We carried out an announced comprehensive inspection at Lakeside Medical Centre on 12 February 2019 as part of our inspection programme.

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.

We have rated this practice as good overall and good for all population groups.

We rated the practice as requires improvement for providing safe services because:

• The practice could not demonstrate that all staff received vaccinations and immunisations relevant to their role and that information related to staff immunisation status was recorded.
• The practice could not demonstrate that safe recruitment practices were completed for all staff.
• The practice did not have all the recommended emergency medicines available at the practice and had not completed risk assessments.
• Emergency medicines were not all immediately accessible to staff because they were stored in different areas of the practice.
• There was a lack of records to demonstrate that the provider had ensured that all staff were up to date with immunisations relevant to their role.
• Fire marshals were not named in the fire safety policy and evidence that they had been trained for the role was not available.
• A risk assessment had not been completed for radiators to mitigate any risk of potential scalding or burning.
• The provider had not taken prompt action to replace the defibrillator that was not working or put a risk assessment in place to mitigate any level of risk while waiting for a decision.

We rated the practice as good for providing effective, caring, responsive and well led services because:

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. When incidents did happen, the practice learned from them and improved their processes.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

The areas where the provider must make improvements are:

• Care and treatment must be provided in a safe way for service users.

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