The Killingholme Surgery

On this page

• Overview
• Shared direction and culture
• Capable, compassionate and inclusive leaders
• Freedom to speak up
• Workforce equality, diversity and inclusion
• Governance, management and sustainability
• Partnerships and communities
• Learning, improvement and innovation

We looked for evidence that service leadership, management and governance assured high-quality, person-centred care; supported learning and innovation; and promoted an open, fair culture

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 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 shared vision, strategy and culture. This was based on transparency, equity, engagement, and understanding challenges and the needs of people and their communities.

The practice had a small staff group and there was a positive and friendly culture with a family feel. The practice knew the local population and local challenges well and worked with partner agencies to provide the service.

The practice had been through significant changes in the last four months and had a new practice manager who was reviewing all governance procedures and was working closely with staff to make improvements. The staff told us they had felt supported during this time and were appreciative of the changes and improvements made.

The service had inclusive leaders who understood the context in which they delivered care, treatment and support and embodied the culture and values of their workforce and organisation. Leaders had the skills, knowledge, experience and credibility to lead effectively. They did so with integrity, openness and honesty.

Staff told us leaders in the practice were approachable and responded to any concerns raised.

We saw the leadership team worked with other practices in the primary care network.

The service fostered a positive culture where people felt they could speak up and their voice would be heard.

The new practice manager had reviewed and improved Freedom to Speak up arrangements. Staff were aware of how to raise concerns and contact details of the Freedom to Speak Up Guardian were displayed for staff. Staff told us they felt well supported and felt they could raise any concerns they may have.

The service valued diversity in their workforce. They work towards an inclusive and fair culture by improving equality and equity for people who work for them.

Policies and procedures to promote diversity and equality were in place and most staff had completed training in this area, but two staff had not been enrolled on the training at the time of the assessment.

The service did not always have clear responsibilities, roles, systems of accountability or good governance. They did not always act on the best information about risk, performance and outcomes, or share this securely with others when appropriate.

We found there had been limited provider oversight of governance processes prior to the employment of a new practice manager in March 2026. During this assessment we found shortfalls in areas such as recruitment, health and safety, infection prevention and control and medicines management.

The new manager had commenced a review of all governance processes, and a quality improvement plan had been developed and implemented to help drive improvements in services. This was work in progress and had included review of for example, staff training and appraisals, recruitment, health and safety risk assessment, infection prevention and control audit, and financial governance. Although improvements were underway, actions had not yet mitigated all the risks identified.

Leaders and managers supported staff, and all staff we spoke with were clear on their individual roles and responsibilities. They confirmed improvements were being implemented and they felt supported through the changes.

Staff could access all required policies and procedures but some of these required review and updating.

The manager had held two practice meetings and regular practice meetings were to be introduced. Actions arising from these meetings were recorded and shared with staff.

Staff took patient confidentiality and information security seriously and had received training in this area.

The service understood their duty to collaborate and work in partnership, so services worked seamlessly for people.

The provider worked with other practices within their primary care network to offer extended access.

The practice manager had identified they could improve coordination of their service with community healthcare services to support patients with complex needs and was going to recommence regular multidisciplinary team meetings.

The practice worked well with the long-standing Patient Participation Group (PPG) and held quarterly meetings. They had 8 members and their representative told us the practice worked well with them, and they were working on improving patient non-attendance following the last meeting.

The service did not always focus on continuous learning, innovation and improvement across the organisation and local system. They did not always encourage creative ways of delivering equality of experience, outcome and quality of life for people. They did not always actively contribute to safe, effective practice and research.

We found there had been limited provider oversight of the service prior to the employment of a new practice manager in March 2026. The new manager had commenced a review of all governance processes, and a quality improvement plan had been developed to help drive improvements in services.

Some clinical audits had been conducted. For example, a minor surgery audit had been undertaken in May 2026 and an action for learning for a coding issue was recorded. A joint injection audit had been undertaken in April 2026 no learning opportunities were identified, and this was to be reviewed annually. However, we found there was limited focus on improving care in areas such as prescribing and care of patients with long term conditions. The provider had accessed the CQC clinical audits just prior to the assessment and had commenced work to review patients where required. They had also identified that the recall system to monitor patients care required improvement to ensure compliance and was working with the practice manager to achieve this.

Learning from areas such as complaints were limited due to a lack of records. Lack of review of incidents such as dispensary near misses also meant learning opportunities may be missed.