The Care Quality Commission
  • Doctor
  • GP practice

Archived: Cleveland Surgery

Overall: Good read more about inspection ratings

Vanessa Drive, Gainsborough, Lincolnshire, DN21 2UQ (01427) 613158

Provided and run by:
Cleveland Surgery

All Inspections

23 Jan 2020

During a routine inspection

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

23 May 2019

During a routine inspection

We carried out an announced comprehensive inspection at Cleveland Surgery on 23 May 2019.

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 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.

We undertook the inspection of this service on 23 May 2019 following concerns that had been raised with us by the Clinical Commissioning Group and NHS England.

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 have rated this practice as inadequate overall.

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 have been provided with the essential services to meet their needs


As a result of the inspection team’s findings from the comprehensive inspection, as to non-compliance, but more seriously, the risk to service users’ life, health and wellbeing, the Commission decided to issue 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.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

01 Nov to 01 Nov 2018

During a routine inspection

This practice is rated as requires improvement overall. (Previous rating May 2018 – Inadequate)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires improvement

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? – Requires improvement

We carried out an announced comprehensive inspection at Cleveland Surgery on 01 November 2018. This inspection was carried out to follow up on breaches of regulations.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation, some of which was at an early stage. Practice leaders had worked collaboratively with the staff to improve systems and processes moving forward.
  • The practice’s GP patient survey results were below local and national averages for questions relating to kindness, respect and compassion and access to care and treatment. However, we saw patient feedback to the practice included comments about the kindness shown by practice staff and that patients appreciated the care and treatment they received.
  • Staff we spoke with told us they were proud to work in the practice and there were positive relationships between staff and teams.
  • Some patients we spoke with told us they found it difficult to get through to the practice to make an appointment.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • QOF results were worse than CCG and national averages for the period 01/04/2017 to 31/03/2018. However, QOF data for the current year 2018/19 reflected improvements made in managing long term conditions in particular.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence-based guidelines.
  • Practice leaders had responded to performance concerns and had implemented action plans to monitor and improve performance. However, there was limited evidence available to show improved outcomes as systems had been recently implemented and were still being embedded.

The areas where the provider should make improvements are:

  • Take action to complete a risk assessment for Dexamethasone as part of the emergency medicine protocol
  • Continue to embed the significant event process
  • Take action to identify all carers

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

30 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Inadequate overall. (Previous inspection 29/07/2016 – Good)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Inadequate

Are services caring? – Requires improvement

Are services responsive? – Inadequate

Are services well-led? – Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those recently retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) – Inadequate

We carried out an announced comprehensive inspection at Cleveland Surgery on 30 January 2018 as part of our inspection programme.

At this inspection we found:

  • The practice did not have clear systems to manage risk so safety incidents were less likely to happen. When some incidents happened, the practice failed to log them. Although the incidents were discussed at meetings, evidence of learning and improved processes were absent.

  • Patients told us they found it difficult getting through on the telephone to make an appointment so were unable to access care when they needed it.

  • Team meetings took place infrequently, meeting records were ineffective and opportunities to share and promote good practice were missed.

  • Complaint levels were high. Although staff dealt with complaints and concerns considerately, the practice missed opportunities to learn lessons from individual concerns and complaints. Complaints were not discussed at practice meetings or reviews undertaken to consider trends.

  • The practice was not receiving and acting upon all relevant patient safety alerts.

  • Staff told us the influx of new patients on to the practice list had impacted on the timeliness of care and treatment reviews.

  • We saw evidence the practice was reviewing patient feedback and considering ways to improve services. However the actions, timescale and outcome were not clear or reviewed.

  • Staff involved and treated patients with compassion, kindness, dignity and respect.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

More detail can be found in the enforcement actions section at the end of this report.

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

More detail can be found in the requirement notices section at the end of this report.

The areas where the provider should make improvements are:

  • Consider patient feedback around access to female GP appointments.

  • Review the newly implemented system for monitoring prescriptions through the practice to ensure it is embedded.

  • Review the system in place to report, analyse and discuss significant events with all relevant staff so that learning is disseminated effectively.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve. The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to vary the provider’s registration to remove this location or cancel the provider’s registration. Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

29 July 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced focussed follow up inspection on 29 July 2016 to follow up concerns we found at Cleveland Surgery on 3 September 2015. Overall the practice is rated as good.

We found the practice had made improvements since our last inspection in September 2015. Specifically the practice was:

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Incidents were recorded and accessible on the intranet for staff. Meeting minutes contained details of discussion and learning.
  • All staff had received an annual appraisal within the last 12 months. Appraisals were recorded on the intranet and flagged to staff member and manager when they were due for review. Clinical supervision was informal and there were plans to implement a more structured supervision.
  • The practice had a number of policies and procedures to govern activity, these were reviewed within the past 12 months. The practice intranet where they were stored was accessible to all staff and when a document was due to be reviewed a reminder would be sent to the practice manager.
  • The practice participated in regular multi-disciplinary meetings which were documented each month.
  • All staff that performed chaperone duties had undertaken the required training to perform the role.
  • There was a robust system for infection control and the lead attended regular link meetings for updates and refresher training.
  • An infection control audit had taken place in February 2016 and actions from this had been assessed and completed.

  • A robust system for disseminating NICE guidance to staff was in place and these were discussed at clinical meetings.

  • A cleaining schedule was in place including carpet cleaning and changing of curtains. Cleaning audits of all areas were completed monthly and any issues were identified and rectified.

  • COSHH sheets were available for all hazardous substances, in date and available to staff.
  • A fire risk assessment was conducted in December 2015 with actions to be taken which had been completed. The legionella risk assessment was conducted in September 2016.
  • Risk assessments were carried out, reviewed regularly and accessible to staff .
  • The practice had a protocol in place for the handling of safety alerts.
  • A cold chain policy was in place and staff understand their roles and responsibilities in relation to this policy however this was the overarching NHS England policy and the practice were looking at producing a process that was practice specific including signing sheets for the recording of daily fridge temperatures.
  • Not all staff were aware of the lead roles for the practice such as safeguarding, however they did know where to access this information.

The areas where the provider should make improvements are:

  • Continue to improve the availability of non-urgent appointments.

  • Ensure all staff are aware of lead roles in the practice such as safeguarding and infection control.

  • Ensure any actions from Legionella risk assessment are identified and acted upon.

We have changed the rating for this practice to reflect these changes. The practice is now rated good for the provision of safe, responsive and well-led services. The practice had been rated as good for the provision of caring and effective services at the inspection in September 2015.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

3 September 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cleveland Surgery on 3 September 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to be requires improvement for providing safe, responsive and well led services. It also required improvement for providing services for older people; people with long-term conditions; families; children and young people; working age people (including those recently retired and students); people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).It was good for providing a caring and effective service.

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

  • There was a clear leadership structure in place and staff felt supported by management despite the practice suffering recent GP and nurse shortages which had impacted on the provision of appointments for patients. The practice had a clear plan in place to address these issues and had been proactive in making improvements for patients and to the services it offered.
  • The practice proactively sought feedback from patients and acted upon it.
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses however information about safety was not always recorded, monitored and appropriately reviewed and addressed. There was limited evidence of learning from significant events and complaints, discussion in meetings and dissemination to staff.
  • Not all staff had received an appraisal within the last 12 months. However, we saw evidence of a schedule of appraisals to ensure all staff were appraised during September 2015.  We saw evidence that clinical supervision processes were in place for the nursing team.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments but they understood the challenges the practice had faced recently with a shortage of GPs and nurses.
  • The practice had a number of policies and procedures to govern activity, but some of these were either out of date or due a review, the practice did not have a cold chain policy in place however this was addressed and a comprehensive policy was implemented immediately after our inspection.
  • Regular multi-disciplinary meetings had taken place including partnership and staff meetings.  We saw evidence of meeting minutes during our inspection.

The areas where the provider must make improvements are:

  • Ensure all staff have appropriate, accurate, in date policies, procedures and guidance to carry out their roles in a safe and effective manner, ensuring they are current and reviewed and disseminated to staff.
  • Ensure chaperone training is undertaken by staff who perform chaperone duties.
  • Ensure robust system and processes for infection control ensuring the clinical lead for infection control is appropriately trained, ensuring that an up to date infection control audit is carried out.
  • Ensure a robust system for disseminating NICE guidance to staff and ensuring updated guidance is acted upon. 
  • Ensure a carpet cleaning schedule and a schedule for changing curtains is in place and appropriate records are kept up to date.
  • Ensure COSHH sheets are available for all hazardous substances and that they are in date and available to staff.
  • Ensure an up to date legionella and fire risk assessment is in place and accessible to all staff and ensure risk assessments are carried out and reviewed regularly and accessible to staff ensuring a risk register is held by the practice.
  • Ensure a protocol is in place for the handling of safety alerts.
  • Ensure all staff have regular appraisals and performance reviews and objectives agreed.
  • Ensure a system is in place to ensure all significant events and near misses are reviewed and recorded correctly, investigated and learning outcomes agreed and cascaded to staff.

In addition the provider should:

  • Improve the availability of non-urgent appointments.

  • Ensure all staff are aware of lead roles in the practice such as safeguarding and infection control.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

8 May 2014

During a routine inspection

Cleveland Medical Practice is located in the town of Gainsborough in Lincolnshire. The practice provides primary medical services to approximately 9,827 patients and is situated in purpose built premises. The building provides good access with ramps and hand rails, with accessible toilets and car parking facilities. Cleveland Medical Practice is a training practice providing training for GP registrars. These are trained doctors experienced in hospital medicine who wish to pursue a career in General Practice.

The regulated activities we inspected were diagnostic and screening procedures, family planning, surgical procedures and treatment of disease and disorder or injury.

We found that the practice was responsive to the needs of older patients, patients with long term conditions, mothers, babies, children and young patients, the working age population and those recently retired patients in vulnerable circumstances and patients experiencing poor mental health. Patients with long term conditions, such as epilepsy or chronic obstructive pulmonary disease received regular reviews of their health condition at the practice. We saw the practice had procedures in place to inform patients of the services available, this included information in other languages. The practice encouraged patients experiencing poor mental health to attend for regular health care reviews. We saw they responded quickly to appointment requests for young children and babies.