During an assessment under our new approach
Date of Assessment: 23 April 2025 to 30 April 2025
The practice is situated within the North-East Lincolnshire Clinical Commissioning Group and delivers general medical services to a patient population of about 3283. This is part of a contract held with NHS England. The building is shared with three other GP practices.
The provider is registered with CQC to deliver the following regulated activities: diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury. They were previously rated as ‘requires improvement’ following an inspection in March 2022 when improvements were required in the following areas: safe, well-led and effective.
The National General Practice Profiles states that the ethnic make-up of the practice area is 96.3% white,1.1% mixed, 1.4%Asian. 0.5% black and other 0.7%. The age distribution of the practice population is slightly above the national average for older people (20.6% v 17.9%) and slightly below the national average for young people (18.1% v 19.6%).
Information published by the Office for Health Improvement and Disparities shows that deprivation within the practice population group is in the first decile (1 of 10). The lower the decile, the more deprived the practice population is relative to others. This assessment considered the demographics of the people using the service, the context the service was working within and how this impacted service delivery. Where relevant, further commentary is provided in the quality statements section of this report.
We rated the key question of safe as good. The service had a good learning culture and people could raise concerns. Managers investigated incidents thoroughly. People were protected and kept safe. Staff understood and managed risks. The facilities and equipment met the needs of people, were clean and well-maintained and any risks were mitigated. There were enough staff with the right skills, qualifications and experience. Managers made sure staff received training and regular appraisals to maintain high-quality care. Medicines were mostly well managed. Some shortfalls were identified.
We rated the key question of effective as good. People were mostly involved in assessments of their needs. Staff reviewed assessments taking account of people’s communication, personal and health needs. Care was mostly based on latest evidence and good practice. Staff worked with all agencies involved in people’s care for the best outcomes and smooth transitions when moving services. Staff made sure people understood their care and treatment to enable them to give informed consent. Staff involved those important to people and took decisions in people’s best interests where they could not do so themselves.
We rated the key question of caring as good. People were treated with a high degree of kindness and compassion. Staff protected their privacy and dignity. They treated them as individuals and supported their preferences. People had choice in their care and treatment. The service supported staff wellbeing.
We rated the key question of responsive as good. People who used the service were involved in decisions about their care. The service provided information people could understand. People knew how to give feedback and were confident the service took it seriously and acted on it. The service was easy to access and worked to eliminate discrimination. People received fair and equal care and treatment. The service worked to reduce health and care inequalities through training and feedback. People were involved in planning their care and understood the options around choosing to withdraw or not receive care.
We rated the key question of well-led as good. Leaders and staff had a shared vision and culture based on listening, learning and trust. Leaders were visible, knowledgeable and supportive, helping staff develop in their roles. Staff felt supported to give feedback and were treated equally, free from bullying or harassment. Staff understood their roles and responsibilities. Leaders worked with the local community to deliver the best possible care and were receptive to new ideas. There was a culture of continuous improvement with staff given time and resources to try new ideas.
Since the last inspection, the practice had made improvements and is no longer in breach of regulations 12, 18 and 19.