09 November 2023
During a routine inspection
We carried out an announced focused inspection at Hendford Lodge Medical Centre on 9 November 2023. Overall, the practice is rated as requires improvement.
Safe - requires improvement
Effective - requires improvement
Caring - not inspected, rating of good carried forward from previous inspection
Responsive - requires improvement
Well-led - requires improvement
During the inspection process, the practice highlighted efforts they are making to improve outcomes and treatment for their population. These had only recently been implemented so there is not yet verified evidence to show they were working. For example, changes to systems to improve access for patients to the service. As such, the ratings for this inspection have not been impacted. However, we continue to monitor the data and where we see potential changes, we will follow these up with the practice.
We recognise the pressure that practices are currently experiencing and the efforts staff are making to maintain levels of access for their patients. At the same time, our strategy commits to delivering regulation driven by people’s needs and experiences of care. Although we saw the practice was attempting to improve access, this was not yet reflected in the GP patient survey data or other sources of patient feedback. Therefore, the rating is requires improvement, as ratings depend on evidence of impact and must reflect the lived experience that people were reporting at the time of inspection.
Following our previous inspection in October 2019, the practice was rated good overall and for all key questions.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Hendford Lodge Medical Centre on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection to follow up concerns reported to us.
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.
- A short 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:
- The practice had not consistently provided care in a way that kept patients safe and protected them from avoidable harm. For example, more work was required to ensure all aspects of medicine management were safe.
- Patients’ needs were assessed and the care and treatment provided were delivered in line with current legislation, standards and evidence-based guidance although not all patients had access to health checks.
- The practice could not fully demonstrate that all staff had the skills, knowledge and experience to carry out their roles.
- The number of cervical screenings carried out in the practice had not met the national targets.
- Patients could not always access care and treatment in a timely way.
- The way the practice was led and managed did not always promote the delivery of high-quality, person-centre care due to a lack of consistent oversight of all systems and processes.
We found 1 breach of regulations. The provider must:
- Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
Additionally, the provider should:
- continue to develop and embed systems to enable patients to access relevant health checks and carry out appropriate monitoring for their long-term conditions.
- continue to take action to increase the cervical screening carried out at the practice.
- Continue to embed systems to review safeguarding concerns within the practice. For example, reinstating and holding regular safeguarding review meetings.
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 Health Care