The Killingholme Surgery

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as good. At this assessment, the rating remains the same.

This service scored 63 (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 made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

Feedback from people using the service was positive. People felt involved in any assessment of their needs and felt confident that staff understood their individual needs.

Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs.

Staff checked people’s health, care, and well being needs during health reviews.

Systems to identify people with previously undiagnosed conditions and to review patients with long term conditions were not effective. We found small numbers of patients who had not had long term condition monitoring reviews completed or had appropriate follow-up following blood results which showed their long-term condition required review. For example, of the 3 patients prescribed rescue courses of steroids for their asthma, 2 had not had steroid cards provided and 1 required assessment for adequate bone protection. 1 person with chronic kidney disease was outstanding for monitoring. 8 of 81 patients diagnosed with hypothyroidism were outstanding for monitoring and 1 person with diabetes had not been reviewed following blood results which indicated this was required. We provided patient information where we had identified a follow up was required and the provider confirmed this had been completed. The provider had identified that the systems for long term conditions reviews required improvement. They were working with the practice manager to address this. They had also reviewed the CQC clinical audits available on their system just prior to our assessment and had invited patients in for reviews and monitoring where these were overdue.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber and could book appointments with the social prescriber who visited the practice fortnightly.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. However, they did not always do this in line with current evidence-based good practice and standards.

People told us they received good care, staff listened to them and they could access care as required.

Clinical records demonstrated care was mostly provided in line with current guidance. Our clinical searches identified some people did not always receive care and treatment in line with national guidance for example, people with long term conditions and on high-risk medicines did not always receive the recommended follow ups and monitoring required.

The practice had maintained a good performance for delivering children’s vaccines and immunisations for at least the last 5 years. The most recent data available to CQC showed that in 2025 the practice had met or exceeded targets in 4 of 5 areas measured. In the one area where the target was not met this equated to two children of 11 eligible not attending.

The most recent data available to CQC showed that in 2024 the practice exceeded the 80% target for provision of cervical screening for women aged 50 - 64 years achieving 81% and had achieved 78% for women aged 25-29 years.

The service worked across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. However, there had been no recent multi-disciplinary team meetings held in the practice to discuss complex patients’ needs, and the practice manager was planning to restart these.

Due to the small staff team and working patterns scheduling staff meetings was difficult and staff meetings had not been held on a regular basis. Since commencing in role, the practice manager had held 2 meetings with staff to explain the management changes and was reviewing the meeting schedule.

The practice had a social prescriber who held clinics fortnightly and the practice could book appointments for patients.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

Patients with a learning disability had had regular reviews and three of the 4 eligible patients had had a Learning Disability Annual Health Review within the last 12 months.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met clinical expectations. However, patients felt their needs were met.

From the clinical notes we reviewed, we found that people who used the service did not always receive care and treatment in line with national guidance for example, people with long term conditions and on medicines with specific risks did not always receive the recommended follow ups and monitoring required.

The practice mostly met or exceeded national targets for screening and immunisations.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Consent for minor surgery was included in audits. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were monitored by the Advanced Nurse practitioner and the GP.