This practice is rated as Good overall. (Previous rating October 2018 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

We carried out a focused desk-based review of Lathom House Surgery on 11 April 2019. This inspection was to see whether the breaches of Regulations 12 (Safe Care and Treatment) and 19 (Fit and Proper Persons Employed) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 found at our last inspection had been addressed. For this inspection, we focused on the key question of Safe which we rated as requires improvement in October 2018.

We also looked at the areas we indicated for improvement at our previous inspection.

At this inspection we found:

• The practice had reviewed the recruitment policy and procedure and put systems in place that would allow for safe recruitment of staff. Documentation in existing staff files had been strengthened.
• A full infection and prevention control audit had taken place and any actions identified had been addressed.
• The management of patients taking high-risk medicines was comprehensive and patients were appropriately monitored. Checks on medicines held in doctors’ bags were added to practice existing medicines checks.
• There was improved management of significant incidents; an annual review of incidents was scheduled and an ongoing summary of events planned.
• The practice had expanded the patient participation group; they had displayed a new poster in the waiting area and discussion had taken place as to how the group would be better used in the future.

The areas where the provider should make improvements are:

• Implement plans for an ongoing summary of significant incidents and annual review.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

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

This practice is rated as Good overall. This was the first inspection of this GP practice under this provider.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Lathom House Surgery on 1 October 2018. The GP registration with the CQC for the provision of this service was completed in December 2017.

This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• The practice had experienced a change in leadership within the last 12 months. The practice also recruited a business manager in 2017 to lead and support the team to provide a safe and effective service.
• Patient feedback on the quality of care and treatment they received was very positive.
• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• Medicine management systems required improving.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• An overarching infection control audit was not in place and staff recruitment files needed improving.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they could access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

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

• Ensure care and treatment is provided in a safe way to patients.
• Ensure specified information is available regarding each person employed

The areas where the provider should make improvements are:

• Undertake an annual review of significant events to identify themes.
• Implement a full infection control audit.
• Establish, and promote the patient participation group
• Identify options to enable patient access to a male chaperone should this be requested.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

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