Lakeside Healthcare at Yaxley

We carried out an announced comprehensive inspection at Lakeside Healthcare at Yaxley on 11 November 2019 as part of our inspection programme. The overall rating for the practice was Good. The full comprehensive report on the November 2019 inspection can be found on our website at www.cqc.org.uk.

We are mindful of the impact of Covid-19 pandemic on our regulatory function. This meant we took account of the exceptional circumstances arising as a result of the Covid-19 pandemic when considering what type of inspection was necessary and proportionate, this was therefore a desk-based review.

On 21 September 2020 we carried out a desk-based review to confirm that the practice had carried out their plan to meet the legal requirements in relations to the breaches of regulation we identified at our previous inspection on 11 November 2019. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

We found that improvements had been made and the provider was no longer in breach of the regulations and we have amended the rating for this practice accordingly. The practice is now rated as Good for the provision of safe services. We previously rated the practice as Good for providing effective, caring, responsive and well-led services.

During this desk-based review we looked at a range of documents submitted by the practice to demonstrate how they met the requirement notices. This included:

•Risk assessments

•Medicines and Healthcare products Regulatory Agency (MHRA) alerts processes

•Audits

•Minutes of meetings

•Policies and procedures

During the desk-based review we looked at the following question:

Are services safe?

We found that this service was providing a safe service in accordance with the relevant regulations and had demonstrated they had acted on the required improvements and had implemented the following:

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

•Risks to patients were assessed and the systems and processes to address these risks were implemented to ensure patients were kept safe. For example, fire and legionella.

•The system the practice had in place for the summarisation of patient’s notes was now effective.

Action had been taken for areas where the provider had been advised they should make improvements.

•The practice now had effective systems and processes in place to ensure good governance in accordance with the fundamental standards of care.

•We have seen that the cleaning company had issued a new COSHH folder which contained December 2019 COSHH risk assessments.

•The practice carried out fire extinguisher checks and fire door checks on a weekly basis.

•Fire drills were being carried out on an annual basis.

•The practice was recording emergency lighting checks on a weekly basis.

•The practice had carried out a fire risk assessment in October 2019, with another one scheduled for October 2020. The practice had acted to mitigate the risks that were highlighted in the risk assessment.

•The practice had carried out an infection control audit and had taken appropriate action such as replacing a couch roll holder that was broken and highlighting to the cleaners for a deeper clean on some equipment, such as ceiling lights.

•We found previously that the practice had a considerable backlog of patient notes that required summarisation. Summarising of patient notes means that an accurate history of the patient’s medical history is visible on the patient electronic record so that GPs could effectively diagnose, treat and refer the patient if required. A flag was added to the medical records to ensure the GP was aware that the notes had not been summarised. The practice hadtaken on an additional administrator and had undertaken a recovery plan to ensure they were up to date with this.

•The practice process for monitoring patients’ health in relation to the use of medicines including high risk medicines needed a review to ensure that recommendations from secondary care were added to the patient record. We have now seen that the practice has a policy in place to ensure that recommendations are added to the patient record.

•During the last inspection we looked at meeting minutes in relation to Medicines & Healthcare products Regulatory Agency (MHRA) and patient safety alerts. At the time the practice was unable to evidence that all staff were aware of any relevant alerts and where they needed to take action. We could not see any evidence these were discussed or any actions taken forward. We were told that relevant staff were aware and carried out the appropriate actions. We have now seen evidence that the practice actioned all alerts appropriately.

During the inspection in November 2019 further areas were identified where improvements should be made. These were:

•Review the appraisal process to enable all staff to receive a yearly appraisal. The provider had reviewed the appraisal process to enable all staff to receive an annual appraisal. The practice had currently suspended annual appraisals due to the pandemic. They had continued with the relevant regular probationary reviews for all new members of staff.

•Continue to monitor exception reporting to ensure the current system was effective. The provider provided evidence to confirm that exception reporting was now monitored effectively.

•Review the business continuity plan so that the identified risks were mitigated. The provider had reviewed this so that identified risks had been mitigated.

•Review meeting minutes to include all areas of practice governance and allow opportunities for learning. The provider shared meeting minutes where learning from complaints and significant events had been shared at a practice wide level.

The practice should:

•Continue to monitor the process to enable all staff to receive an annual appraisal.

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