The Care Quality Commission
  • Doctor
  • GP practice

Trent Valley Surgery

Overall: Requires improvement read more about inspection ratings

85 Sykes Lane, Saxilby, Lincoln, Lincolnshire, LN1 2NU (01522) 263444

Provided and run by:
Suresh Nagappa and Partners

Important: The provider of this service changed. See old profile

All Inspections

11 July 2023

During an inspection looking at part of the service

We carried out an announced focused inspection at Trent Valley Surgery on 11 July 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement.

Effective – requires improvement.

Caring – not inspected rating of good carried forward from previous inspection.

Responsive - good.

Well-led - good.

Following our previous inspection on 7 September 2022, the practice was rated requires improvement overall and inadequate for providing safe services and requires improvement for providing effective and well- led services.

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

Why we carried out this inspection

We carried out this inspection to follow up breaches of regulation from a previous inspection in line with our inspection priorities.

How we carried out the inspection/review

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

  • Conducting staff interviews using video conferencing.
  • Completing clinical searches on the practice’s patient records system (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.
  • A shorter visit to the main and branch site.

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:

  • The practice had taken reasonable steps to protect patients and others from the risks.
  • Staff received appropriate training and supervision.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • Managers understood the challenges to providing safe and effective care.
  • Patients received care and treatment that met their needs.
  • There was a focus on continual learning and improvement.
  • The provider was trialling a new way to manage safety alerts, but further work was required in this area to help improve performance.
  • Medicine reviews were not always conducted effectively.
  • Patients with long term conditions were reviewed but further work was required in this area to help improve patient outcomes.

Whilst we found no breaches of regulations, the provider should:

  • Take steps to improve coding relating to families of patients with a safeguarding concern.
  • Take action to consolidate cleaning schedules and their completion by staff.
  • Improve the process in relation to documentation and actions taken in relation to medicine reviews and long- term medicine management.
  • Introduce a system to safely manage prescribed medication if a patient fails to attend for monitoring.
  • Consolidate control of substances potentially hazardous to health (COSHH) data sheets and keep with the related substances.

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

07 September 2022

During a routine inspection

We carried out an announced inspection at Trent Valley Surgery on 7 September 2022. This is the first time this service has been inspected by the Care Quality Commission (CQC) following its registration as a new provider in March 2020.

Overall, the practice is rated as Requires Improvement.

Safe - Inadequate

Effective - Requires Improvement

Caring - Good

Responsive - Good

Well-led – Requires Improvement

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included:

  • Conducting staff interviews using video conferencing
  • Completing clinical searches on the practice’s patient records system and discussing findings with the provider
  • Reviewing patient records to identify issues and clarify actions taken by the provider
  • Requesting evidence from the provider
  • A short site visit
  • Reviewing information from external interested parties.

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 have rated this practice as Requires Improvement overall

We found that:

  • The practice did not always provide care in a way that kept patients safe and protected them from avoidable harm.
  • The provider could not be assured staff delivered effective care and treatment that met their needs.
  • The practice had not taken reasonable steps to protect patients and others from the risks.
  • The provider did not have effective oversight of the systems and processes designed to deliver safe and effective care.
  • Governance and leadership systems were ineffective.
  • Staff did not always have the training, supervision or appraisal required.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.

We found two breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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 Hospitals and Interim Chief Inspector of Primary Medical Services