- GP practice
The Killingholme Surgery
Assessment report published 22 September 2026
Contents
Ratings
Our view of the service
Date of Assessment: Undertaken between 9 July 2026 and 21 July 2026. The Killingholme Surgery is a GP practice and delivers service to 1,650 patients under a contract held with NHS England. The National General Practice Profiles states that 98.2% are white, 0.8% Asian, 0.1% black, 0.6% mixed and 0.2% other. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 4th decile (4 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
SAFE: People could raise concerns however; there was a lack of records to evidence how these were managed as complaints records could not be found and only one incident had been recorded.
People were not always protected and kept safe as safety alert information was not always shared with patients where this impacted them and not all patients prescribed high risk medicines had received the recommended monitoring. Provision of emergency equipment had not been risk assessed and there was lack of regular documented checks.
Not all risks relating to fire safety and infection prevention and control had been well managed however, the new practice manager had identified this and had reviewed and improved these processes.
There were enough staff with the right skills and experience. However, safe recruitment processes had not been followed, and not all the required checks had been completed. Not all staff had had the required training or refresher training. There was a lack of oversight of clinical staff training and competencies and clinical supervision.
There was a lack of evidence of monitoring to ensure staff prescribed medicines appropriately to optimise care outcomes, including antibiotics where data showed prescribing was higher than the national average.
There was a lack of evidence of learning from errors in the dispensary. Delivery staff had not been provided with appropriate storage for controlled drugs or medicines requiring refrigeration, this was resolved during the assessment.
EFFECTIVE: People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Systems to identify people with previously undiagnosed conditions and to review patients with long term conditions were not robust. Small numbers of patients had not had long term condition monitoring completed or had appropriate follow-up following blood results which showed their long-term condition required review. The provider had identified that the systems for long term conditions reviews required improvement and they were working with the practice manager to address this. They had also reviewed the CQC clinical audits available on their systems just prior to our assessment and had invited patients in for reviews and monitoring where these were overdue.
Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent.
Caring: People were treated with kindness and compassion. Data showed high levels of patient satisfaction with the service provided. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff well-being and all the staff enjoyed working at the service.
RESPONSIVE: People were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. Data showed high levels of patient satisfaction with access to the service. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback.
WELL LED: There had been a lack of management oversight and systems had not always been fully implemented and monitored. The new practice manager, who had commenced employment in March 2026, was in the process of reviewing all governance systems and had developed and implemented an action plan for improvement.
Leaders and staff had a shared vision and culture based on listening and trust. Leaders were visible, knowledgeable and supportive. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Managers worked with the local community to deliver the best possible care and were receptive to new ideas. There had been limited work towards continuous improvement until the employment of the new practice manager.
We found two breaches of regulation in relation to:
Safe Care and Treatment due to the provider not having adequate systems and processes in place to enable them to assess the risks to the health and safety of service users receiving care or treatment. –
Fit and proper persons employed due to the provider not having implemented recruitment procedures to ensure persons employed meet the requirements set in regulation.
We have asked the provider for an action plan in response to the concerns found at this assessment.
People's experience of this service
People were positive about the quality of their care and treatment. Recent survey results, including from the National GP Patient Survey and the NHS Friends and Family Test, showed people were highly satisfied with services and access to appointments. Patients told us the staff were kind, friendly and helpful.
There was an active patient participation group (PPG) who represented the views of people using the service. Representatives from the PPG told us the provider and manager worked well with them and were always available to discuss any issues.