- GP practice
Lupset Health Centre
All Inspections
22 July 2022
During a routine inspection
We carried out an announced inspection at Lupset Health Centre between 21 July 2022 and 22 July 2022. Overall, the practice is rated as Good.
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 15 November 2017, the practice was rated Good overall and for all key questions except Responsive which was rated as Outstanding.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Lupset Health Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We undertook this inspection as part of a random selection of services rated Good and Outstanding to test the reliability of our new monitoring approach.
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 some staff interviews using video/telephone 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 short site visit.
- Reviewing completed staff 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 found that:
- There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Leaders reviewed the effectiveness and appropriateness of the care the service provided. They ensured that care and treatment was delivered according to evidence-based guidelines.
- The practice adjusted how services were delivered to meet the needs of patients during the COVID-19 pandemic.
- There was a programme of quality improvement, this included both clinical and non-clinical audit.
- Staff had the skills, knowledge and experience to deliver effective care. The practice had a strong training ethos. They operated as a GP training practice, provided placements for student nurses, and had supported a number of staff in the development of their professional careers.
- The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
- Leaders and managers in the practice demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
- Staff reported that they felt that they worked well together as a team, and were well supported by senior managers.
Whilst we found no breaches of regulations, the provider should:
- Fully implement revised processes to ensure that ‘Do Not Attempt Cardio Pulmonary Resuscitation’ documentation is stored in the patient record.
- Improve processes for the assessment of incoming medicines safety alerts and updates to ensure that these have been correctly assessed and implemented.
- Improve the process for monitoring of patients with long-term conditions to ensure blood tests are undertaken according to required timeframes.
- Fully establish the immunity status of staff in line with national guidance.
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
15 November 2017
During a routine inspection
Letter from the Chief Inspector of General Practice
This practice is rated as Good overall.
The practice had been previously inspected on 22 September 2015 when it was rated as Good overall, with one domain being rated Requires Improvement for the provision of responsive services.
The key questions are rated as:
Are services safe? – Good
Are services effective? – Good
Are services caring? – Good
Are services responsive? – Outstanding
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students) – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Lupset Health Centre on 15 November 2017. The inspection was carried out as part of our inspection programme and was also used to follow up areas where at the time of the last inspection, on 22 September 2015, the provider was informed they should take action to improve some areas in respect of the provision of responsive services. This included improving access to the practice for patients with a disability, improving the ease of patients contacting the practice by telephone, and the need to provide patients with access to information about how to make a complaint. We noted at the 15 November 2017 inspection that the practice had taken action to improve these service areas.
At this inspection we found:
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The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
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The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
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A number of higher level services were provided within the practice which would otherwise be usually delivered in secondary care settings.
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The practice showed better than average performance in relation to the prescribing of antibiotic items.
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The practice offered home visits from 9am, which supported provision of earlier interventions, and prevented deterioration and possible admission to secondary care services. Urgent care was also prioritised with appointments being available for these patients on the day of presentation.
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Staff discussed treatment options with patients, and we were told by carers and patients that they were treated with compassion, kindness, dignity and respect by all the staff in the practice.
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The practice provided services to patients who were assessed as being potentially violent and had been excluded from mainstream GP services.
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Public engagement was positive and active. The practice sought patient feedback via a number of routes, such as carrying out individual surveys and engagement with the established Patient Participation Group. The practice was responsive to patient feedback and had implemented improvements to the practice telephone system in light of previous low patient satisfaction.
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There was a strong focus on continuous learning and improvement at all levels of the organisation.
We saw two areas of outstanding practice:
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The practice recognised there was high local patient demand for mental health services (including those for dementia). In response to this it had employed a mental health nurse and delivered a number of dedicated services to meet these needs.
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The practice provided services to patients who had been assessed as being potentially violent, and had therefore been excluded from accessing services provided by their own GP practice. As well as having delivered care to these patients, over time Lupset Health Centre had supported a significant number to return to other mainstream GP services.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
22 September 2015
During a routine inspection
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Lupset Health Centre on 22 September 2015. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
- There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
- Risks to patients were assessed and well managed.
- Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
- Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
- Information about services and how to complain was available and easy to understand although complaints information was not openly visible in the practice.
- Urgent appointments were available the same day and early morning and late evening appointments were also available. Although the practice had recognised that patients were dissatisfied with access to the practice by telephone and to appointments with GPs of their choice and had made changes, these changes had achieved a limited impact on patient satisfaction.
- The practice had good facilities and was well equipped to treat patients and meet their needs. However, these were not always used effectively to support patients with a disability.
- There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
- There was an active patient participation group.
- The provider was aware of and complied with the requirements of the Duty of Candour.
We saw one area of outstanding practice:
- Performance for mental health related indicators was 100% with a 6.2% exception rate, well above the CCG and national average of 94.2% and 90.4%. The practice had employed a mental health nurse as part of an external funding arrangement due to the high prevalence of mental health problems experienced by their patient group. This had been so successful the practice had continued the nurse’s employment when the funding had ended. This service ensured patients received timely care and support at the practice, reducing the need for referrals to secondary care services. The mental health nurse held hour-long appointments once a week for patients living with dementia and their carers. The nurse had developed their consulting room to ensure a comfortable and welcoming space for patients.
The areas where the provider should make improvement are:
- Ensure disabled patients are able to use the facilities provided such as the lowered reception desk and the electronic check in system.
- Improve access for patients in wheelchairs and pushchairs through the reception doors.
- Improve access to the practice by telephone.
- Ensure patients can easily access complaints information in the practice.