Background to this inspection
Updated
13 September 2022
Merton Lodge Surgery is located at:
33 West Street,
Alford
Lincolnshire
LN13 9HT
The practice has a patient list size of approximately 7,281. The list has been closed to new patients since February 2022. The practice serves the small market town of Alford and surrounding villages.
The surgery can dispense medicines to 3,082 eligible patients. These are patents that reside 1.6km or more from a community pharmacy.
The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services and treatment of disease, family planning, disorder or injury and surgical procedures.
The practice is situated within the NHS Lincolnshire Integrated Care System and delivers Personal Medical Services (PMS). This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices known as SOLAS Primary Care Network.
Information published by Public Health England shows that deprivation within the practice population group is in the third lowest decile (three of 10). The lower the decile, the more deprived the practice population is relative to others.
The practice has a larger percentage of older patients (33.4%) compared to both the CCG (23.3%) and national average (17.7%).
0.4% of the practice population are from BAME groups, lower than the Lincolnshire average of 2%.
Chronic disease prevalence was generally higher than both CCG and national averages.
The practice has one GP partner and one salaried GP. There are two advanced nurse practitioners, a nurse practitioner, a trainee nurse practitioner, one practice nurses, a trainee practice nurse, a Health Support Manager, a phlebotomist and a health care assistant. They are supported by dispensary, reception and administration staff.
Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, many GP appointments were telephone consultations.
Out- of- hours GP services are provided by Lincolnshire Community Health Services NHS Trust.
Updated
13 September 2022
We carried out an announced inspection at Merton Lodge Surgery on 30 June 2022. Overall, the practice is rated as Good.
The ratings for each key question are;
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Why we carried out this inspection.
- This was a full comprehensive inspection that looked at all the key questions.
- This practice had not previously been inspected.
How we carried out the inspection.
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews.
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider
- Reviewing patient records to identify issues and clarify actions taken by the provider
- Requesting evidence from the provider
- A shorter site visit
- Receiving written staff feedback prior to the on-site inspection taking place
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 have rated this practice as Good overall.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- Patients received effective care and treatment that met their needs.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- Patients could access care and treatment in a timely way.
- The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
Whilst we found no breaches of regulations, the provider should:
- Record alerts regarding safeguarding on the records of parents and adult family members of children with safeguarding concerns.
- Ensure that any overdue annual long-term condition reviews and medication reviews are performed.
- Put in place an audit/quality improvement project plan and restart quality improvement work.
- Review the process for dealing with un-collected prescriptions.
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