We carried out an announced comprehensive inspection) at Ley Hill Health Centre on 8 December 2022. Overall, the practice is rated as good.
Safe – Good
Effective – Good
Caring – Good
Responsive – Good
Well-led – Good
This is the first inspection following the registration of Ley Hill Health Centre with new providers.
The full reports for previous inspections carried out under the previous registered providers for the location previously called Ley Hill Surgery can be found by selecting the ‘all reports’ link for Ley Hill Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection in line with our inspection priorities.
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 clinical interviews.
- 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.
- 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 found that:
- Staff files were not organised to make ensure recruitment records were easily accessible and there were gaps in the completeness of information in the files.
- The immunisation status of some non-clinical staff was not available and risk assessments were not sufficiently detailed to demonstrate how any level of risk would be mitigated.
- The premises were visibly clean and tidy. An infection control lead was in place to ensure guidelines were being followed.
- Risk management processes were in place and risk assessments had been completed. this included fire safety and a range of health and safety assessments.
- The practice had a system in place for the actioning of significant events and incidents.
- We found limited documentation detailing the content and outcome of medicine reviews.
- Regular formal supervision was not carried out to monitor the prescribing practices of non-medical prescribers.
- The practice had management oversight of staff qualifications and training.
- Staff were clear and knowledgeable about their lead roles and responsibilities.
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- There was poor uptake of preventative treatments and screening procedures by patients. This was particularly in the areas of childhood immunisations and cervical screening.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- Effective governance arrangements had been implemented to mitigate risks and ensure patients were kept safe.
- The way the practice was led and managed promoted an inclusive culture where people could speak openly and be involved in the delivery of high-quality, person-centred care.
Whilst we found no breaches of regulations, the provider should:
- Improve the standard and order of staff documentation held.
- Provide evidence that staff vaccination and immunity for potential health care acquired infections are recorded or risk assessed for all staff.
- Continue to promote and explore ways to improve the uptake of childhood immunisations and cervical screening.
- Implement systems for the ongoing monitoring and review of the completeness of documentation and updating of patient records following clinical and medicine reviews.
- Continue to proactively identify carers so that they can be supported to access services available to them.
- Introduce a formal system for the supervision of non-medical prescribers.
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