Park Lane Surgery

Updated 4 March 2024

Park Lane Surgery is located in Broxbourne Hertfordshire.

At the time of our inspection, the practice was experiencing staff sickness and had informed us this had impacted their non-clinical staffing levels.

The provider is registered with CQC to deliver the Regulated Activities, diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

The practice is situated within the NHS Hertfordshire and West Essex Integrated Care System (ICS) and delivers General Medical Services (GMS) to a patient population of about 10,370 patients. This is part of a contract held with NHS England.

Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the ninth lowest decile (9 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic makeup of the practice includes 94.7% white patients, 1.7% Asian patients, 1.5% black patients, 1.6 mixed patients, and 0.5% other patients.

The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.

There is a team of 3 GP partners and 3 salaried GPs at the practice. There is a team of 3 practice nurses who provide nurse led clinics for long-term condition. The GPs are supported at the practice by a team of 2 healthcare assistants, 15 reception/administration staff. The practice manager provides managerial oversight.

The practice is open between 8am to 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by Hoddesdon and Broxbourne primary care network, where late evening and weekend appointments are available. Out of hours services are provided by Hertfordshire urgent care (HUC).

Updated 4 March 2024

We carried out an announced comprehensive at Park Lane Surgery on 24 October 2023. Overall, the practice is rated as requires improvement.

Safe – Inadequate

Effective - requires improvement.

Caring - Good

Responsive - requires improvement.

Well-led - requires improvement.

Following our previous inspection on 1 December 2016, 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 Park Lane 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.

This was a comprehensive inspection to review the following domains:

• Safe
• Effective
• Caring
• Responsive
• Well Led

How we carried out the inspection/review

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
• 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.
• Reviewing patient feedback.

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:

• There were safeguarding processes to keep people safe from abuse, however not all staff were trained to the appropriate levels of their role.
• There was an absence of appropriate staff recruitment checks to ensure safety and checks of staff immunisation status or appropriate risk assessments had not been completed for all staff.
• Patients care, needs and assessment for treatment were not always delivered in line with national and recommended guidance.
• The building and premises required upgrading to meet health and safety requirements; the practice had works booked for repair.
• The provider did not always review or keep up to date risk assessments and action plans.

We found breaches of regulations. The provider must:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure all premises and equipment used by the service provider is fit for use.
• Complete a risk assessment on the surgical clinical room.

Whilst we found no breaches of regulations, the provider should:

• Take action to complete mandatory training for staff employed at the practice.
• Take action to implement a strengthened process for reviewing coding of patients with a misdiagnosis.
• Take action to audit and monitor non-medical prescribing staff.
• Take action to review and update all risk assessments and action plans.
• Take action to maintain childhood immunisation uptake.
• Take steps to increase patient satisfaction in line with the national GP patient survey.

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