Hendford Lodge Medical Centre

Updated 20 December 2023

Hendford Lodge Medical Centre is located in Yeovil at:

74 Hendford Lodge

Yeovil

Somerset

BA20 1UJ

The practice has a branch surgery at:

Abbey Manor Medical Centre

The Forum

Abbey Manor Park

Yeovil

Somerset

BA21 3TL

At this inspection we did not visit the branch surgery.

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 offers services from both a main practice and a branch surgery. Patients can access services at either surgery.

The practice is situated within the Somerset Integrated Care System (ICS) and delivers General Personal Medical Services (PMS) to a patient population of about 14,000. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices known as a Primary Care Network (PCN).

Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the seventh highest decile (7 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 97% White, 2% Asian and 1% Other.

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 4 GPs who provide cover at both practices. The practice has a team of 8 nurses (including registered nurses, assistant practitioner and health care assistants) who provide nurse-led clinics for long-term conditions. The GPs are supported at the practice by a team of reception/administration staff. The practice manager and assistant practice manager are based at the main location to provide managerial oversight.

The practice is open between 08.30 am to 6.30 pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and home visits.

Out-of-hours services are provided by NHS 111 and the out-of-hours doctors service.

Updated 20 December 2023

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