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CQC Rating Posted or Updated on 18 Dec 2023

We are obviously very disappointed with the CQC rating awarded to Lyndhurst Medical Centre following the CQC visit in February, but we would strongly recommend that you read the full report before judging our service. The full report is available via the following link  (Google ‘CQC Lyndhurst Road’) The full report contains many positive findings/comments about our Practice but these have been overshadowed by the fact that we were found to be ‘requires improvement’ in SAFE and WELL LED for the following reasons:


There was a lack of oversight for the management of infection control and infection control audits were not routinely carried out.

We would like to stress that they did not find any evidence that infections had spread due to a lack of cleanliness.  All staff members (clinical and non-clinical) employed at the Practice have undertaken infection control training. However, our monthly infection control/cleaning audits were not sufficiently robust.

We have since had an infection control Audit undertaken by NHS England (at our request) and once the full report is received, we will complete any actions if required.  We will shortly be able to use a six monthly computerised Audit tool that is being devised by NHS England, which will feed through data direct to NHS England but in the meantime we will undertake a monthly Audit in a format advised by NHS England. 

There were gaps in oversight of the monitoring of high risk medicines. 

Inspectors found that prescriptions had been issued without evidence that patients had attended for monitoring blood tests or the Practice did not have sight of blood tests undertaken at hospital appointments.  However, prescriptions were issued following clinical risk assessments and when it was felt it was in the patients’ best interest not to withhold medication. 

GPs issue prescriptions for high risk drugs under Shared Care Agreements with hospitals, which enables patients to obtain prescriptions locally rather from the hospital. 

In view of this criticism, patients prescribed high risk drugs will only receive a one month supply at a time. Patients who have not had the relevant blood test in the specified time frame specified will not be issued with a prescription regardless of situation. We will no longer accept blood test results from hospitals or any other clinics that we are unable to view electronically.

Printer prescriptions are not tracked

Guidance regarding the security of prescriptions paper has changed.

We have devised a new procedure/protocol that covers everything required by CQC regulations and this will be implemented from week commencing 10 June 2019.

Not all prescribers were aware of the guidance within the repeat prescribing policy

Although all prescribers adhere to the guidance within the repeat prescribing policy, not all prescribers were able to recount specific parts of policy.  The policy has been re-issued to all prescribers.

 Action in relation to safety alerts was not always recorded.

All safety alerts are logged when received and circulated as appropriate.  The CQC saw evidence that action had been taken but they require the actions to be recorded on a log sheet.

All safety alerts and actions will now be maintained on a log.

Well Led

No legionella risk assessment.

Annual water testing for legionella is undertaken. A full risk assessment was undertaken in March 2019, which highlighted no issues. Regular water temperature monitoring is now being undertaken.

No liquid nitrogen risk assessment.

Our supplier carries out a risk assessment every time the Dewar is refilled but the CQC want the Practice to also undertake an additional risk assessment of the room housing the Dewar.  The Practice up until now continued this unpaid service but in view of these increasingly onerous demands has decided to cease provision of the cryo therapy therefore mitigating the need for having liquid nitrogen.

If you feel that we offer a good service and would like to support your surgery please visit (google ‘lyndhurst road review’) to leave a review.

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