The Care Quality Commission
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Archived: Kidgate Surgery

Overall: Good read more about inspection ratings

The Kidgate Surgery, 32 Queen Street, Louth, Lincolnshire, LN11 9AU (01507) 602421

Provided and run by:
Kidgate Surgery

All Inspections

19 December 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced focussed follow up inspection on 19 December 2016 to follow up on concerns we found at Kidgate Surgery on 7 July 2016. The inspection in December 2016 was to ensure that improvement had been made following our inspection in July 2016 when breaches of regulations had been identified. The inspection in July 2016 found breaches of regulation and rated the practice as requires improvement in safe services. However the practice was rated as good overall.

At the inspection on 19 December 2016 we found that overall the practice had implemented changes and that the service was meeting the requirements of the regulations. The ratings for the practice have been updated to reflect our findings following the improvements made since our last inspection in July 2016. The practice was therefore rated as good for providing safe services.

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

  • The practice had applied for DBS for all staff. The majority of these had come through however there were still three checks outstanding although we saw evidence that these had been applied for.

  • Emergency medicines included all those recommended for all activities carried out by the practice, specifically atropine for emergency treatment if required, during the fitting of contraceptive coils or minor surgery.

  • Handling of blank prescription forms reflected nationally accepted guidance as detailed in NHS Protect Security of prescription forms guidance.

  • The practice had written consent process and patient satisfaction feedback in place for minor surgery where more invasive procedures i.e. excisions occurred.

  • There was adequate levels of security in relation to access to the dispensary.

The areas where the provider should make improvements are:

  • Ensure that the patient participation is active and feedback from patients is sought

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

7 July 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kidgate Surgery on 7 July 2016. Overall the practice is rated as good. The purpose of this inspection was to ensure that sufficient improvement had been made following the findings at our inspection in October 2014 when we found the practice to be requires improvement in safe.

Following the most recent inspection we found that overall the practice was rated as good however safe still remained requires improvement although significant improvements had been made and the areas identified at the previous inspection had been addressed.

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.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • Patients were positive about the care and treatment received. The practice was rated higher than national and local averages in almost all the national survey questions.
  • The practice facilities were well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had not sought feedback from patients and the patient participation group were not active.
  • Blank prescription forms and pads were securely stored but there were no systems in place to monitor their use.
  • The side door that staff accessed the reception area and the dispensary was open at times and there was no lock or secure keypad on the door.
  • References, qualifications and registration with the appropriate professional body had been completed however the appropriate checks through the Disclosure and Barring Service had only been completed for the GPs. The nursing staff, dispensing staff and staff that chaperone had not had a DBS check completed.
  • There was no evidence that a risk assessment had been carried out to ascertain what emergency medicines were and were not suitable for the practice to stock.

  • There was no audit completed in relation to minor surgery and no evaluation completed. We spoke to the practice who agreed that evaluation of minor surgery would enable audit to be completed and that written consent would also be audited.

The areas where the provider must make improvements are:

  • Ensure that recruitment checks are completed for all clinical staff and those that chaperone. Other staff should have a documented risk assessment in place if they are not part of the DBS process.

  • Ensure that emergency medicines include all those recommended for all activities carried out by the practice, specifically atropine for emergency treatment if required, during the fitting of contraceptive coils or minor surgery.

The areas where the provider should make improvements are:

  • Ensure that the patient participation is active and feedback from patients is sought

  • Improve handling of blank prescription forms to reflect nationally accepted guidance as detailed in NHS Protect Security of prescription forms guidance.

  • Have written consent in place for minor surgery where more invasive procedures i.e. excisions occurred.

  • Ensure adequate levels of security in relation to access to the dispensary.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

21 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

Kidgate Surgery offers a range of primary medical services from a single location at 32 Queen Street Louth, Lincolnshire, LN11 9AU

We carried out an announced, comprehensive inspection on 21 October 2014.

Prior to our inspection we consulted with the local clinical commissioning group (CCG) and the NHS local area team about the practice. A CCG is an organisation that brings together local GPs and experienced health professionals to take on commissioning responsibilities for local health services. Neither of these organisations had any significant concerns.

We spoke with patients and staff including the management team. The inspection focussed on whether the care and treatment of patients was safe, effective, caring, responsive and well led.

During the inspection we spoke with patients and carers that used the practice and met with members of the patient participation group (PPG). A PPG is a group of patients who have volunteered to represent patients' views and concerns and are seen as an effective way for patients and GP surgeries to work together to improve services and to promote health and improved quality of care.

We also reviewed comments cards that had been provided by CQC on which patients could record their views.

We looked at patient care across the following population groups: Older people; those with long term medical conditions; mothers, babies, children and young people; working age people and those recently retired; people in vulnerable circumstances who may have poor access to primary care; and people experiencing poor mental health.

Our key findings were as follows:

  • Patients were treated by caring GPs and staff who demonstrated compassion, dignity and respect.
  • Patients were positive about their experience of using the practice which had scored highly in the NHS Patient Survey.
  • Staff were able to identify and respond to changing risks to patients including deteriorating health and well-being or medical emergencies.
  • Staff understood their responsibilities to raise concerns, and report incidents and near misses.
  • Patients reported good access to the practice, a named GP and continuity of care. Urgent appointments were available the same day.

The overall rating for Kidgate Surgery is ‘Good’. However there are some issues that the practice should address;

Importantly the provider must;

  • Ensure that all clinical staff receive training on infection prevention and control.
  • Ensure that infection prevention and control audits are undertaken to help protect patients, staff and others from the risk of healthcare associated infections.
  • Undertake regular audits of cleaning to help ensure patient safety.
  • Ensure that all staff are provided with fire safety training.

In addition the provider should;

  • Review its policies and protocols to ensure they are up to date and relevant.
  • Develop the patient participation group.
  • Undertake local surveys of patients as a means of assessing and monitoring the quality of service provision.
  • Consider installing a means of staff summoning assistance to the treatment room in the event of a medical emergency or if a patient became violent or aggressive.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice