Archived: Lime Grove Surgery

We carried out an announced comprehensive inspection at Lime Grove Surgery on 11 September 2019 as part of our inspection programme.

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 rated the practice as requires improvement for providing safe services because:

• The systems for ensuring staff were appropriately authorised to administer medicines to patients was not robust.

• The systems for managing the safeguarding of vulnerable patients was not robust.

• The system for ensuring that all the required documentation to demonstrate safe recruitment processes was not robust.

• The system to ensure that the premises were safe was not robust.

We rated the practice as requires improvement for providing well-led services because:

• Improvements were needed to the systems in place to ensure safe premises, safe staff recruitment, safe authorisation of medicines and to safeguard vulnerable patients.

We rated the practice as good for providing effective, caring and responsive services because:

• The needs of patients were

• Staff dealt with patients with kindness and involved them in decisions about their care.

• There was a commitment to improving the service and the practice responded to feedback from patients and staff.

We rated the population groups as good.

The area where the provider must make improvements are:

• Ensure that care and treatment is provided in a safe way.

• Ensure patients are protected from abuse and improper treatment.

• Ensure all premises and equipment used by the service provider is fit for use

• Systems and processes must be in place to ensure specified information is available regarding each person employed.

The areas where the provider should make improvements are:

• Take steps to improve access for patients accessing the service by telephone and using the branch practice.

• Formalise the system for reviewing the practise of clinical staff to ensure consultations, referrals and prescribing are appropriate.

• Put adrenaline in clinical rooms were vaccines are administered.

• Continue to monitor patients with long-term conditions and poor mental health to ensure that improvements are demonstrated in the number of patients receiving reviews of care.

• Develop a system to review infection control standards in between annual audits from the CCG.

• Put in place a planned programme of quality improvement.

• Provide formal training to non-clinical staff in the Mental Capacity Act 2005 and the Deprivation of Liberty Safeguards (DoLS).

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care