The Care Quality Commission
  • Doctor
  • GP practice

Lilyville @ Parsons Green

Overall: Good read more about inspection ratings

5-7 Parsons Green, London, SW6 4UL (020) 7736 4344

Provided and run by:
Lilyville @ Parsons Green

Important: This service was previously registered at a different address - see old profile

All Inspections

6 July 2023

During a monthly review of our data

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

18 August 2021

During an inspection looking at part of the service

We carried out an announced inspection at Lilyville @ Parsons Green from 11-18 August 2021. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Well-led - Good

Following our previous inspection on 19 December 2019 , the practice was rated Requires Improvement overall and for the key questions: Are services effective? and Are services well-led? It was rated Good for the key questions: Are services safe? Are services caring? and Are services responsive?

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

Why we carried out this inspection

This inspection was a focused inspection to follow up:

  • The key questions for: Safe, Effective and Well-led. The ratings for the key questions: Caring and Responsive will be carried forward from the previous inspection.
  • The previously identified breach of Regulation 17 (Good governance).
  • Specific issues identified for improvement including: low uptake of childhood immunisations and cervical screening; lack of evidence of learning from complaints; an ineffective system for policy review and version control; and, the identification of carers.

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 for all population groups except for the population group Older people which is rated as Outstanding.

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.
  • The practice was collaborative in approach and innovative in meeting the needs of patients with complex needs.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
  • The practice had taken action to address the risks identified at the previous inspection.

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

  • Ensure that patients can reasonably access the service by telephone at busy times of the day
  • Continue to work to identify carers who might benefit from additional support.

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

19 December 2019

During a routine inspection

We carried out an announced comprehensive inspection at Lillyville at Parsons Green on 19 December 2019 as part of our inspection programme.

We inspected this practice on one previous occasion, on 19 April 2016, as The Lilyville Surgery, and the practice was rated as good overall, in all domains and in all patient population groups.

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.

We rated the practice as good for providing safe services because:

  • The practice had systems and processes to keep patients safe.
  • Receptionists had been given guidance on identifying deteriorating or acutely unwell patients. They were aware of actions to take in respect of such patients.
  • The practice learnt and make improvements when things went wrong.

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

  • There were some gaps in regular training for clinical and non-clinical staff.
  • Some performance data was significantly below local and national averages.

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

  • While the practice had a clear vision and that vision was supported by a credible strategy.
  • Some governance arrangements were ineffective.
  • The practice did not have clear and effective processes for managing risks, issues and performance.
  • The practice did not have an appropriate fail-safe system in place for the safe management of patients who had been referred via the two-week wait urgent referral system.
  • The practice did not have an appropriate fail-safe system in place to monitor and manage cervical screening for female patients.

These areas affected all population groups so we rated all population groups as requires improvement.

We rated the practice as good for providing caring and responsive services because:

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).

The areas where the provider should make improvements are:

  • The provider should consider reviewing its complaints system to ensure all relevant information is documented.
  • The provider should consider implementing a system to ensure practice policies are regularly reviewed to ensure all relevant information is documented.
  • The provider should consider additional strategies to enable them to identify carers within their patient community.
  • The provider should continue to work towards improving achievement rates regarding childhood immunisations.
  • The provider should continue to work towards improving achievement rates regarding cervical screening.

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