We carried out an announced inspection at Lodge Road Surgery on 3 March 2022. Overall, the practice is rated as Good.
Ratings for each key question
Safe - Good
Effective - Good
Caring - Good
Responsive - Good
Well-led – Good
Why we carried out this inspection
This inspection was a comprehensive inspection as part of our inspection programme and included:
- The safe, effective, caring, responsive and well-led key questions
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.
We found that:
- There were clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
- 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 organised and delivered services to meet patients’ needs.
- Patients could access care and treatment in a timely way.
- The practice continually reviewed and monitored the effectiveness of their services.
- The practice had comprehensive management and governance structures in place to oversee and monitor services and identify where further improvements were needed.
- The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care. Teams worked together to help deliver improvements, in particular to improve the patient experience.
- Leaders demonstrated they had the capacity and skills to deliver high quality, sustainable care.
- The practice was consistent in their approach to continuously improve services, work collaboratively and to develop systems and shared learning to make improvements
- There was a strong emphasis on learning and sharing outcomes with the whole team and external organisations to promote best practice. All opportunities for learning from internal and external incidents were maximised. All learning was shared with staff regularly.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
Whilst we found no breaches of regulations, the provider should:
- Continue to increase the uptake of childhood immunisations.
- Continue to increase the uptake for cervical, breast and bowel cancer screening.
- Continue to improve patient satisfaction in relation to patient survey results.
We found an area of outstanding practice:
- Lodge Road Surgery continually strived to improve services. Leaders were knowledgeable about the challenges faced and demonstrated a commitment to achieve outcomes and tackle health inequalities for their patients. At the time of our inspection the practice had identified patients who were digitally excluded and were supporting patients by providing digital literacy workshops. The practice had introduced new coding to identify digital exclusion and support patients by providing training to build confidence and reduce barriers in accessing the service.
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