This practice is rated as Good overall. (Previous inspection October 2015 – Good)
The key questions are rated as:
Are services safe? – Good
Are services effective? – Requires Improvement
Are services caring? – Good
Are services responsive? – Good
Are services well-led? - Good
As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:
Older People – Good
People with long-term conditions – Good
Families, children and young people – Good
Working age people (including those recently retired and students – Good
People whose circumstances may make them vulnerable – Good
People experiencing poor mental health (including people with dementia) - Good
We carried out an announced comprehensive inspection at Lakenham Surgery on 22 February 2018.
At this inspection we found:
- The practice had clear systems to manage risk so that safety incidents were less likely to happen. When they did happen, the practice learned from them and improved their processes. The practice shared outcomes of significant events with staff and other local GP practices.
- The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment were delivered according to evidence based guidelines.
- Staff involved and treated patients with compassion, kindness, dignity and respect.
- Staff were consistent and proactive in helping patients to live healthier lives.
- The facilities and premises were appropriate for the services delivered.
- QOF performance for 2016/17 for diabetes related indicators was 85%; this was below the CCG average of 93% and below the England average of 91%.
- Annual health assessments for people with a learning disability were undertaken but required improvement. The practice had 79 patients on the learning disabilities register, of which only 3 had received a health review in 2017/18 at the time of inspection.
- There was a system for receiving and acting on safety alerts. For example, Medicines and Healthcare Products Regulatory Agency (MHRA) alerts were reviewed by the practice management team and GPs. Actions as a result were recorded but there was no log kept of historical responses. The practice informed us they would commence this immediately.
- Staff had the skills, knowledge and experience to carry out their roles and there was a strong focus on continuous learning and improvement at all levels of the organisation.
- The practice performed consistently above average for its satisfaction scores in the national GP patient survey. Patients responded positively to questions about their involvement in planning and making decisions about their care and treatment and felt they were treated with compassion, dignity and respect.
- Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these concerns would be addressed.
- The practice had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.
The areas where the provider should make improvements are:
- Ensure QOF performance for diabetes and asthma achieves a good standard.
- Ensure annual health assessments for patients with learning disabilities are undertaken.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice