The Care Quality Commission
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  • GP practice

Archived: Springcliffe Surgery

Overall: Good read more about inspection ratings

42 St Catherines, Lincoln, Lincolnshire, LN5 8LZ (01522) 524725

Provided and run by:
Springcliffe Surgery

All Inspections

14 & 15 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Springcliffe Surgery, 42 St Catherines, Lincoln, LN5 8Z on the 14 and 15 April 2016. We carried out this inspection to check that the practice was meeting the regulations and to consider whether sufficient improvements had been made.

Our previous inspection in June 2015 found breaches of regulations relating to the safe delivery of services and concerns and regulatory breaches relating to the management and leadership of the practice, specifically in the well led domain. The concerns which led to these ratings applied to all population groups which meant that all six population groups were rated as requires improvement. The practice was rated as good in the effective, caring and responsive domains. The overall rating of the practice in June 2015 was requires improvement. Following the inspection, we received an action plan which set out what actions were to be taken to achieve compliance.

At the inspection in April 2016, we found the practice had made significant improvements since our last inspection in June 2015 and that they were meeting the regulations which had previously been breached.

We carried out an announced comprehensive inspection at Springcliffe Surgery on 14 and 15 April 2016. Overall the practice is rated as good.

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

  • All the partners and staff worked hard to undertake a complete review of the service since the previous inspection and made sustainable improvements.

  • The practice had implemented a process for discussion of safeguarding issues.We saw that concerns were raised and were required patients were flagged with an alert, such as vulnerable adults, children and carers. Staff were aware of this system and what this meant.

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents. Learning following investigation was shared at meetings and were necessary sent to all staff electronically. Annual reviews were carried out and presented to all staff. Low level, non clinical incidents were not always recorded although lessons were learned and documented in meetings.

  • A locum procedure was in place to check that locums were appropriately qualified and fit to practice before they deliver a service to patients. We saw that a locum that was currently in place had all the required documentation.

  • Risks to patients were assessed and well managed.

  • Ensure emergency equipment and medicines were checked monthly in line with the practice policy.

  • The practice had implemented a system to ensure that dispensed controlled drugs (CD) were appropriately recorded.

  • The practice had a system to track prescription pads in line with national guidance.

  • All staff had been trained in Mental Capacity Act (2005) and infection control.

  • Staff had access to policies, procedures and guidance which are robust, reviewed and updated to enable them to carry out their role, for example, consent, management of medicines and repeat prescribing. The practice were moving over to having these stored on the practice intranet in addition to the paper copies.

  • Patient surveys and feedback prompted the delivery of improvement.

  • The practice had a number of policies and procedures to govern activity.

  • The practice had commenced a triage system for all on the day appointments following feedback from patients that said they had to wait to see a GP. This was led by advanced nurse practitioners.
  • Data showed patient outcomes were at or above average for the locality. Completed audits had been carried out, we saw some evidence that audits were driving improvement in performance to improve patient outcomes.
  • 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.

The areas where the provider should make improvement are:

  • Review the process of reporting significant events to include non-clinical incidents and near misses.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 June 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

REQUIRES IMPROVEMENT

We carried out an announced comprehensive inspection at Springcliffe Surgery on 10 June 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing safe and well led services. It also required improvement for providing services for all the population groups. It was good for providing a effective, caring and responsive service.

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. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed
  • Data showed patient outcomes were at or above average for the locality. Completed audits had been carried out, we saw some evidence that audits were driving improvement in performance to improve patient outcomes.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients who responded to the January 2015 national GP survey rated their overall experience as good. 81.7% of patients would recommend the surgery to others.
  • 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.
  • The practice had a number of policies and procedures to govern activity.

The areas where the provider must make improvements are:

  • Disseminate learning from significant events, near misses and complaints to all staff and ensure that actions resulting from investigations are implemented in a timely way.
  • Review the current system for the flagging up of alerts for safeguarding vulnerable adults and children and carers and ensure that outstanding safeguarding concerns have been followed up effectively. Provide guidance for staff on the flagging of vulnerable adults on the patient electronic system.
  • Improve safeguarding processes to reduce risks to vulnerable patients

In addition the provider should:

  • Ensure that all locum doctors are appropriately qualified and fit to practice before they deliver a service to patients.
  • Improve access for patients who work.
  • Have a robust system in place to track prescription pads
  • Ensure all staff have had MCA and infection control training.
  • Ensure all staff have access to policies, procedures and guidance which are robust, reviewed and updated to enable them to carry out their role, for example, consent, management of medicines and repeat prescribing.
  • Ensure that patient surveys prompt the delivery of improvement.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 April 2014

During a routine inspection

Springcliffe Surgery provides general medical services to a population of 2,439 registered patients in the city of Lincoln. The surgery has three consultation rooms on the ground floor which can be accessed by patients with a disability. The service is provided by a team of five GP partners, nursing and administrative staff who also work at a larger GP practice registered separately. 

Improvements were needed to ensure the service is safe.

Most of the systems in place at the practice to monitor the safety of the service were effective. This included the management of safety incidents, infection control and prevention, emergency situations and the recruitment of appropriate staff. There was an appropriate system in place to work with other agencies to safeguard vulnerable children. However, a similar system was not in place to ensure the safety and protection of vulnerable adults and this required improvement.

The services were effective.

The practice had effective methods in place to monitor the clinical needs of their patients and ensure they received relevant care and treatment to keep them well. Best practice guidelines were followed although the systems to share best practice updates with the staff team could be further strengthened. Procedures for staff recruitment, training and development ensured that all employed staff had the right skills for their role. However, improvements could be made to ensure that the procedures were fully completed. The practice demonstrated they had effective professional relationships with other services.

The services were caring.

We spoke with seven patients who told us the staff always treated them with respect and considered their individual needs. Most patients were involved in decisions about their care and treatment and staff ensured they found answers to any questions they were unable to answer. However, we were concerned that staff did not know how to access translation services for patients who spoke little or no English so that they could be certain patients could make decisions and choices about their care and treatment. We have asked the practice to make improvements.

The services were responsive to patient’s needs.

The staff were responsive to individual patient needs and we saw evidence to support this. However, the practice had not considered the needs of the growing European population in terms of communication and provision of information. The number of registered patients was increasing and this placed more demand on the appointments system and some patients told us they had difficulty accessing an appointment when they needed one. The practice had commenced their first patient survey which included questions about the appointments system to help them review current arrangements. A low number of complaints had been received about the practice. Each one had been considered, investigated and an appropriate response provided.

The services were well-led

There was a structure in place to support leadership and management of the service. Staff told us the team worked well together and that senior staff were approachable although some staff groups did not have the opportunity to engage with the senior team to discuss and contribute to service improvements. Staff received informal support, regular training and an annual appraisal although not all staff had received an appraisal at the time of our inspection. Monthly business meetings involved GPs, nurses and senior administrative staff  and addressed a range of quality issues effecting the day to day management of the service.  Some clinical and non clinical audits took place but there was no overarching audit plan to engage the team and ensure that quality was being measured, reviewed and improved to benefit patients who used the service. Risk management procedures were in place.

The practice was able to demonstrate that they used feedback from complaints to improve the service.

The practice must take action on one issue where we found that improvement was needed;

The systems used by staff to identify, protect and support vulnerable adults  who were at risk of abuse or were experiencing abuse were not adequate. This was because staff had limited knowledge about the actions they should take if they suspected that a patient was at risk of, or experiencing abuse.

1 May 2014

During an inspection