Background to this inspection
Updated
27 March 2020
Cleveland Surgery provides primary medical services to a population of 12,650 patients in Gainsborough and surrounding villages. More than 200 of those patients reside in residential care and nursing homes.
The practice has a higher distribution of patients between the ages of 40-54 years and an even distribution of male and female patients. The practice lies in an area of higher than average deprivation, it being in the third decile of the index of multiple deprivation where one represents the most deprived and ten the least deprived. Life expectancy for both males and females is below CCG and national averages.
Following the inspection conducted by CQC on 23 May 2019, the CCG commissioned another GP provider, The Welby Practice, to undertake a diagnostic review. In November 2019, The Welby Practice became the provider of services at Cleveland Surgery.
At the time of our inspection the practice had two partners, one being a GP and the other a managing partner. There are four salaried GPs, two advanced nurse practitioners, three practice nurses, one emergency care practitioner, and three health-care assistants. They are supported by a pharmacy technician and a range of administrative and reception staff. They also employ a clinical pharmacist and a transformation manager.
The provider has a General Medical Services (GMS) contract. The GMS contract is the contract between general practices and NHS England for delivering care services to local
communities. The practice is located within the area covered by NHS Lincolnshire West Clinical Commissioning Group (LWCCG).
The practice has one surgery which is Cleveland Surgery, Vanessa Drive, Gainsborough, Lincolnshire, DN21 2UQ. There are no branch surgeries and it is not a dispensing practice.
The provider is registered to provide the following Regulated Activities;
- Diagnostic and screening procedures
- Family planning
- Surgical procedures
- Treatment of disease, disorder or injury
The practice is open from 8am to 6.30pm Monday to Friday. Pre-bookable extended hours access appointments are available from 6.30pm to 9pm Monday to Friday and form 9am to 12 noon on Saturday and Sunday from this practice who also provide the service for four neighbouring practices.
When the practice is closed out-of-hours services are provided by Lincolnshire Community Health Services NHS Trust that is accessed through NHS111.
Updated
27 March 2020
We carried out an announced comprehensive inspection at Cleveland Surgery on 23 January 2020.
We had previously inspected this service on;
3 September 2015. We rated it as requires improvement in safe, responsive and well led and good in caring and effective. It was rated as requires improvement overall.
29 July 2016. We rated it as good in safe, responsive and well led.
30 January 2018. We rated it as inadequate in effective, responsive and well-led and requires improvement in safe and caring. It was rated as inadequate overall and placed in Special Measures.
1 November 2018. We rated it as good in safe and requires improvement in effective, caring, responsive and well led. The practice was taken out of Special Measures.
23 May 2019. We rated it as inadequate in safe, effective, responsive and well led. It was rated as requires improvement in caring. It was rated as inadequate overall and placed in Special Measures.
We rated the practice as inadequate for providing safe services because:
- The practice did not have clear systems and processes to keep patients safe.
- The practice did not have appropriate systems in place for the safe management of high-risk medicines.
- There were many new patient notes that had not been summarised and there were no plans to address the backlog.
- Outgoing mail had not been sent for a full week, resulting in a significant quantity of unsent mail.
We rated the practice as inadequate for providing effective services because:
- Clinical records were shown to be inaccurate.
- There was limited monitoring of the outcomes of care and treatment.
- Some performance data was significantly below local and national averages.
- Immunisation rates for children were below the 90% minimum.
We rated the practice as inadequate for providing responsive services because;
- We rated all the population groups as inadequate as the overarching issues affected all patients at the practice.
- Patients reported that they found it difficult to access the service by telephone and were dissatisfied with their experience.
- The practice did not have in place an effective complaints process.
We rated the practice as inadequate for providing well-led services because:
- Leaders could not show that they had the capacity and skills to deliver high quality, sustainable care.
- While the practice had a vision, that vision was not supported by a credible strategy.
- The practice culture did not support high quality sustainable care.
- The clinical and administrative governance arrangements were ineffective.
- The practice did not have clear and effective processes for managing risks, issues and performance.
- The practice did not act on appropriate and accurate information as the clinical records were shown to be inaccurate.
- We saw little evidence of systems and processes for learning, continuous improvement and innovation.
- The provider had not taken the necessary steps to ensure their CQC registration was a true reflection of the practice partnership.
These areas affected all population groups, so we rated all population groups as inadequate.
We rated the practice as requires improvement for caring because:
- We could not be assured that patients with long term conditions had been provided with the essential services to meet their needs.
As a result of the inspection team’s findings from the inspection in May 2019, as to non-compliance, but more seriously, the risk to service users’ health and wellbeing, the Commission decided to initially suspend the provider registration but following assurances received from the CCG, later issued an urgent notice of decision to impose conditions on the provider’s registration. The notice was served on the provider on 29 May 2019 and took immediate effect. The practice was placed into Special Measures.
We undertook the inspection of this service on 23 January 2020 to see if enough improvements had been made for the practice to come out of Special Measures. We found that the issues had been addressed and the practice had made significant improvements.
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.
The key questions safe, caring, responsive and well-led are now rated as good. The practice is rated as good overall.
We rated all the population groups, with the exception of vulnerable people, as requires improvement as there was no verified data available to support any rating higher than that in the effective key question. This was because no Quality Outcomes Framework (QOF) data was available and as a result we only had unverified data to rely on. Consequently, the effective key question is also rated as requires improvement.
Whilst we found no breaches of regulations, the practice should;
- Continue to address the back-log of patient notes requiring summarising and coding.
- Continue to review patient notes to ensure that patients receive the necessary levels of care and treatment.
- Maintain appropriate records of staff immunisations.
- Review the prescribing of hypnotics.
I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Dr Rosie Benneyworth BM BS BMedSci MRCGP
Chief Inspector of Primary Medical Services and Integrated Care