This practice is rated as Good (previous inspection 18 October 2016 – Requires Improvement and 7 September 2017 - Good).

We carried out an announced comprehensive inspection at Lingfield Surgery on 18 October 2016 and a focused follow up inspection on 7 September 2017. The practice was rated good overall. However, we found that the practice continued to require improvement for the provision of safe services because breaches of regulation were identified. The full reports on the inspections can be found by selecting the ‘all reports’ link for Lingfield Surgery on our website at www.cqc.org.uk.

Specifically, we said they must:

• Ensure that all premises and equipment used by the provider are clean, secure, suitable, properly used and maintained and appropriately located. Specifically the provider must ensure that a risk assessment for the control of substances hazardous to health (COSHH) complies with the policy in place at the practice.

After the focused inspection on 7 September 2017, the practice wrote to us to say what they would do to meet legal requirements. We also received information of concern that led us to carry out this announced comprehensive inspection at Lingfield Surgery on 15 May 2018. The concerns raised were regarding the care plans for residents at a nearby nursing home and the responsiveness of GPs to that nursing home. The review of the concerns is incorporated into the findings in this report.

We undertook this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check they had followed their plan and to confirm whether the provider met all of 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.

The key questions 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

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

At this inspection we found:

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• There were processes to identify, understand, monitor and address current and future risks including risks to patient safety. However, some of these processes were not always implemented effectively, including the recording and oversight of safety alerts, the arrangements for managing waste, ensuring the safe storage of vaccines, the oversight of vulnerable patients and the planning and monitoring for staff absence.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. However, we found that not all staff were provided with suitable guidance on the use of the practice computer system, and non-clinical staff had not been given guidance to identify seriously ill patients.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it. The practice ensured patients had good access to care by offering extended hours surgeries and telephone consultations, as well as offering appointment booking on the practice website.
• Although the practice had good facilities and was well equipped to treat patients and meet their needs, we found that not all reasonable adjustments had been made.
• The practice provided primary care to a local residential school for young students with severe learning disabilities. This included twice weekly clinics which provided reassurance to the students who would otherwise find trips to a busy surgery both traumatic and distressing.
• 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.
• There was a strong focus on continuous learning and improvement at all levels of the organisation. The practice were in the process of implementing an online triage and consultation tool to improve access to medical care and advice.

The areas where the provider must make improvements are:

• Ensure care and treatment is provided in a safe way to patients.
• 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:

• Strengthen the guidance provided for reception staff to include identification of symptoms for potentially seriously ill patients, such as sepsis.
• Strengthen the guidance provided to all clinical staff to include information on the location of care plans on the practice computer system.
• Review the facilities provided and ensure all reasonable adjustments are made, including that all patients can raise an alarm if they require assistance.

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 Lingfield Surgery on 18 October 2016. During this inspection we found breaches of legal requirement and the provider was rated as requires improvement under the safe, effective and well led domains. The full comprehensive report on the October 2016 inspection can be found by selecting the ‘all reports’ link for Lingfield Surgery on our website at www.cqc.org.uk. The practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:-

• Ensuring that risk assessments were carried out regularly within the practice.
• Ensuring that staff training was monitored and that all staff were trained appropriately for their role.
• Reviewing patient satisfaction in relation to access to appointments and satisfaction with consultations.
• Ensuring that prescription forms were tracked and monitored within the practice.

Additionally we found that:

• The practice needed to continue to monitor their performance in diabetes management and secondary prevention of fragility fractures to ensure patient outcomes were managed effectively. The practice also needed to review exception reporting where this was above average and take action appropriately.
• The practice needed to review and update their business continuity plan.

This inspection was an announced focused inspection carried out on 7 September 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 18 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is now rated as good.

Our key findings were as follows:

• The practice had undertaken risk assessments and had completed any actions required. However, the practice still needed to undertake work on their risk assessment in relation to substances that are hazardous to health.
• The practice were now monitoring the training of all their staff groups appropriately and evidence was seen that staff had undergone the required training.
• The practice had a system in place that monitored the tracking of prescription forms throughout the practice.
• The practice had reviewed patient satisfaction and evidence was seen that the friends and family test feedback was positive.
• The practice had reviewed and updated their business continuity plan.
• The practice had continued to monitor their performance in relation to diabetes and secondary prevention of fragility fractures. They had also taken action to assist in the compliance of medicines being taken for diabetes.

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

Importantly, the provider must:

• Ensure that all premises and equipment used by the provider are clean, secure, suitable, properly used and maintained and appropriately located. Specifically the provider must ensure that a risk assessment for the control of substances hazardous to health (COSHH) complies with the policy in place at the practice.

At our previous inspection on 18 October 2016, we rated the practice as requires improvement for providing safe services as not all risk assessments had been undertaken as required. At this inspection we found that the assessment for monitoring the control of substances hazardous to health was still incomplete. Consequently, the practice is still rated as requires improvement for providing safe services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lingfield Surgery on 18 October 2016. Overall the practice is rated as requires improvement.

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. There was a structure of significant event meetings where incidents would be discussed and information was shared with staff.
• Risks to patients were not always assessed and well managed. There was no control of substances hazardous to health (COSHH) risk assessment and records of mitigating action following a legionella risk assessment were not always maintained.
• A fire risk assessment was dated 2011 and not all staff had received fire training.
• Not all staff had attended regular training that the practice had identified as a requirement for their role.
• Data showed patient outcomes were comparable in a number of areas when compared to the national average, however diabetes performance was below average and exception reporting was high in some areas.
• Clinical audits had been carried out and we saw evidence that audits were driving improvements to patient outcomes.
• GP patient survey results showed that the practice performed lower than average in some areas relating to patient access to appointments and by phone and GP and nurse consultations.
• The practice had a system of policies in place and these were generally reviewed and up to date, however a business continuity plan had not been reviewed and did not have up to date information within it.
• Patients said they were treated with compassion, dignity and respect.
• The practice had identified 2.5% of the patient population as carers and provided good levels of support and advice, including support to access carer’s holiday.
• The practice supported the work of a local food-bank and had access to food parcels and vouchers within the practice. Staff had been involved in delivering food parcels in situations where patients were unable to collect them.

The areas where the provider must make improvements are:

• Ensure that risk assessments are carried out regularly as appropriate within the practice.
• Ensure that staff training is monitored and that all staff are trained appropriately for their role.

• Review patient satisfaction and take action in relation to access to appointments and satisfaction with consultations.

• Ensure that prescriptions within the practice are tracked and monitored.

In addition the provider should:

• Continue to work to improve performance in patient outcomes in relation to diabetes and secondary prevention of fragility fractures and continue to review exception reporting where this is above average and take action to address this.
• Review and update the business continuity plan.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

This was a follow up inspection that related to complaints.

We found on this follow up inspection that the provider had taken the necessary steps to address areas identified during our previous inspection in November 2013.

We saw that the provider had displayed a complaints policy for patients in the waiting area.

During our inspection to Lingfield Surgery we spoke with six staff, two GPs, one member of the Patient Participation Group (PPG) and four patients. We also collected six responses to a survey questionnaire we left in the waiting area.

People told us that they were treated with dignity and respect. People told us that they felt involved in their treatment and one person told us “It was really good and I felt that I was being kept informed about my care throughout the process.”

We found that staff were aware of procedures around safeguarding vulnerable adults and children.

We found that the practice had up to date infection control procedures and most staff had received training.

The staff that we spoke with all felt supported. One member of staff said “100%!” We saw that there was opportunity for regular appraisal and clinical supervision.

The practice had a complaints system; however on the day we noted it was not readily accessible to patients.