The Care Quality Commission
  • Doctor
  • GP practice

Archived: Market Cross Surgery

Overall: Good read more about inspection ratings

Bourne Road, Corby Glen, Grantham, Lincolnshire, NG33 4BB (01476) 550056

Provided and run by:
Dr John Elder

All Inspections

21 July 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 2 December 2015. A breach of legal requirements was found. After the comprehensive inspection the practice wrote to us to say what they would do to meet the legal requirements in relation to the breach of Regulation 12.

We undertook a focussed inspection on 21 July 2016 to check that they had followed their action plan and to confirm they now met their legal requirements. This report only covers our findings in relation to those requirements. You can read the last comprehensive inspection report from the December 2015 by selecting the ‘all reports’ link for Market Cross Surgery on our website at www.cqc.co.uk

  • We found that a new significant event system had been put in place by a new GP partner. With a new policy and reporting form in place. Some further improvement was required to ensure that the investigations were detailed and actions were identified and implemented.

  • Risks to patients were now assessed and well managed.

  • The practice had embedded a process to ensure emergency equipment and medicines are checked as per the practice protocol.
  • Medicine refrigerators were checked and reset on a daily basis.

  • Audits were driving improvement in performance to improve patient outcomes. The practice had completed further audits in minor surgery and intrauterine contraceptive devices since the last inspection.

  • Staff had received an annual appraisal

  • The practice had commenced a more formalised process for the recording of minutes of meetings but the clinical meeting minutes still required more detail.

The areas where the provider should make improvements are:

  • Continue to embed the new system for significant events.

  • Ensure that guidance received within the practice is checked and interpreted correctly to ensure patient safety. For example, in relation to repeat prescriptions.

  • Ensure all staff files have the appropriate recruitment documents as per the practice policy.

  • Complete the appraisal process ensuring the notes of the discussions that had taken place are typed and added to the staff file.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

2 December 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Market Cross Surgery on 2 December 2015. The practice is rated overall 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. However, reviews and investigations were not always thorough enough and done in a timely manner.
  • Risks to patients were not assessed and well managed.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • 100% said they had confidence and trust in the last GP they saw compared to the CCG average of 95% and national average of 95%.
  • 99% of patients who responded to the July 2015 patient survey described their overall experience of the surgery as good.
  • A sit and wait clinic ensured urgent appointments were available on the day.
  • Audits were driving improvement in performance to improve patient outcomes.
  • The practice had proactively sought feedback from patients and had an active patient participation group.

The areas where the provider must make improvement are:

  • Have a system in place to ensure significant events and near misses are recorded correctly, investigated and any learning cascaded to staff.

  • Ensure there are formal governance arrangements in place including systems for assessing and monitoring risks and the quality of the service provision. For example, fire, legionella and health and safety risk assessments

  • Ensure a risk assessment is carried out in relation to the three medicine pick up points.

  • Embed a process to ensure emergency equipment and medicines are checked as per the practice protocol.

The areas where the provider should make improvements:

  • Within the Business Continuity Plan ensure mitigating risks and actions are included.
  • Ensure standard operating procedures for the dispensary include a competency section.
  • Embed a system where fridge temperatures in all treatment rooms are reset in line with practice policy.
  • Ensure first aid equipment is in date.
  • Consider undertaking more audits in regard to minor surgery and intrauterine contraceptive devices.
  • Have a system in place for the summarising of patient notes. Clear the backlog of paper records for new patients.
  • Ensure all staff have a yearly appraisal
  • Embed a formalised process for the recording of minutes of meetings.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice