Lakeside Healthcare at New Queen Street and Stanground surgeries

We carried out an announced inspection at Lakeside Healthcare at New Queen Street and Stanground Surgeries on 25 May 2022. Overall, the practice is rated as requires improvement.

Set out the ratings for each key question

Safe - Requires improvement

Effective - Good

Caring - Good

Responsive - Requires improvement

Well-led – Requires improvement

We previously inspected the location under its previous name of Lakeside Healthcare at The New Queen Street Surgery in May 2017 and the practice was rated good overall. The practice has changed their name and inherited the regulated history and ratings of the predecessor location, and is now called Lakeside Healthcare at New Queen Street and Stanground Surgeries.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Lakeside Healthcare at New Queen Street and Stanground Surgeries on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a comprehensive inspection.

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
• Staff questionnaires

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 Requires Improvement overall

We found that:

• The systems and processes to ensure infection prevention and control were not wholly effective.
• The practice had ineffective systems for ensuring all emergency medicines and equipment were safe to use.
• Patients did not always receive effective care and treatment that met their needs.
• The process in place for medicine reviews and coding of diagnosis of treatments was not always effective.
• The management and central team did not have full oversight of vaccination history held in staff records to ensure that staff were kept safe from harm.
• The process for recording near misses and incidents in the dispensary did not ensure there was sufficient detail of the events recorded. Reviews of near misses or incidents were not conducted in a timely way to ensure that learning was shared, or that changes were made to prevent reoccurrences.
• The practice had effective processes for supervision and competency checks for all staff, these were formally recorded for proactive learning.
• The practice respected patients privacy and dignity and patient confidentiality was maintained throughout the practice.
• GP patient survey data was below CCG and national averages, and the practice had not engaged in patient feedback exercises to understand patients poor experiences of accessing the practice.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
• The way the practice was led and managed promoted the delivery of person-centre care.

We found a breach of regulation. The provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

• Continue to encourage patients to attend their cervical screening appointments.
• Continue to identify and offer support to carers within the practice.
• Review and improve the opportunities for patients to access health checks.

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