The Care Quality Commission
  • Doctor
  • GP practice

Newhall Surgery

Overall: Good read more about inspection ratings

46-48 High Street, Newhall, Swadlincote, Derbyshire, DE11 0HU (01283) 217092

Provided and run by:
Newhall Surgery

All Inspections

During an assessment under our new approach

Date of Assessment: 28 May 2025 to 5 June 2025. Newhall Surgery is a GP practice and delivers service to 11,013 people under a contract held with NHS England. We carried out an assessment because the service had not been inspected since 2015. The National General Practice Profiles states that the ethnic make-up of the practice area is 97.1% White, 1% Asian, 1.3% Mixed, 0.4% Black and 0.2% other. The age distribution of the practice population indicates the practice had a higher number of young and older people than the local and national averages and lower numbers of working age people. Information published by Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the 6th decile (10 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.

The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained, and the majority of risks had been mitigated. Following our assessment the provider forwarded information confirming action had to been taken address identified risks. Improvements had been made to the systems in place to assess and manage the risk of infection. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Staff managed medicines well and involved people in planning any changes. However, record keeping in relation to prescription stationary needed to improve. The provider forwarded the updated prescription tracker following our assessment.

People were involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was based on latest evidence and good practice. 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. Staff involved those carers, who were important to people, when decisions in people’s best interests were made, where they did not have capacity.

People were treated with kindness and compassion. 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 wellbeing.

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. The service had introduced an appointment booking and triage tool for appointments and requests to address issues around access. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. The service was developing the service offered to transgender community and participated in shared care agreements. People were involved in planning their care and understood options around choosing to withdraw or not receive care.

Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. The majority of staff felt supported to give feedback and were treated equally, free from bullying or harassment. However, freedom to speak up processes needed to be strengthened through policies and procedures, including named individuals for staff to share any concerns with. 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 was a culture of continuous improvement with staff given time and resources to try new ideas.

Since the last inspection, the service had made improvements and is no longer in breach of regulation 12.

 

6 December 2023

During a routine inspection

We carried out an announced comprehensive inspection at Newhall Surgery on 6 December 2023. Overall, the practice is rated as requires improvement.

Safe – requires improvement

Effective - requires improvement

Caring - good

Responsive - requires improvement

Well-led - requires improvement

At our previous comprehensive inspection on 10 February 2016, we rated the practice as good in the safe, caring, responsive and well-led questions, and as good overall. We rated the practice as outstanding in effective due to evidence of innovative ways to engage with children which enabled attendance rates of 98% to 100%. Additionally, the practice proactively monitored and managed all reported patient falls impacting on the number of emergency hospital admissions for patients aged over 65.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Newhall Surgery on our website at www.cqc.org.uk

Why we carried out this inspection.

We carried out this inspection due to our current inspection priorities. In this case, the practice was selected for inspection due to the length of time since our previous inspection.

How we carried out the inspection.

  • An announced site visit.
  • Conducting staff interviews using video conferencing prior to the site visit.
  • Completing remote clinical searches on the practice’s patient records system and discussing findings with the provider (this was with consent from the provider and in line with all data protection and information governance requirements).
  • Reviewing patient records to identify issues and clarify actions taken by the provider.
  • Requesting evidence from the provider to be submitted electronically, and to review further evidence on site on the day of the inspection.
  • Speaking with a member of the Patient Participation Group and a representative of a care home where the provider provided care and treatment.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • There was strong evidence to support that the practice’s most vulnerable patients, including those at end of life and those with known safeguarding concerns, received holistic and joined-up care to provide them with the care they required.
  • There was a proactive approach to safeguard patients.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients views were listened to and used to influence developments.
  • We saw that professional development was actively supported for clinicians. We also saw some examples where non-clinical staff had been supported to develop their role.
  • Our remote clinical searches identified areas where the monitoring and review of patients being prescribed medicines required strengthening.
  • The monitoring of patients with long-term conditions needed to be strengthened to support effective outcomes and the optimum management of their condition.
  • We saw that the practice had established effective systems to support good governance arrangements. However, the practice had not identified, managed and responded to some long-standing risks, following a change in management.
  • Staff felt disengaged with management, and ways to meaningfully improve this required further exploration.
  • Although the practice had introduced a new telephone system in the summer of 2023, and had received positive feedback, more evidence was required to assess the longer-term impact on patient experience. The CQC recognises the pressure that practices are currently working under and the efforts staff are making to maintain levels of access for their patients. At the same time, our strategy makes a commitment to deliver regulation driven by patients’ needs and experiences of care. Although we saw the practice was attempting to improve access, this was not yet reflected in the GP National Patient Survey data or other sources of patient feedback.

We found a breach of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

In addition, the provide should:

  • Fully consider staff feedback and develop an effective plan to respond to this, ensuring staff participation.
  • Continue to develop sustainable improvements to improve patient experience regarding telephone access.
  • Strengthen the process to provide assurance on the quality and safety of non-medical prescribing.
  • Implement the proposed plan for the management of patients with a long-term condition to enhance monitoring arrangements and patient outcomes.
  • Review confidentiality arrangements at the reception desk.
  • Complete a risk assessment for historically appointed staff where there may be gaps in evidence to support safe recruitment.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care

10 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Newhall Surgery on 10 February 2016. Overall the practice is rated as Good.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. All meetings across all staff groups included significant events as a standard agenda item.
  • There were comprehensive risk assessments undertaken and regularly reviewed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. Personal development was encouraged and provision made regularly for this for all staff via the appraisal process.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Patients were routinely given the opportunity to assist in writing their own care plan.
  • Information about services and how to complain was available and easy to understand.
  • Feedback from patients about their care was consistently and strongly positive and they were always able to see a GP or nurse on the day they called.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. This included baby changing facilities and treatment rooms which had been purposefully refurbished.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example: equipment had been purchased following fundraising activities, events to raise awareness of health issues were conducted regularly, ‘Teddy bear’ clinics had been introduced to reduce anxiety for children receiving immunisations.
  • The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was reviewed and discussed with staff.

We saw two areas of outstanding practice

  • The practice had introduced innovative ways of engaging children within the practice for example; the Teddy Bear clinics which enabled an attendance rate of 98%-100%.
  • The practice proactively monitored and managed all patient falls that were reported. This had resulted in the number of emergency hospital admissions for over 65s being around 250 per 1,000 people which is substantially lower than the CCG and locality averages (CCG was around 285 and locality average was around 295).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

11 June 2014

During an inspection looking at part of the service

We carried out this inspection to see if the provider had made improvements to safeguarding procedures and recruitment practices following our last inspection in August 2013.

At the time of our last inspection, people told us they were happy with the care they received and felt safe at Newhall Surgery. During this inspection we found people who use the service were protected from the risk of abuse because the provider had taken reasonable steps to identify the possibility of abuse and prevent abuse from happening.

At our last inspection we identified a concern that appropriate background checks had not been completed for all staff prior to employment at Newhall Surgery. People that we spoke with did not express an opinion about this subject. During this inspection we saw that the provider had developed a robust recruitment policy and appropriate checks were present for all staff.

People were cared for, or supported by, suitably qualified, skilled and experienced staff.

13 August 2013

During a routine inspection

Patients told us they felt they were treated with dignity and respect. One patient told us 'I'm satisfied with the service I receive.' Another said 'Staff are friendly and welcoming.' Patients told us sometimes they could overhear other patients discussing health issues at reception. However, they knew they could request a private consultation with reception staff. No one spoken with expressed any concerns about booking an appointment, or about how long they waited to be seen once they had arrived at the practice. Several patients told us they disliked discussing their symptoms with reception staff, even though the information was used to assist with allocation of appointments.

Patients said they felt involved in their care and were able to ask questions. They said treatment options were discussed with them, and results of tests were fully explained. We saw patients had access to a range of written information about medical conditions.

We saw there were robust systems in place for safeguarding children, but the arrangements for safeguarding adults were less robust. However, staff had a good understanding of safeguarding issues and how to recognise and respond to signs of abuse or neglect.

Risk assessments had not been completed for staff who had been employed prior the current recruitment checks being in place.

Patients were asked their views about their care and treatment and these were acted upon. Patients knew how to raise any complaints.