We carried out a review of the data available to us about Elm Lodge Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.
This could change at any time if we receive new information. We will continue to monitor data about this service.
If you have concerns about Elm Lodge Surgery, you can give feedback on this service.
We carried out an announced comprehensive inspection at Elm Lodge Surgery on 10 May & 7 June 2016. The practice was rated good overall and requires improvement for key question: Are services safe? The full comprehensive report from this inspection can be found by selecting the ‘all reports’ link for Elm Lodge Surgery on our website at www.cqc.org.uk.
This inspection was an announced desk-based review carried out on 10 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 10 May & 7 June 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.
At our previous inspection undertaken on 10 May & 7 June 2016, we rated the practice as requires improvement for providing safe services as:
The practice had not taken the necessary action to mitigate risks associated with infection control.
The practice did not have a supply of chlorphenamine (used to treat allergic reactions) and hydrocortisone for injection (used to treat swelling or inflammation) in their supply of emergency medicines in accordance with current legislation and guidance.
Not all equipment in the doctor’s emergency bags had been calibrated to ensure that it was functioning and safe to use.
Not all staff had received essential training including safeguarding, basic life support training and infection control.
In addition to the breaches in regulation we found areas where we suggested the practice should make improvement. For example:
The practice had identified a lower number of patients with chronic obstructive pulmonary disease compared to rates of identification in other practices locally and nationally.
The practice’s system of recruitment checks was not sufficiently comprehensive.
One member of staff was not chaperoning in accordance with current guidance.
The practice is now rated as good for the key question: Are services safe?
Our key findings were as follows:
The practice had taken actions to ensure that risks associated with infection control had been addressed.
The practice had a supply of emergency medicines which reflected current guidelines.
All staff had completed essential training in accordance with current recommendations and guidance.
All clinical equipment had been calibrated.
We also saw evidence the practice had:
Undertaken comprehensive recruitment checks for their most recently recruited member of staff.
Sent a reminder to staff regarding chaperone procedures within the practice.
Not taken action to increase the identification of patients with Chronic Obstructive Pulmonary Disease. However, the practice had reviewed their performance and attributed lower prevalence to being located in an area of low pollution and as a result of having a lower proportion of smokers on their patient list.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Elm Lodge Surgery on 10 May 2016. Due to unforeseen circumstances, not related to the practice, we undertook a second visit on 7 June 2016. Overall the practice is rated as good.
Our key findings across all the areas we inspected were as follows:
The areas where the provider must make improvement are:
The areas where the provider should make improvement are:
Professor Steve Field CBE FRCP FFPH FRCGP Chief Inspector of General Practice