Archived: Lavender Centre

This practice is rated as Requires Improvement overall. (Previous rating under former provider 01 2017 – Good)

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at Gardiner Crescent Surgery on 22 and 23 August 2018 as part of our inspection programme.

At this inspection we found:

• Staff demonstrated a very caring approach to their patients and it was clear they treated them with compassion, kindness, dignity and respect.
• The practice scored well in the National GP Patient Survey across all areas.
• Clinicians assessed patients’ needs and delivered person-focussed care and treatment.
• The practice had some systems in place to manage risk, so that safety incidents were less likely to happen. When incidents did happen, the practice improved processes to keep patients safe. However, the practice’s arrangements for responding to safety alerts was not sufficient. There were some gaps in the practice’s arrangements for identifying, assessing and managing risk.
• Staff demonstrated they were committed to making improvements and there was some evidence of this in the quality improvement activity they undertook. . However, there was no programme of continuous clinical audit to monitor quality.
• There were gaps in some staff’s training.
• Appropriate recruitment checks had not been carried out for some staff who worked at the practice.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was some evidence the practice engaged with their patients. However, this was limited and the practice did not have an active patient participation group.

The areas where the provider must make improvements as they are in breach of regulations are:

• Establish effective systems and processes to ensure good governance, in accordance with the fundamental standards of care.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal to enable them to carry out their duties.
• Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.

The areas where the provider should make improvements are:

• Review the process for prescribing antibiotics to conform with best practice.
• Consider increasing the support provided to carers.
• Review arrangements for offering the meningitis vaccine to students.
• Continue to take steps to encourage uptake of annual checks for patients with learning disabilities.
• Review and improve patient engagement.
• Reduce those exception reporting rates which are higher than the local clinical commissioning group and England averages.
• Continue to provide support to ensure the practice management team have the relevant skills to fulfil their roles.
• Take steps to ensure the practice obtains assurance that the defibrillator is regularly serviced and checked to ensure it is in full working order.
• Carry out a risk assessment to determine which emergency drugs are suitable to store at the practice.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.