We carried out an announced focused inspection at Gashouse Lane Surgery (also known as Drs O’Neill, Evans & Lunn) on 7 and 9 December 2022. Overall, the practice is rated as Good.
The key question ratings were:
Safe – Good
Effective – Good
Caring – Not inspected rating of Good carried forward from last inspection
Responsive - Not inspected rating of Good carried forward from last inspection
Well-led – Good
At our previous inspection in April 2016 we rated the practice as Good overall. They were rated as Good for all of the key questions. We did not inspect the key questions of Caring or Responsive during this inspection, therefore they remain rated as Good
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Drs O’Neill, Evans & Lunn on our website at www.cqc.org.uk
Why we carried out this inspection
This was a focused inspection to respond to risk and follow up on concerns that were raised with us.
How we carried out the inspection
Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.
This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.
This included:
- Conducting staff interviews using video conferencing.
- Staff questionnaires
- Completing clinical searches on the practice’s patient records system and discussing findings with the provider.
- Reviewing patient records to identify issues and clarify actions taken by the provider.
- Requesting evidence from the provider.
- A short site visit.
Our findings
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 the Key Questions of Safe, Effective and Well-Led.
We found that:
- The practice provided care in a way that kept patients safe and protected them from avoidable harm.
- The practice was working hard to ensure backlogs created by COVID-19 were being reduced quickly and safely.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic.
- The practice aimed to promote the delivery of high-quality, person-centre care.
- People were satisfied with the way they accessed services the practice offered. The practice had introduced new measures to address this issue.
Though we found breaches of regulation the provider should:
- Continue to develop and improve its records relating to the immunisation of staff.
- Appoint a Freedom to Speak Up Guardian to facilitate staff having access to independent support to raise any concerns they may have.
- Continue to re-establish and develop the patient participation group.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services