The Care Quality Commission
  • Doctor
  • GP practice

Archived: The Spalding GP Surgery

Overall: Requires improvement read more about inspection ratings

Spalding Road, Pinchbeck, Spalding, PE11 3DT (01775) 652164

Provided and run by:
Lincolnshire Community Health Services NHS Trust

All Inspections

14 June 2022

During an inspection looking at part of the service

We carried out an unannounced focused inspection at The Spalding GP Surgery on 14 June 2022 after receiving information of concern.

The inspection focused on aspects relating to staff training and recruitment, care for patients with long term conditions and the leadership arrangements at the practice. The focused areas were covered under the following key questions:

Safe - Inspected not rated

Effective – Inspected not rated

Well-led – Inspected not rated

Following our previous inspection on 30 November 2021, the practice was rated Requires Improvement overall.

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

How we carried out the inspection/review

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.

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 insufficient assurance around recruitment checks and training of staff.
  • The practice did not have an effective system to learn and make improvements when things went wrong. Significant events were not always investigated, and learning was not always implemented.
  • The practice had worked hard to address a backlog of patients whom were not able to access care for long term conditions due to a shortage of clinical staff in the Spring of 2022.
  • Staff told us leaders were not always visible.
  • Due to low staffing the practice at times had not been able to achieve high quality sustainable care.
  • The practice were working towards an improvement programme addressing staffing challenges by appointing locum GPs and actively recruiting for more nursing and reception staff.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice had improved how it delivered services to meet the needs of patients. Patients could access care and treatment in a timely way.

We found a breach of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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

  • Continue to monitor staffing levels at the practice so that enough support is made available to reception and administrative staff to manage workloads at the practice.
  • Continue to monitor staffing levels at the practice so that enough support is made available to clinical staff to manage workloads at the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

30 November 2021

During a routine inspection

We carried out an announced inspection at The Spalding GP Surgery on 30 November 2021.

Overall, the practice is rated as Requires Improvement.

Safe - Requires Improvement

Effective – Requires Improvement

Caring - Good

Responsive – Requires Improvement

Well-led – Requires Improvement

The previous provider was rated as inadequate by the Care Quality Commission in April 2018 and placed into special measures. The Lincolnshire Community Health Services Trust (LCHS) acted as a caretaker for the practice for the years 2018 – 2019 and were registered under the LCHS registration. LCHS then applied in September 2019 for registration with the CQC as a GP practice under LCHS and was formally registered to deliver services from 15 October 2019. It was recognised that the practice had worked hard to address previous safe care and treatment issues found at that inspection in 2018.

Why we carried out this inspection

This inspection was a comprehensive inspection as part of our inspection programme. The service formally registered with CQC in 2019 and this was our first inspection of this location.

How we carried out the inspection/review

Throughout the pandemic the 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

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 rated Safe as requires improvement because:

  • The practice did not always provide care in a way that kept patients safe or monitored their treatment in line with national guidance.
  • There were further improvements required for comprehensive medication reviews completed for patients with long term conditions.
  • Significant events were not always acted upon or investigated. Lessons were not always learnt, and actions put in place.

We rated Effective as requires improvement because:

  • Do not attempt cardiopulmonary resuscitation (DNACPR) were not always completed in line with national guidance.
  • Patients’ long-term conditions were not always monitored in line with national guidance.

We rated Responsive as requires improvement because:

  • Information on how to complain was not readily available.
  • Complaints were not always used as an opportunity to learn and make improvements.
  • Information was not available to a complainant about how to take action if they are not satisfied with how the provider manages and/or responds to their complaint.

We rated Well-led as requires improvement because:

  • There were not always governance and oversight in areas of the practice such as clinical oversight, health and safety oversight and infection prevention and control.
  • The practice had not always identified risks or had assurance that actions had been completed.

We rated Caring as good because:

  • Staff treated patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.

We found two breaches of regulations. The provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Ensure there is an effective system for identifying, receiving, recording, handling and responding to complaints by patients and other persons in relation to the carrying on of the regulated activity.

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

  • Improve uptake rates for cervical screening.
  • Improve uptake rates for childhood immunisations.
  • Continue to monitor staffing levels at the practice that enough support is made available to reception and administrative staff to manage workloads at the practice.
  • Continue to monitor staffing levels at the practice so that enough support is made available to clinical staff to manage workloads at the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care