Lees Medical Practice

We carried out an announced comprehensive at Lees Medical Practice on 25 and 29 August 2023. Overall, the practice is rated as requires improvement with the following key question ratings:

Safe – requires improvement

Effective - requires improvement

Caring - requires improvement

Responsive - requires improvement

Well-led - requires improvement

Following our previous inspection on 7 September 2022, the practice was rated requires improvement overall and for all the key questions. We found breaches of Regulations 12 (safe care and treatment) and 17 (good governance).

At this inspection we found the practice had made improvements in the areas previously identified, but other concerns were found.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Lees Medical Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to check that our concerns and the breaches of regulation from our previous inspection had been acted on.

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 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 rated the practice requires improvement for providing safe services:

• Required pre-recruitment checks were not carried out.
• There were typographical errors on the health and safety and fire risk assessments, and the health and safety risk assessment had not been completed accurately.
• Routine checks stipulated in the fire safety policy were not carried out.
• The infection prevention and control policy and statement gave conflicting information.
• Significant events were not managed effectively.

We rated the practice requires improvement for providing effective services:

• The practice had completed induction documents for staff, but these were generic and not linked to individual roles. Dates on induction forms were not always correct.
• The system for managing training was not effective.
• Training was not carried out in accordance with the practice’s recorded procedures.
• Probation reviews were not carried out in line with the practice’s procedures.
• Although the uptake for cervical screening had increased since the previous inspection it was still below 70%.

We rated the practice requires improvement for providing caring services:

• Patient satisfaction had declined in some areas.
• There was some conflicting information in the in-house patient survey.

We rated the practice requires improvement for providing responsive services:

• Patient satisfaction had declined in some areas.
• Improvements were required around complaints’ governance and learning from complaints.

We rated the practice requires improvement for providing well-led services:

• We found several areas where improvement was required in governance procedures.
• Some policies were inaccurate or not being followed.
• Significant events and complaints were not used to encourage continuous improvement.
• Processes for managing non-clinical risk were not clear.

We found 2 breaches of regulations. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed, and that specified information is available regarding each person employed.

In addition, the provider should:

• Take further steps to improve the uptake of cervical screening.
• 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