Church Walk Surgery

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We looked for evidence people were safe and protected from abuse and avoidable harm.

We found a good learning culture and people and external key stakeholders felt listened to. Processes in place protected people from abuse and the service worked well together across multiple pathways and systems. Risks related to the environment and infection prevention and control were well managed.

The service did not always monitor and review patient care delivery in line with national guidance. Recruitment processes were not always followed and training was not monitored effectively. This meant people were not always protected from avoidable harm.

This is the first assessment of the service and we rated this key question as requires improvement.

The service was in breach of legal regulations relating to safe care and treatment and governance.

This service scored 62 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service had a proactive and positive culture of safety, based on openness and honesty. They listened to concerns about safety and investigated and reported safety events. Lessons were learnt to continually identify and embed good practice. People were supported to raise concerns and staff treated them with compassion and understanding.

The provider worked well with the very active PPG in place. For example, following concerns raised about the low usage of electronic platforms to book appointments the managers and PPG have organised an open meeting in the local village hall where training will be given to patients on how to use digital access platforms.

Managers encouraged staff to raise concerns when things went wrong. Incidents were discussed and learning disseminated through staff meetings. Staff told us they felt there was an open culture, and that safety was a top priority.

The provider had processes for staff to report incidents, near misses and safety events. There was a system to record and investigate complaints and when things went wrong, staff apologised and gave people support. A formal annual review of complaints to identify themes was not completed though managers were aware of all recent complaints and confirmed the predominant issue was related to access to appointments.

Learning from incidents and complaints are shared at practice meetings with minutes available for staff not in attendance. Learning resulted in changes that improved care for others. Safety is a priority for everyone and is supported by those with clear roles and responsibilities for safety.

The service worked with people and healthcare partners to establish and maintain safe systems of care. The practice made sure there was continuity of care, including when people moved between different services. There was a clear policy and process in place to ensure patient records were summarised in a timely way. This meant when new patients transferred into the service up to date medical information was available to provide safe care. We reviewed an audit of summarised notes to check quality of information transferred, this was carried out in February 2025 and no issues were identified.

During the inspection, we reviewed patient correspondence, tasks and test results. A system was in place to manage test results and tasks. Test results were sent back to the requesting clinician and a buddy system was in place to provide cover if clinicians were absent. This was not always effective as we saw some abnormal test results had not been reviewed for up to 3 working days. The provider took action immediately to review all abnormal results and review the system in place to prevent reoccurrence.

Open tasks were prioritised into urgent and non-urgent to allow staff to prioritise. We saw some tasks had been open for some considerable time but these were administration tasks and used as a staff reminder system.

Referrals to specialist services were documented in the patient record, safety netting is carried out with each patient advised to contact the surgery within a specified time frame if they had not been contacted. When a referral was made prompts to complete a task within the clinical system are created. Every 2 weeks administration staff carry out a search to identify any delays in referrals. Urgent referrals were monitored to ensure patients attended external appointments.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. The service shared concerns quickly and appropriately. Safeguarding policies were in place and known to staff who were appropriately trained in safeguarding procedures.

The service maintained a list of vulnerable people and acted on concerns by working in partnership with other organisations. Multidisciplinary team meetings were used to raise awareness of potentially vulnerable groups of people. There were systems in place to follow up people who failed to attend important appointments in primary and secondary care.

Review of the clinical system on site showed patients at risk of abuse were identified by an alert and family members or others residing at the same address were linked.

The service did not always work well with people to understand and manage risks. They did not always provide care to meet peoples’ needs that were safe, supportive and enabled people to do the things that mattered to them.

Individual risks were not always adequately assessed or people were not always appropriately involved in this. For example, medicine reviews, medicines monitoring and care for patients living with asthma were not always completed in line with guidance. People are therefore not always provided with information about how to keep themselves safe.

The provider had appropriate emergency equipment and medicines available. Systems were in place for checking and monitoring of equipment and medicines.

Staff had received training to recognise and manage patients with deteriorating health. Staff told us how they had successfully supported a patient with significant breathing issues who required emergency ambulance and admission to the local acute hospital.

Patient triage, to identify the appropriate appointment type and times scales for patients to attend is carried out by reception staff. The staff have received training, are supported by a written decision making flow chart. This includes red flag information to identify any urgent health care issues requiring referral to accident and emergency is used. A duty doctor is allocated every day and available to give advice as required.

People were advised on risks related to their condition and the actions to take if their condition deteriorated.

Church Walk Surgery was purpose built in 1970 with a capacity for between 3500 and 4000 patients. At the time of our assessment the patient population had increased to 5500 following closure of a nearby GP Practice and new housing developments, with no extra space or facilities. The lack of space was evident during our assessment and any increase in service provision is impeded by the constraints this places on the staff and service. We saw evidence the provider had initially highlighted these concerns to the Lincolnshire Integrated Care Board (ICB) in 2020.

The service detected and controlled the potential risks in the care environment. They made sure equipment and facilities supported the delivery of safe care despite constraints around the building.

Risk assessments were in place where appropriate. A full legionella risk assessment was completed in 2015 by an external company. All identified high risk issues had been actioned or mitigated.

A legionella risk review had been completed in 2024. Actions identified were all low risk and action had been taken. A log book was in place which evidences consistent temperature monitoring of hot and cold water to the required temperature, the provider has no little used outlets that require routine flushing. Annual water sampling was sent to an external provider to check for the presence of legionella and this was negative in January 2025.

A Radon assessment was in process within the building and results will be reported to the provider once assessment is completed.

A fire risk assessment was completed In October 2024, all actions required were completed. Records showed the fire alarm and emergency lighting was routinely tested, fire extinguishers had been serviced, fire doors had automatic closure devices in place. Fire drills were carried out every 6 months and results an any actions required were documented. Staff had completed online fire training.

We saw certificates that showed the gas boiler was serviced routinely on an annual basis. Chemicals and substances deemed to be subject to Control of Substances Hazardous to Health (COSHH) regulations are managed appropriately with data sheets in place. Electrical equipment had been calibrated and tested and a hard wire check had been completed appropriately.

The service had some gaps in staffing of hard to fill clinical medical posts. Any gaps were usually filled using regular locum staff know to the practice. Locum staff always had a regular member of clinical staff to work with them in the practice and were given the lowest risk patients.

A policy was in place for recruitment of staff. During our assessment we reviewed 4 randomly selected staff recruitment files. The review showed that the staff personal files did not always align with the requirements outlined in the providers policy for safe recruitment.

We identified missing references, missing immunisations records, missing Disclosure and Baring Service (DBS) information and gaps in employment records. After our visit the provider told us the missing DBS and reference had been received but had not been placed in the staff files. A recruitment checklist is now in use for all staff members to ensure all information is in place.

Clinical supervision processes had recently been amended within the practice. We saw evidence of audits of prescribing practice carried out for non-medical prescribers in June 2025. The changes had not been in place long enough to assess their full impact and evidence ongoing sustainability.

There were a range of clinical and non-clinical roles within the practice. Staff were working within their agreed areas of competence and were positive about the support, training and development they received. They worked together well to provide safe care that met most people’s individual needs.

A system was in place to monitor staffs mandatory training. Review showed significant gaps in a clinicians mandatory training completion and did not include all the training required by or completed by staff. This meant the provider did not have oversight of staff training as the system was not comprehensive. Further review by the provider identified that some further training was required and some training was recorded elsewhere but had not been included on the system.

Staff received regular appraisals. Systems were in place to ensure staff working on behalf of but not directly employed by the service were recruited safely and working within their agreed areas of competence.

The service assessed and managed the risk of infection. They detected and controlled the risk of it spreading and shared concerns with appropriate agencies promptly.

The practice had a designated infection, prevention and control lead and all staff had had relevant training. Cleaning schedules were in place and followed by cleaning staff.

There were no cleaning schedules for staff and practice nurses who used equipment. Staff told us they clean equipment down before and after use but this was not recorded anywhere.

Risk assessments and audits were completed and actions taken to mitigate risks.

Appropriate clinical waste procedures in place. Most staff provided information about their immunisation status as part of the recruitment process either through documentary evidence or completing and signing a declaration. This was not always available for locum medical staff who were employed at short notice.

The practice and equipment were visibly clean and dust free but the fabric of the building due to the properties age was in need of cosmetic upgrade in places. The provider is in discussion with the leaseholder in regard to this.

Remote clinical searches carried out during our assessment identified concerns in the management of patients on medications which required monitoring.

Management of patients on a medicine used to treat inflammatory or autoimmune disease was not always in line with national guidance to ensure safety. For example, a delay was identified in prescribing contraception to women of child bearing age indicated due to the risk of birth defects while taking the medicine, the day of administration of medicine was not identified and monitoring of blood results was not being carried out at periods in line with national guidance.

Patients prescribed medication to thin the blood had not all been managed and monitored in line with national guidance. For example, we found a patient who appeared to have been inappropriately prescribed the medicine, documentation within the patient record did not include all appropriate information and an alert relating to this did not appear to have been actioned. Some patients were not being monitored within the time scale and this had not been identified at the medication review and alerts identifying the delay had not been actioned. The GP lead told us they were aware of the patient inappropriately prescribed medication and had tried alternatives unsuccessfully but no further action had been taken to mage the risks this posed.

Patients taking a medication to treat epilepsy and migraine had not all completed an annual risk assessment relating to the risk of birth defects in the event of a pregnancy.

Patients prescribed a combination of medicines to manage high blood pressure had not all been monitored in line with national guidance.

The provider immediately contacted the patients identified to arrange clinical review as required. Following our assessment the provider reviewed and amended the processes in place to improve and increase the monitoring of patient taking medicines that require monitoring.

Clinical searches identified a lack of oversight and failure to act on electronic alerts related to medications and Medicine and Healthcare products Regulatory Agency (MHRA) alerts during medication reviews and patient consultations. Details in medication reviews were not always sufficient and patients were not always safety netted. Potential contraindications of prescribed medications were not always taken into account when new medications were added following a patients discharge from hospital.

Since our assessment visit the provider has reviewed their processes in place for medication reviews and management of MHRA Safety Alerts. Standardised templates for medication reviews to improve consistency and safety are now in use. MHRA Safety Alerts are now reviewed more frequently and clinical searches are run for both current and historic alerts to identify any patients whose medicines require reviewing.

The process to manage structured medication reviews had been changed before our assessment visit. Risk levels were now included for patents, with those with the most serious health concerns prioritised to improve the care received. At the time of our assessment this had not been in place long enough to assess its impact.

A Medication Monitoring Group has been created to provide consistency and improve governance and oversight.

The changes made had not been in place long enough to assess their full impact and evidence ongoing sustainability.

The practice ensured medicines were stored securely with access restricted to authorised staff.

Detailed standard operating procedures were in place for each process in the dispensary. Blank prescriptions were recorded upon delivery and stored securely in locked cupboards and printers. Prescriptions were signed before medicines were dispensed and handed out to patents.

There was a process for requesting repeat medicines and evidence of structured medication reviews taking place.

Appropriate emergency medicines and medical oxygen were available. Vaccines were stored in line with national guidance.

The practice monitors the prescribing of antibiotics to reduce the risk of antimicrobial resistance.

Dispensary staff had received appropriate training and regular checks of their competency. Dispensing incidents and near misses were recorded and reviewed regularly.

Patient Group Directions (a written instruction for the administration of medicines to groups of patients not previously prescribed for) were in place and up to date.

There was a process with in the dispensary for staff to check for uncollected dispensed prescriptions each month. If any were identified as being uncollected for more than 28 days after the date of dispensing, staff told us that the patient would be contacted to ensure the medication was still required. However, we found 3 uncollected dispensed prescriptions awaiting collection and no action had been taken. One prescription had been dispensed 6 months prior to our inspection.

Temperature records to ensure the safe storage of medicines were not always completed in accordance with national guidance. This meant we could not be assured that medicines requiring refrigeration were safe for use. The provider has changed the processes in place following our assessment to be in line with guidance.