12:30pm and the locally agreed out of hours provider covers telephone calls made to the practice when it is closed.

The Lyndhurst Surgery operates regulated activities from one location and is registered with the Care Quality Commission to provide surgical procedures, family planning, treatment of disease disorder or injury, maternity and midwifery and diagnostic and screening procedures.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Overall inspection

Good

Updated 22 May 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Lyndhurst Surgery on 29 October 2014. The overall rating for the practice was requires improvement. The full comprehensive report published in May 2015 can be found by selecting the ‘all reports’ link for The Lyndhurst Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 21 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 29 October 2014. There were breaches in medicines management procedures including the repeat prescribing process and also in recruitment processes. There were also concerns with the management and leadership in the practice, particularly with the training of staff members, risk assessments including fire safety and legionella testing, the safety of electrical equipment and procedures for dealing with medical emergencies. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

The practice used a system to ensure vaccines were safely stored and managed, including an effective cold chain policy and a system for ensuring all vaccines were in date.
All emergency medicines and disposable equipment were in date and there was a system to monitor their use.
Risks to patients were well assessed, there was a fire risk assessment, all staff had fire safety training appropriate to their role and regular fire drills were carried out and learning was shared.
There was an up to date infection control audit and a legionella risk assessment and the practice had carried out the actions identified as a result.
All staff had completed mandatory training including chaperone training and equality and diversity training and had access to an online training portal where they were able to complete training other than mandatory training that they had an interest in.
There was an effective medicines management system, which included a policy, staff were aware of their roles and remits, only GPs issued prescriptions for controlled and high risk medicine or for medicines when the patient review was overdue.
Electrical equipment had been tested to ensure it was safe to use and clinical equipment had been calibrated to ensure it was safe, in good working order and fit for purpose.
The practice had a risk assessment to mitigate against the risks of not having a defibrillator and a signed guidance sheet for summoning appropriate help in the event of a medical emergency or cardiac arrest, however the practice purchased a defibrillator by the end of the inspection.
The practice carried out regular meetings which all staff were expected to attend, there were standing agenda items, which included significant events, complaints and any other business. Regular clinical meetings were also held and copies of the minutes were provided to the practice nurse when they could not attend, the practice nurse also attended the local nurse’s form.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice