The Care Quality Commission
  • Doctor
  • GP practice

Luson

Overall: Good read more about inspection ratings

Luson Surgery, 41 Fore Street, Wellington, Somerset, TA21 8AG (01823) 662836

Provided and run by:
Luson

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Luson 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 Luson, you can give feedback on this service.

22 June 2021

During an inspection looking at part of the service

We carried out an announced review at Luson Surgery on 22 June 2021. Overall, the practice is rated as good.

Following our previous inspection on 11 December 2019 the practice was rated Good overall and for all key questions, except for the effective key question and the long-term condition, working age people and people experiencing poor mental health population groups which were rated as requires improvement.

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

Why we carried out this review

This was a follow up review of concerns identified in the 2019 inspection.

The focus of this review was:

  • To review the services provided to people with long-term conditions and the outcomes for these patients using the Quality and Outcomes Framework (QOF) performance.
  • To review the services provided to Working age people (including those recently retired and students).
  • To review the services provided to people experiencing poor mental health the outcomes for these patients using the Quality and Outcomes Framework (QOF) performance.

How we carried out the review

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 reviews differently.

This review was carried out off site. This was with consent from the provider and in line with all data protection and information governance requirements.

Our approach included:

  • Conducting staff interviews using tele-conferencing
  • Reviewing performance data available at the time of our inspection.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we undertook the review
  • 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 of the population groups.

We found that:

  • Patients with long-term conditions and people experiencing poor mental health had their needs assessed and their care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.
  • Throughout the pandemic, patients with long-term conditions were recalled as appropriate. Patients were proactively contacted using text messages and through personal contact from healthcare assistants and clinical staff. Patients were opportunistically contacted to carry out reviews.
  • Childhood immunisation and cervical screening data was below expected national targets for some indicators but the practice had an action plan in place to target and work with individuals who declined these services to better understand the rationale of patient choice.
  • Work had been undertaken to increase the completion of care reviews for those patients diagnosed with cancer.
  • Face-to-face appointments were offered when clinically necessary.
  • The practice worked in a multidisciplinary manner to ensure that patient needs were met. Staff worked proactively with the local Primary Care Network (PCN) to increase access to a range of services, including access to health coaches and mental health practitioners.

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

  • Continue to monitor and improve care for patients with diabetes and frailty.
  • Continue to take action to increase the uptake of cervical screening.
  • Continue to take action to increase the uptake of childhood immunisations.

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

11 December 2019

During an inspection looking at part of the service

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a change to the quality of care provided since the last inspection.

This inspection focused on the following key questions:

Is the service effective?

Is the service well-led?

Because of the assurance received from our review of information we carried forward the ratings for the following key questions:

Is the service safe? - Good

Is the service caring? - Good

Is the service responsive? - Good

The practice was previously inspected on 3 December 2015 and the report was published on 21 January 2016. The practice was awarded an overall rating of Good.

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 for providing effective and the population groups of people with long term conditions, working age people and people experiencing poor mental health.

The practice was rated as good for providing well led services and for the population groups; older people; families, children and young people and people whose circumstance makes them vulnerable. The practice was awarded an overall rating of good.

We found that:

  • The performance and achievement data relating to supporting patients with long term conditions was inaccurate. We could not be assured that patients had received appropriate care and treatment.
  • In addition, we were not assured that all patients with cancer had received appropriate reviews.
  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • 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.
  • Clinical and internal audit processes functioned well and had a positive impact in relation to quality governance.
  • There was a low turnover of staff and feedback from staff about working at the practice was positive.
  • Patients and staff said communication was effective at the practice.
  • GPs operated personal lists and had an effective buddy system in place to ensure there was continuity of care.

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

  • Continue to review arrangements and implement actions to improve uptake in relation to patients with long term conditions, patients experiencing poor mental health, cervical screening and childhood immunisations.

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

3 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Luson Surgery on 3 December 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw areas of outstanding practice:

  • The practice made reasonable adjustments to remove barriers when patients found it hard to use or access services for example, through the provision of appointments to see a GP outside the GPs normal working hours.
  • The practice provided regular twice weekly clinics by a male and female GP for students at a local boarding school to ensure their health needs were being met. In addition they provided rugby concussion assessments for students if required.
  • The practice worked effectively with patients diagnosed with learning disabilities to ensure they received appropriate treatment. Where patients lacked capacity to make decisions for themselves they involved the local authority Independent Mental Capacity Assessor to ensure safe decisions about appropriate treatment were made on behalf of the patient.

The area where the provider should make improvement are:

  • In support of the whole staff group; consider ways of enabling all staff to gather collectively to review the performance of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

16 October 2013

During a routine inspection

We spoke with eight patients who were pleased with the service they received and all said they had been involved in the decisions made about their care. One patient said 'They explain what is happening' and another said 'All the decisions I make are mine using his advice.'

Patients said they could get an appointment when they needed and said staff treated them with respect and dignity. One patient said 'It is a small practice which makes it more personal.'

Patients appreciated the continuity of care. One patient said 'I see the same doctor which is great because they know me and my family.'

All staff knew the correct local safeguarding procedures to follow if abuse was suspected and all had attended training.

Patients told us that they always felt safe in the care of the staff. There were appropriate arrangements in place which ensured that staff kept their knowledge and skills up to date. Staff spoke about the supportive environment and confirmed that they had access to adequate training.

The practice was organised and well led. There were effective systems in place to monitor the quality of the service provided and patients felt able to give feedback about the service they received.