Lindley Village Surgery

We carried out an announced comprehensive inspection at Lindley Village Surgery on 24 and 30 August 2022. Overall, the practice is rated as good.

Safe - requires improvement

Effective – good

Caring - good

Responsive - good

Well-led - good

Why we carried out this inspection

This announced comprehensive inspection was carried out following changes to the provider registration and legal entity of the practice. This was the first inspection since this change.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• Reviewing staff questionnaires.
• A site visit.

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 have rated this practice as good overall with the key question safe rated as requires improvement.

We found that:

• There were gaps in the management of clinical correspondence and patient-related tasks and referrals, aspects of medicine management, blank prescription forms, patient specific directions and patient safety alerts. We found some patients with long-term conditions were not managed in line with guidance.
• 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.
• There was a system in place for reporting and recording significant events.
• Patient satisfaction was higher than local and national averages for patient experience specifically in relation to their care and treatment.
• 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.
• During the COVID-19 pandemic, the practice had funded and made up essential food parcels and delivered them to their known vulnerable housebound patients.
• The practice had recently completed an extension to the premises to increase clinical and non-clinical space, which would improve patient and staff experience.
• The clinical and management team demonstrated that they understood the challenges to healthcare provision.

We found one breach of regulation. The provider must:

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

The provider should:

• Review the process to formally document the reviews of the consultation notes and prescribing of the non-medical prescribers.
• Continue to monitor and make improvements to increase the uptake of cervical screening.
• Continue to improve the identification of carers.

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

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services