Archived: Central Lakes Medical Group

We carried out an announced comprehensive follow up inspection at Central Lakes Medical Group on 30 September 2019. We undertook this inspection following an inspection in March 2019. At that time, we rated the service as Requires Improvement. We issued the provider with a requirement notice for a breach of regulation 17, Good governance. The full report from our March 2019 inspection visit can be found here www.cqc.org.uk

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 and good for all population groups.

We found that:

• The practice had made improvements to their quality assurance systems which were now underpinned by consistent monitoring.
• Patients received effective care and treatment that met their needs.
• Health and safety, fire safety and infection control checks and audits were now being completed for both the Ambleside site and the Hawkshead branch surgery.
• Patients commented that staff were caring and professional.
• Staff were well trained and competent in the delivery of good patient care.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider should make improvements are:

• Continue to develop their electronic quality assurance systems.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

We carried out an announced comprehensive inspection at Central Lakes Medical Practice on 7 March 2019. We had previously inspected the practice in May 2015; this inspection had resulted in an overall rating of Good. The full comprehensive report following the inspection in May 2015 can be found on our website here: https://www.cqc.org.uk/location/ 1-549363386.

We carried out our most recent inspection in order to ensure the practice was continuing to maintain good standards.

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 requires improvement overall and good for all population groups.

We rated the practice as requires improvement for providing safe services because:

• The risk of fire was not properly mitigated at Hawkshead branch surgery.
• Risks in relation to recruitment processes and pre employment checks were not always comprehensively mitigated.
• Infection control audts had not been fully completed at Hawkshead branch surgery.
• The provider had nor assured itself that processes around the management of incoming correspondence were safe.
• It was not possible to tell who had received what training from the training records.

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

• The practice governance arrangements had failed to note that recruitment processes were not sufficiently robust, audits were incomplete and risk assessments had not been carried out.

However, we also found that:

• Patient feedback was strongly and consistently positive about the standard of care and treatment received. The practice’s results from the national GP patient survey were higher than local and national averages.
• 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 organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

(Please see the specific details on action required at the end of this report).

In addition, the provider should:

• Improve the identification of carers to enable this group of patients to access the care and support they need.
• Improve communication so staff are aware of leadership roles within the practice team.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice