Background to this inspection
Updated
2 December 2019
Sutherland Lodge Surgery is located at 113-115 Baddow Road, Chelmsford, Essex, CM2 7PY. The practice is part of a local primary care network of three practices. There is a small car park onsite.
The practice is registered with the CQC to carry out the following regulated activities - diagnostic and screening procedures, treatment of disease, disorder or injury, family planning and maternity and midwifery services.
The practice provides NHS services through an Alternative Provider Medical Services (APMS) contract to approximately 10,530 patients. The practice is part of Mid Essex Clinical Commissioning Group (CCG).
The practice’s clinical team is comprised of two part-time female doctors, one full-time and one part-time male doctor, along with four part-time sessional GPs. There was a nursing team who supported the GPs, with additional nursing staff being recruited, as well as reception and administrative staff.
Standard appointments are 10 minutes long, with patients able to book a longer appointment should they require this. Patients who have previously registered to do so may book appointments online. The provider can carry out home visits for patients whose health condition prevents them attending the surgery.
In addition to the extended hours operated by the practice on Tuesday and Thursday evening, the CCG has commissioned an extended hours service, which operates between 6.30pm and 8pm on weeknights and from 8am to 2pm at weekends at “Hub” locations across the borough. Patients may book appointments with the service through the practice.
The practice has opted out of providing an out-of-hours service. Patients calling the practice when it is closed are signposted to the local out-of-hours service provider via NHS 111. In mid Essex this service is provided by IC24.
The practice has a slightly higher than average population of older people. The practices population is in the fourth decile for deprivation, which is ranked on a scale of one to ten. The lower the decile the more deprived an area is compared to the national average. The ethnicity of the patient population based on demographics collected in the 2011 census shows the patient population is predominantly white British with; 1.8% mixed, 3.4% Asian and 1.4% black.
Updated
2 December 2019
We carried out an announced comprehensive inspection at Sutherland Lodge Surgery on 7 October 2019 as part of our inspection programme.
At this inspection, we followed up on breaches of regulations identified at a previous inspection on 13 November 2018, when we rated the practice as requires improvement overall. Specifically we rated safe, effective and well-led as requires improvement with caring and responsive rated as good.
Prior to the inspection of November 2018, we inspected the practice in December 2017 and rated the practice as inadequate overall. They were placed in special measures for a period of six months.
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.
We rated the practice as requires improvement for providing caring services because:
- Data from the national GP patient survey reflected that patient satisfaction was below local and national averages for some of the areas measured.
We rated the practice as good for providing safe, effective, responsive and well-led services because:
- The practice had clear systems and processes to keep patients safe.
- The practice had appropriate systems in place for the safe management of medicines.
- The practice learnt and made improvements when things went wrong.
- Staff had the skills, knowledge and experience to carry out their roles.
- Unverified performance data showed that the practice performance in the year 2018-2019 had improved from the year 2017-2018.
- The practice had clear and effective processes for managing risks, issues and performance.
- Staff dealt with patients with kindness and respect.
- The practice acted upon appropriate and accurate information.
- Leaders showed that they had the capacity and skills to deliver high quality, sustainable care.
- The practice culture supported high quality sustainable care.
- We saw evidence of systems and processes for learning, continuous improvement and innovation.
The areas where the provider should make improvements are:
- Review the national GP patient survey data and take steps to improve patient satisfaction, as highlighted by data in the caring domain.
- Review performance around inadequate cervical screening results and consider how to improve uptake of this screening.
- Continue to monitor and review the level of antibacterial prescribing.
- Review the way that informal complaints are categorised and managed to ensure that they receive the same attention as formal complaints.
- Continue to improve patient satisfaction with telephone access to the practice.
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