17/10/22
During a routine inspection
We carried out an announced comprehensive at Linden Hall Surgery on 17 October 2022 Overall, the practice is rated as good.
Safe - requires improvement
Effective - good
Caring - good
Responsive - good
Well-led - good
Following our previous inspection on 14 July 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 Linden Hall Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We carried out this inspection due to the length of time the practice was previously rated. We assessed all key questions.
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 to the main site and the Muxton branch practice.
- Staff feedback questionnaires.
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:
- Recruitment checks were not always carried out in accordance with regulations.
- Not all health and safety risks had been assessed and appropriate actions taken.
- Vaccines were appropriately stored but not monitored effectively to ensure they remained safe and effective.
- Not all staff were up to date with training in safe working practices.
- Not all medical alerts had been acted on.
- Patients received effective care and treatment that met their needs. The uptake rates of breast and bowel cancer screening were above the local and national averages.
- 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. The practice achieved higher than local and national averages for providing responsive services within the national patient survey.
- Patients were very positive about the service. All four indicators from the national GP survey for providing caring services were above the local and national averages. Ninety eight point nine percent of respondents to the GP patient survey stated that during their last GP appointment they had confidence and trust in the healthcare professional they saw or spoke to.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
We found one breach of regulations. The provider must:
Ensure care and treatment is provided in a safe way to patients
The provider should:
- Continue to improve cervical cancer screening uptake and childhood immunisations for those aged five years.
- Improve the quality of recording of significant events.
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