Lavender Hill Group Practice

We carried out an announced focused inspection at Lavender Hill Group Practice on 11 May 2021 as part of our inspection programme. Overall, the practice is rated as Good.

Ratings for each key question:

Safe - Good

Effective - Good

Well-led - Good

Following our previous inspection on 26 February 2019, the practice was rated Requires Improvement overall and good for the key questions caring, effective and responsive. The practice was rated requires improvement for providing safe and well led services and issued requirement notices for Regulation 12 Safe care and treatment and Regulation 17 Good governance.

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

Why we carried out this inspection

This inspection was a focused inspection to follow up on breaches of Regulation 12 Safe care and treatment and Regulation 17 Good governance. At the previous inspection we found:

• The practice could not demonstrate that the recommendations identified in their Legionella risk assessment had been actioned. Their log of water temperatures showed that they were consistently out of range, but no actions had been identified to mitigate this.
• The practice did not keep a log of blank prescription stationery held in clinicians’ rooms.
• Out of date vaccines and medical equipment was identified during our inspection.
• The practice did not have proper oversight of staff training.
• The practice did not maintain oversight of risk assessments. They did not record that actions required had been completed and not all actions identified had been addressed.

We also followed up on areas we identified the practice should improve at the last inspection. Specifically:

• Improve the identification of carers to enable this group of patients to access the care and support they need.
• Continue to take action to improve the uptake of cervical screening to meet the minimum national target.
• Support staff to obtain the appropriate safeguarding training as set out in the intercollegiate guidance.
• At the previous inspection, we rated the practice good for key questions caring, effective and responsive

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 using video conferencing
• 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 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 have rated this practice as Good overall and good for all population groups.

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.
• Policies and procedures were monitored, reviewed and updated.
• 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.
• There was a clear leadership structure and staff felt supported by management.
• The practice proactively sought feedback from patients, which it acted on.
• There were clear responsibilities, roles and systems of accountability to support good governance and management.
• There was evidence of quality improvement activity.

Whilst we found no breaches of regulations, the provider should:

• Ensure that all actions from risk assessments, including fire, health and safety and infection control, are actioned and that the practice records that they have been completed so they can assure themselves of risk.
• Continue to consider ways to improve uptake for childhood immunisations.
• Ensure that all staff have protected time for learning and development that is sufficient for their needs.

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