We carried out an announced comprehensive inspection at Lavender Hill Group Practice on 26 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 requires improvement for providing safe services.

We found that:

• The practice’s process to act on concerns identified in their legionella risk assessment did not keep people safe.
• The practice’s process to ensure medicines and medical equipment was in date and safe to use was not embedded.
• The practice did not keep a record of blank prescription stationery that was held in clinicians’ rooms.

We rated this practice as requires improvement for providing well led services.

We found that:

• The practice’s process to ensure all staff had received training appropriate to their role was not embedded.
• The systems and processes to demonstrate good governance for the service provided were not always effective.

We rated this practice as good for providing effective, caring and response services.

We found that:

• 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.

We rated this practice as good for all population groups.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• Ensure persons employed in the provision of the regulated activity receive the appropriate support, training, professional development, supervision and appraisal necessary to enable them to carry out the duties.

The areas where the provider should make improvements are:

• Improve the identification of carers to enable this group of patients to access the care and support they need.
• Continue to take action to improve the uptake of cervical screening to meet the minimun national target.
• Support staff to obtain the appropriate safeguarding training as set out in the intecollegiate guidance.

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

Rosie BenneyworthChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive of Lavender Hill Group Practice on 1 October 2015. Overall the practice is rated as good.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

• 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.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• 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.
• Regular clinical and multi-disciplinary meetings were held at the practice, although not all of these meetings were minuted.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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.

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

Importantly the provider should

• The practice should ensure that its formal clinical meetings are minuted.
• The practice should agree clear terms of reference with it’s patient participation group (PPG).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice