LADMS GP Enhanced Access Service - Louth

On this page

• Overview
• Learning culture
• Safe systems, pathways and transitions
• Safeguarding
• Involving people to manage risks
• Safe environments
• Safe and effective staffing
• Infection prevention and control
• Medicines optimisation

We had not inspected this service before. At this assessment the overall rating is requires improvement. This meant safety was not always a priority, and people were not always protected from abuse and avoidable harm.

This service scored 53 (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 did not always demonstrate a positive approach to safety and learning. Managers told us they listened to concerns and took steps to investigate safety events. However, we found little evidence that learning regarding complaints and significant events was shared with staff. Whilst we were told there were regular staff meetings, we only saw three sets of minutes for the twelve months prior to the assessment. Staff we spoke with told us that they had not received any information regarding outcomes of complaints, significant events or incidents.

The service had systems in place to manage complaints and processes for reporting incidents, near misses and safety events when they arose. We looked at four complaints and significant events. We saw they were fully investigated and learning had been identified. For example, the service identified that not all referrals were being processed efficiently which resulted in some delays for people. The service carried out referral management training in December 2025, with sessions for new staff undertaken in March 2026 and April 2026. The training allowed all team members to understand and manage referrals pathways correctly. By so doing the service ensured that they adhered to NICE Guidelines for referral times. The service advised that the training removed the single point of failure previously experienced. Since teamwide training was completed referral numbers had remained low with a quick turnaround and referral pathway were more widely known to team members.

In addition, the service received a complaint pertaining to availability of equipment, and specifically Dermoscopes to exam moles. As a result the service carried out regular site inspections of all equipment. However, we did not see evidence of further dissemination of learning to the wider team of complaints or significant events

The service did not have systems in place to support the delivery of safe care.

We found that leaders did not have oversight of safe premises, infection prevention and control, and emergency equipment at the Louth location. For example, the service was unable to assure us that emergency equipment was regularly checked to ensure that equipment was working and emergency drugs were in date. Staff told us that they did not have a check list for what should be held in the emergency equipment. During our assessment we found one pack of urine testing strips being used which were out of date.

Arrangements were in place to support continuity of care. People received follow-up appointments where appropriate, including review of test results and advice where needed. Referrals, correspondence and test results were managed in a timely way.

The service worked with people and healthcare partners to understand what being safe meant to them and the best way to achieve that. They concentrated on improving people’s lives while protecting their right to live in safety, free from bullying, harassment, abuse, discrimination, avoidable harm and neglect. The service shared concerns to relevant organisations quickly and appropriately to keep people safe.

The practice’s safeguarding policy included all aspects of the statutory framework, to include female genital mutilation (FGM), radicalisation and due regard to the need to prevent people from being drawn into terrorism, modern slavery and human trafficking. Clinicians we spoke with were aware of safeguarding.

Staff were appropriately trained in safeguarding procedures and acted on concerns working collaboratively with other organisations.

People were offered chaperones for intimate examinations or procedures, for example, breast assessments. Staff had received training on chaperoning and had a clear understanding of their role.

The service worked with people to understand and manage risks using a holistic approach. The service provided care to meet people’s needs that was safe, supportive, and enabled people to do the things that mattered to them.

The practice engaged with people to obtain their views on access to a health care professional via comment cards which were available at all locations. We saw feedback and compliments from six people who had used the service which were all positive.

The service did not always detect and control potential risks in the care environment. They did not always make sure equipment, facilities and technology supported the delivery of safe care.

The service supplied emergency medicines and emergency equipment, including oxygen, and defibrillator. The service was unable to assure us that the emergency medical equipment was regularly checked to ensure that equipment was working and emergency drugs were in date. Staff told us that they did not have a check list for what should be held in the emergency equipment. During our assessment we found that the defibrillator pads were expired by over two years. We requested reassurance from leaders that new pads would be fitted immediately, however, we did not receive this assurance. On 17 June 2026 we carried out a further assessment, this time the assessment was unannounced in order to recheck the expiry date of defibrillator pads. We found that the fitted pads had not been replaced and they remained two years out of date. The service had purchased new pads but had not fitted them. This meant that people were not safe when they used the service. We also found one pack of urine testing strips being used were out of date.

Receptionists had a daily security checklist to complete to include the opening and closing of the units. Access to the Woldside unit was adequately signposted to the entrance. However, we found that the entrance and exit doors were marked as a fire exit co-located to mandatory fire extinguishers and fire notices. This meant that people were at risk due to non-compliance of fire regulations. The service was unable to assure us that there were robust safety arrangements to keep people and staff safe.

Leaders did not have oversight of safe premises, infection prevention control, cleanliness and emergency equipment at the Louth location. Leaders were unable to assure us that premises were clean and safe, nor were they able to provide evidence of mandatory fire risk assessment or legionella risk assessment. We requested this information prior to our onsite assessment, however, they were unable to provide this information until after the assessment had been completed.

People were greeted on arrival by a dedicated receptionist. The waiting room was visibly clean and had adequate toilet facilities. Contracts were in place to ensure the premises were maintained however managers could not supply us with the details and therefore could not be assured the contracts had been complied with. Managers failed to provide assurance that mandatory risk assessments had been completed to include mandatory fire safety checks, fire risk assessment, and legionella risk assessments. Therefore, we were not assured that people were being kept safe. This information was supplied after we had completed our assessment.

The service made sure there were enough qualified, skilled and experienced staff. However, the service was unable to evidence that staff were registered with mandatory professional organisations, received regular and effective support, supervision and development in order to provide safe care that met people’s individual needs.

The service mainly employed clinical staff on a temporary basis via locum agencies. In total LADMS enhanced access service utilised the services of 10 receptionists, 4 advanced nurse practitioners and 21 doctors, either via locum agencies, or direct employment with LADMS, to deliver the enhanced access service across 5 locations. Additional administrative staff and management were employed by the provider organisation, including executive chairperson, chief operating officer, and wider office management and administrative team members to support the delivery of the enhanced access service.

There were a range of clinical and non-clinical roles within the service. We generally found mandatory training was up to date, however information governance compliance was 71% and mental capacity compliance was 59%. The service maintained a dashboard to record locum and employed doctor and nurse practitioner mandatory training and mandatory registration compliance. The dashboard showed that one staff member only had 53.6% mandatory training compliance. In addition, the dashboard indicated that medical indemnity, registration with the General Medical Council (GMC) and Nursing and Midwifery Council (NMC) had not been recorded or had not been updated by the organisation. The service was unable to assure us that 2 GPs had valid medical indemnity insurance, nor that 4 GPs had valid and in-date registration with the GMC which was noted as expired or overdue. Clinical appraisals were not recorded for all staff members. We looked at 5 staff files; we found references were absent in 2 files. We also found that 2 GPs did not have a curriculum vitae (CV) on file.

We reviewed the clinical oversight of the doctors and nurse practitioners who worked with the service. We saw evidence that monthly audits were being completed to review the appropriateness of medications prescribed and record keeping. However, due to staff turnover and staff sickness clinical oversight reviews had not been completed since October 2025. Failure to complete regular clinical oversight was acknowledged within meeting minutes dated 7 April 2026, where leaders commented that they needed to undertake peer reviews and complete medication audits to provide quality improvement evidence in readiness for the announced CQC assessment.

The service did not always assess or manage the risk of infection. They did not always detect and control the risk of it spreading or share concerns with appropriate agencies promptly. The service ensured staff received immunisations appropriate for their role, in line with national guidance.

Infection, Prevention and Control (IPC) audits had been completed; however, all audits were completed after we had announced our planned assessment date and the service was unable to provide any previous audits. Staff had received relevant training.

The receptionist completed a daily room check upon opening and closing the enhanced access location. We did not see any evidence that clinical rooms were checked for cleanliness or that equipment was cleaned after each use. We did not see any evidence of cleaning audits at any of the locations, despite asking leaders for these audits.

Disposable curtains were available in all clinical rooms which were recorded with a diary date for when they needed to be changed. Examination couches were all in good state of repair and were visibly clean with disposable paper covers for use between each person.

The service used disposal single use equipment, for example, cervical cytology speculums. Clinical waste procedures were in place.

The service made sure that medicines and treatments were safe and met people’s needs, capacities and preferences. They involved people in planning, including when changes happened. People knew what to do and who to contact if their condition did not improve or they experienced any unexpected symptoms from their medicines.

Systems were in place to manage and respond to Medicines and Healthcare Products Regulatory Agency (MHRA) alerts and medicine recalls. Systems for managing the prescribing of medicines and treatment of other medicines were safe and met people’s needs.

Medicines were prescribed appropriately to optimise care outcomes, including antibiotics. Prescribing data reviewed as part of our assessment confirmed this. For example, data on antibiotic prescribing for the treatment of uncomplicated urinary tract infections showed the service’s performance was within national averages relating to safe prescribing.