When we visited Lansdowne Surgery on 22 May 2018, to carry out a comprehensive inspection, we found the practice was not compliant with the regulation relating to good governance. The practice was not doing all that was reasonably practicable to assess, monitor and mitigate the risks relating to the health, safety and welfare of service users. Specifically, we found they had not ensured that:

• Systems were in place to record, monitor and manage staff training to ensure completion.
• Actions in relation to fire safety had been completed.
• Management of health waste was in accordance with regulations.

We also said the practice should:

• Continue to take action to establish a patient participation group.

Overall the practice was rated as Good. They were rated as good for providing safe, effective, caring and responsive services, and as requires improvement for providing well-led services. The full report of the May 2018, inspection can be found by selecting the ‘all reports’ link for Lansdowne Surgery on our website at www.cqc.org.uk.

This report covers the announced follow up focused inspection we carried out at Lansdowne Surgery on 18 December 2018, to review the actions taken by the practice to improve the quality of care and to confirm that the practice was meeting legal requirements.

At this inspection we found the practice had addressed the regulatory breaches we identified on our last inspection. 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.

As a result of this inspection, we have rated Lansdowne Surgery as good for the provision of well-led services. The practice remains rated as good overall, and good for all key questions and population groups.

We found that:

• The practice had reviewed and improved their systems to record, monitor and manage staff training and to ensure mandatory training was completed. However, this system was not yet always working effectively.
• The practice managed health waste in line with regulations.
• All actions in relation to fire safety had been completed.
• 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 take action to establish a patient participation group.
• Continue to develop their system for monitoring staff training and take steps to ensure the system is effective and embedded in the practice.

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

This practice is rated as Good overall. (Previous inspection 11 February 2016 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

We carried out an announced comprehensive inspection at Lansdowne Surgery on 22 May 2018 as part of our inspection programme.

At this inspection we found:

• The practice had systems to manage risk so that safety incidents were less likely to happen, however these did not always operate effectively. When incidents did happen, the practice learned from them and improved their processes.
• The practice reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Not all staff had received essential training. The systems in place to manage and monitor staff training did not support the management to have oversight of staff training requirements.
• Staff involved and treated patients with compassion, kindness, dignity and respect. Patient feedback was consistently positive across all aspects of care. The practice was proactive at seeking patient feedback .
• Patients found the appointment system easy to use and reported that they could access care when they needed it. Routine appointments were available within a few days of requesting one.
• There was evidence of continuous learning and improvement within the organisation.

We saw one area of outstanding practice:

• The practice had clear systems in place for proactively identifying carers. The practice had identified 3% of their registered patients as carers. Of these 50% had received a health care assessment, where needs were effectively identified. During these health checks 67 health issues were detected, examples of which were; two patients with abnormal heart rhythms, two safeguarding concerns, seven patients who needed additional emotional support. Support, in addition to events designed to meet carer’s needs, was facilitated at times when there may be increased emotional need, such as over the Christmas period.

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.

The areas where the provider should make improvements are:

• Continue to take action to establish a patient participation group.

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 Lansdowne Surgery on 17 November 2015. Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• Information about services and how to complain was available and easy to understand.
• Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

• The provider was aware of and complied with the requirements of the Duty of Candour.
• The practice was consistently caring in its approach to patients. This was reflecting in the feedback from patients. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. We heard examples of when the practice went that extra mile for patients.

However there are two areas of practice where the provider needs to make improvements.

Importantly the provider should:

• Review its practices and procedures for storing controlled drugs and ensure that controlled drugs are stored in an appropriate cupboard that meets the standards set out in the regulations.

• Ensure that staff appraisals are done annually.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice