We carried out an announced comprehensive inspection at Lakenheath Surgery on 11 December 2018 as part of our inspection programme. The practice was previously inspected in April 2017 and rated as good.

Our judgement of the quality of care at this service is based 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.

This means that:

• People were protected from avoidable harm and abuse and that legal requirements were met.
• Patients had good outcomes because they received effective care and treatment that met their needs.
• The practice was fully engaged with reviewing and monitoring the clinical service they offered and used this information to make changes and drive care.
• Patients were supported, treated with dignity and respect and were involved in their care.
• People’s needs were met by the way in which services were organised and delivered.
• The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
• Staff reported they were happy to work in the practice and proud of the changes that had been made.

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

• Continue to review outcomes from the national GP Patient Survey and implement plans to improve these.
• Proactively identify and record significant events.
• Ensure dispensing staff receive on-going role specific training and competency checks.
• Ensure the practice has a system for ensuring that the most up to date business continuity plan is available on and off site at all times.
• Provide guidance for non-clinical staff for identifying deteriorating or acutely unwell patient’s suffering from potential illnesses such a sepsis.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lakenheath Surgery on 20 April 2017. This inspection was a follow up to our previous comprehensive inspection at the practice on 28 July 2016 where breaches of regulation had been identified.

The overall rating of the practice following the 28 July 2016 inspection was requires improvement. It was rated as inadequate for providing safe services, good for providing effective, caring and responsive services, and requires improvement for providing well led services. You can read this report by selecting the ‘all reports’ link for Lakenheath Surgery on our website at www.cqc.org.uk.

At our inspection on 20 April 2017 we found that the practice had improved. The ratings for the practice have been updated to reflect our recent findings. The practice is now rated as good for providing safe, effective, caring, responsive and well led services.

Our key findings on 20 April 2017 were as follows:

• The practice had implemented and embedded systems and processes to manage risks to keep patients and staff safe, such as a three year contract for the annual calibration of equipment.
• Furthermore, the practice had reviewed the infection control policy and audit tool used to meet the standards as outlined in The Health and Social Care Act 2008: Code of practice on the prevention and control of infections and related guidance. We saw the practice held a record of all clinical staff immunisation records.
• The partners demonstrated that the clinical leadership within the practice had been improved. Regular meetings were held and minutes were available to ensure that actions were completed. Practice staff we spoke with confirmed that they had been engaged with the improvement plan and worked with the partners to ensure the improvements were made and sustained.
• The system used to ensure that all prescriptions were signed before medicines were dispensed to patients had been improved upon.
• The dispensary had been made more secure. For example, a key safe had been installed and the code was shared with appropriate staff.
• All medicines and devices we checked were within their expiry date.

• The practice was continuing to identify carers at registration and from their patient list.
• The practice held detailed minutes of meetings, such as multidisciplinary team meetings and staff meetings.
• There was a system in place to record the arrival, actions taken, and learning shared from the safety alerts that were sent to the practice.
• The practice had commenced a schedule of audits to monitor and encourage improvement.
• The appointments system was flexible and ensured that same day appointments were available.
• The practice had good facilities including for those with reduced mobility.
• The practice had a number of policies and procedures to govern activity.
• Information about services and how to complain was available. The practice sought patient views about improvements that could be made to the service, including having a patient participation group (PPG).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lakenheath Surgery on 28 July 2016. Overall the practice is rated as requires improvement.

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

• The practice had a number of policies and procedures to govern activity; however, the oversight to ensure that they were reviewed in a timely way needed to be improved.

• Systems to reduce risks to patient safety were in place, however, these were not all effective. Not all equipment had been tested and calibrated within the last 12 months. The systems to manage infection control needed to be improved, an audit had been undertaken two days prior to our inspection; this audit was not robust although it had identified several areas of improvement needed.

• There was a leadership structure; however, this showed weakness, the partners had not maintained oversight of the running of the practice. Staff felt supported by the management team and were an integral part of the running of the practice.

• The appointment system was flexible and ensured that patients who requested to be seen on the same day were.

• The practice had good facilities including for those with reduced mobility.

• Information about services and how to complain was available. The practice sought patient views about improvements that could be made to the service, including having a patient participation group (PPG).

• The practice proactively managed care plans for vulnerable patients and had effective management strategies for patients at the end of their life.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance.

The areas where the provider must make improvements are:

• Ensure that systems and processes to manage and mitigate risk are robust and embedded.

• Ensure that the practice policy for signing of prescriptions is adhered to and that all prescriptions are signed in a timely manner.

• Improve the security arrangements for the dispensary, ensuring that only authorised staff have access.

• Ensure that robust systems are embeded to ensure that all medicines and devices are within their expiry date and fit for use.

• Ensure that all equipment is tested/calibrated and is safe to use.

In addition the provider should;

• Review the infection control policy and audit tool used ensuring that it is robust and meets the standards as outlined in The Health and Social Care Act 2008: code of practice on the prevention and control of infections and related guidance. Including ensuring that they hold a record of all clinical staff immunisation records.

• Proactively identify and offer support to carers.

• Develop a system to routinely take minutes of meetings, cascade and share learning with the wider team.

• Strengthen the clinical supervision of the clinical staff employed at the practice.

• Improve the system to record the arrival, actions taken, and learning shared from safety alerts that are sent to the practice.

• Review the monitoring of the fridge temperatures ensuring that comments and actions as appropriate are taken should the temperature not be within the required range.

• Develop a more comprehensive programme of audits to monitor and improve performance and services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

During our inspection on 9 August 2013, people we spoke with told us that staff treated them respectfully and were helpful. We saw that staff spoke politely to people and consultations were carried out in private treatment rooms. One person who used the service told us: “It’s excellent.” Another person told us: “It is an excellent surgery and I have seen many doctors through the practice over the years.” They confirmed that people would always be seen in an emergency and normally on the same day.

Information was clearly displayed for people, including health promotion, access to support services and information about the practice and the services provided.

During our inspection we saw from the records we looked at that staff had received regular training, supervision and appraisals. Appropriate pre-employment checks had been carried out.

The people we spoke with were happy with the service and did not have any concerns or issues about the care and treatment they received.

There were quality monitoring systems in place within the service. The service had complaints policies and procedures in place to deal appropriately with any issues raised.