The Killingholme 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 that people were protected from abuse and avoidable harm.

At our last assessment, we rated this key question as good. At this assessment, the rating has changed to requires improvement.

This was because there had been a lack of management oversight and systems had not been fully implemented and monitored. The new practice manager was in the process of reviewing all governance systems and had developed an action plan for improvement.

The service was in breach of legal 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.

This service scored 47 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

Although the service had some systems in place to support a positive culture of safety based on openness and honesty, a lack of management oversight meant these systems had not been fully implemented. As a result, lessons had not always been learned and opportunities to continually identify and embed good practice had been missed. The new practice manager was in the process of reviewing all governance systems and had developed an action plan for improvement in this area.

People felt supported to raise concerns and felt staff treated them with compassion and understanding. Representatives from the Patient Participation Group (PPG) felt the provider took concerns seriously and proactively made improvements to the service.

Staff felt there was an open culture. The provider had processes for staff to report incidents, near misses and safety events. However, only one incident was recorded in January 2026 but had not been investigated and acted upon at the time and there was no evidence of incidents recorded prior to this time and no further incidents had been recorded since. The new practice manager had reviewed the incident, and a meeting had been held to share learning. Near misses were recorded in the dispensary, whilst these were minimal in numbers there was no evidence of review to identify patterns and trends and identify learning opportunities.

There was a system to record and investigate complaints, however, the new manager had been unable to find any complaints records to evidence processes were implemented and learning had been identified and they stated they had not received any complaints since commencing in post.

The service worked with people and healthcare partners to establish and maintain safe systems of care, in which safety was managed or monitored. They made sure there was continuity of care, including when people moved between different services.

There were systems in place for processing information relating to new patients. The service worked with other providers to deliver shared care and when patients moved between services.

Referrals and test results were managed in a timely way. We observed referrals and test results were normally dealt with on the same day and records of referrals were maintained so these could be monitored.

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 practice maintained a list of vulnerable people monitored by the manager.

The service did not always work well with people to understand and manage risks.

Patients felt they were well cared for and could access care as required. We observed same day appointments were available, and staff told us patients would be seen on the same day if urgent. Staff could recognise a deteriorating patient and knew of action to take.

We found from clinical searches that some patients prescribed medicines with specific risks had not always been monitored at the required intervals and communication with the patient to ensure compliance was not robust. The GP was aware that these systems required improvement and was working with the new practice manager to establish an improved system. We observed several patients had been contacted just prior to the assessment for monitoring and reviews to be completed where these were overdue.

Emergency equipment, such as oxygen, was available although we found that while the equipment was in working order there was a lack of recorded evidence that this had been regularly checked. The Resuscitation Council UK recommend that emergency equipment is checked at least weekly. Whilst some emergency equipment such as personal protective equipment (PPE), and equipment to administer medicines was available in the practice there was no single system in place to ensure these were immediately accessible in the event of an emergency, such as in the waiting room or car park. For example, the practice had not provided a dedicated emergency bag or trolley containing all the necessary equipment and medicines required for immediate use. A risk assessment for the provision of emergency equipment had not been completed. A defibrillator was available to the practice via a community resource on the outside of the building. Maintenance of this equipment was not the responsibility of the practice however, an assessment to identify any risks relating to the availability of the equipment for practice use had not been undertaken.

Most staff had undertaken basic life support training.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care. The new practice manager was in the process of reviewing all governance systems and had developed and implemented an action plan for improvement in this area.

A health and safety risk assessment had been undertaken by the new practice manager in April 2026 and actions for improvement had been identified. They had identified that safety checks and maintenance had not been undertaken as required and had scheduled this work to be completed. Not all the improvements and scheduled work had been completed by the time of the CQC assessment.

Records showed that fire alarm checks had been completed monthly rather than weekly and the fire risk assessment had last been undertaken in 2022 and had not been reviewed. There were no other records to show if fire extinguisher or emergency lights had been checked and no records of a fire drill. Four of the ten staff had completed health and safety training which included fire training, two of the staff were not enrolled on the training to enable them to complete this. Not all fire extinguishers were safely secured. The practice manager provided evidence after the initial site visit that a review of all fire extinguishers, fire points and emergency lighting had been undertaken by an external company and equipment requiring replacement had been upgraded. They confirmed all extinguishers were now secured, and the necessary service had been completed and new systems forundertaking and recording fire safety checks had been implemented. A fire risk assessment by an external specialist company had been scheduled for August 2026.

Compliance certificates for gas appliances were not available at the assessment but were provided immediately after when the work the manager had arranged prior to the assessment had been completed.

The flooring in the reception area was worn/discoloured but a plan was in place to renew the flooring.

The examination bed in the nurses’ room had not been working for 4 weeks, we were told an engineer had assessed this and they were waiting for a replacement part. The bed was set at its lowest position and could not be raised/lowered to aid access for patients and the staff.

There was a business continuity plan in place which was monitored and reviewed.

The service had not always made sure there were enough qualified, skilled and experienced staff. They did not always make sure staff received effective support, supervision and development. The new practice manager was in the process of reviewing all governance systems and had developed an action plan for improvement in this area.

There was a small staff team who worked hard to support and provide cover for each other. The service had a GP who was also the registered provider and employed a range of clinical and non-clinical roles, which included locum GPs as required, an Advanced Nurse Practitioner (ANP), a practice nurse, 2 dispensers and a 3 reception/administration staff. They had had a new practice manager in recent months who they found to be supportive and approachable. They told us significant improvements had been made within the practice.

There were a range of clinical and non-clinical roles within the practice. The practice manager had identified that staff training was not up to date and had been working with staff to ensure access to training systems so this could be addressed. The manager had an overview of the training completed and was monitoring this. However, the training overview did not include nurse role specific training and there was no oversight of this by the provider. We found there was a lack of evidence nurse training was up to date for example, staff undertaking childhood vaccines had not completed the required refresher training. This was immediately addressed, training was provided, a risk assessment was completed and appropriate action to safeguard patients was taken. There was no evidence the provider had ensured clinical staff were working within their agreed areas of competence. For example, there was no documented evidence scope of practice had been agreed with the nurses to ensure they only undertook tasks they were trained and competent to perform and competency assessments were not undertaken.

Recruitment practices had been reviewed by the new manager, and they had identified safe recruitment procedures had not always been followed. They told us they were working through staff files to try to update these. We looked at five recruitment files and found gaps in the required checks. For example, one member of administration staff had no recruitment checks on their file, a locum member of clinical staff had only a disclosure and barring service (DBS) check and no identity checks or checks of professional qualification or registration. Additionally, not all files had physical and mental health information, a record of immunisation status, full employment history and references. Right to work checks had not been completed.

Staff appraisals had commenced and training requirements had been identified. There was no formal clinical supervision provided. Nurses told us the provider was always available for discussion about a patient.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading. The new practice manager was in the process of reviewing all governance systems and had developed an action plan for improvement in this area.

An infection prevention and control (IPC) audit had been completed by the practice manager in June 2026, and actions had been taken or were in progress to mitigate identified risks.

For example, they had identified staff had not completed IPC training and staff had been enrolled on an IPC course with 5 of 10 staff having completed this at the time of the assessment.

A cleaning schedule for clinical equipment had been developed and nursing staff had dedicated time for cleaning the clinical areas and equipment.

The practice manager reviewed and improved the building cleaning schedules, however; cleaning staff had not followed the schedules as set out and records had not been completed by staff who provided cover for the staff holidays. The manager stated they would address this with the staff immediately.

Staff confirmed several improvements had been made by the new manager, and the building had been cleared and tidied to improve IPC processes.

We observed the plastic shelves on the equipment trolley in the area in the GP room used for minor surgery were cracked and this may impact on the effectiveness of the cleaning.

The practice had IPC policies and procedures to support safe practice; however, these had not been fully implemented. For example, the waste control policy stated each bag of clinical waste should be labeled but this was not being completed to ensure traceability and enable safe handling and completion of annual IPC assessments had not been undertaken prior to June 2026. The policy had not been fully completed to identify the IPC lead and minor surgery room.

The service did not always make sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They did not always involve people in planning.

People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms. Patients reported access was good and they could always speak to a clinician or dispenser if they had any concerns.

Staff had received training and felt confident managing the storage, administration and recording of medicines. Patient Group Directions (PGD’s) were in place although not all had been signed by the nurse or appropriately authorised to enable the nurse to administer the medicines.

Staff managed prescription stationery appropriately and securely.

Staff involved people in reviews of their medicines and helped them understand how to manage their medicines safely. However, some medicines review records were basic and there was a lack of structured medicines reviews. Processes to ensure people prescribed medicines with specific risks received recommended monitoring were not robust and people had not always received all recommended medicines reviews and monitoring. For example, some people (34 of 200) prescribed medicines (ACE inhibitors) for high blood pressure, heart failure and kidney disease had not received the required 6 monthly monitoring of their bloods. Some people (45 of 60) prescribed an oral anticoagulant (DOACs) had not had their kidney function checked by undertaking creatine clearance calculations at least annually. Some people (2 of 4) prescribed anti rheumatic medicines (DMARDs) had not had the required 12 weekly monitoring and 1 of these had not had the required monitoring for 6 months. There was a lack of clear protocols to support the management and monitoring of high-risk medicines, and the provider had identified that the systems for monitoring high risk medicines and medicines reviews required improvement. They were working with the practice manager to address this and to improve communication with patients to encourage attendance for monitoring. 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.

Medicines were not always stored securely. We observed 2 of the 3 filing cabinets in reception which stored dispensed medicines could not be locked. Records of the room temperature in reception and the dispensary where medicines where stored was not monitored and recorded.

Staff regularly checked the expiry dates for all medicines, including emergency medicines, vaccines, and controlled drugs. However, there were no regular stock checks of emergency medicines as per recommended Resuscitation Council UK guidance that at least weekly checks should be undertaken. Equipment, such as needles and syringes, were not held with the medicines to enable the medicines to be administered in an emergency.

Waste medicines were recorded and disposed of appropriately including medicines returned by patients. There had been a delay in disposing of controlled drugs in a timely manner, but this had been resolved by the new manager.

Staff stored medical gases, such as oxygen, safely.

Staff confirmed they received information about safety alerts. Systems to manage and respond to safety alerts and medicine recalls had recently been reviewed and records to document actions taken had been implemented. However, patient records did not always document if patients had been given the appropriate safety advice in respect of the alerts. For example, where patients were taking a medicine which had risks for women of childbearing age there was a lack of evidence that the risks had been discussed with them, and annual risk assessment acknowledgement forms and pregnancy prevention plans were not in place. 42 people prescribed a medicine to lower blood sugar (SGLT-2 inhibitors) had not been advised of the related risks. Of these 42 patients we reviewed 5 patient records in detail and found no evidence advice about risks had been given. We observed some patients had been provided with safety information which had been sent to people by text on the day of the assessment. The provider told us immediately after the assessment that they had reviewed patient records and had ensured they were correctly coded when advice had been given.

There was a lack of evidence of monitoring to ensure staff prescribed medicines appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment showed for example, the number of antimicrobials and opioid and non-opioid analgesics, issued by the provider was higher than national averages.

The practice had a dispensary. There were suitable processes for staff to follow when dispensing medicines. Staff who worked in the dispensary had been trained for the role and had a good awareness of the policies and procedures in place although competency checks had not been completed. Immediately after the assessment the practice manager provided evidence of competency checks, but this document was not dated or signed and did not indicate the staff assessed.

The practice was signed up to the Dispensary Services Quality Scheme (DSQS) and staff had undertaken Dispensary Review of the Use of Medicines (DRUMS) audits. There were a range of standard operating procedures to support practice, and these had been regularly reviewed by the dispenser.

Incidents in the dispensary were recorded but staff who were involved in the incident and any contributing factors were not recorded and there was no evidence of review or learning.

The dispensers prepared medicines in weekly or monthly monitored dosage systems and had dedicated time to do this.

The practice had two voluntary medicines delivery drivers. However, safe recruitment practices had not been completed and equipment such as cold storage for medicines which required refrigeration and secure storage for controlled medicines had not been provided to the drivers. A secure box was purchased during the assessment, and a box to transport refrigerated medicines was available in the practice for their use although the cool packs required freezing at home by staff prior to use.