The Care Quality Commission
  • Doctor
  • GP practice

Nettleham Medical Practice Also known as Dr Waller and partners

Overall: Requires improvement read more about inspection ratings

14 Lodge Lane, Nettleham, Lincoln, Lincolnshire, LN2 2RS (01522) 751717

Provided and run by:
Nettleham Medical Practice

All Inspections

05 September 2023

During a routine inspection

We carried out an announced comprehensive inspection at Nettleham Medical Practice on 6 September 2023. Overall, the practice is rated as requires improvement.

Safe - requires improvement.

Effective - good.

Caring - good.

Responsive – good.

Well-led - requires improvement.

During the inspection process, the practice highlighted efforts they are making to improve outcomes and treatment for their population. These had only recently been implemented so there is not yet verified evidence to show they were working.

As such, the ratings for this inspection have not been impacted. However, we continue to monitor the data and where we see potential changes, we will follow these up with the practice.

Following our previous inspection on 28 April 2016, the practice was rated outstanding overall and for key questions of effective and well led and good for safe, caring and responsive services.

At the last inspection we rated the practice as outstanding for providing effective and well-led services because:

  • The practice had an on-going audit programme in place, demonstrated quality improvement, provided care based on evidence-based guidance, completed audits to monitor end life care and reviewed deceased patient care to identify any improvements required.
  • The practice had a clear vision and strategy to deliver high quality care, a clear leadership structure and staff felt supported, arrangements were in place to monitor and improve quality and identify risk, processes were followed to comply with duty of candour, there was a culture of openness and honesty, systems were in place to manage safety alerts and there was a strong focus on continuous learning, training and improvement at all levels.

At this inspection, we found that those areas previously regarded as outstanding practice were now embedded throughout the majority of GP practices or were no longer in place. While the provider had maintained some of this good practice, the threshold to achieve an outstanding rating had not been reached.

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

Why we carried out this inspection

We carried out this inspection in line with our inspection priorities.

How we carried out the inspection

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 site visit.
  • Interviews with care homes covered by the practice.
  • Interview with a member of the Patient Participation Group.

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 did not have systems and processes in place to ensure patient received safe, effective research and evidence based care.
  • The provider did not have effective process in place to manage and mitigate risks related to care delivery or the environment.
  • Leaders demonstrated they had the capacity and skills to lead the service, but work was required to improve systems and processes in order to improve oversight of the whole practice. The overall governance arrangements were not effective in all areas.
  • Staff delivering speciality care had the skills, knowledge and experience to carry out their roles. Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice had a clear vision, staff reported that they felt able to raise concerns and when people were affected by things that went wrong, they were given an apology and informed of any resulting actions.
  • The practice was actively engaged with research projects and had systems and processes for learning, continuous improvement and innovation.

We found 2 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.

The provider should also:

  • Take steps to improve staff understanding of responsibility to ensure General Data Protection Regulation (GDPR) is followed.
  • Improve staff awareness of documentation required on Do not attempt cardiopulmonary resuscitation (DNACPR) forms.
  • Improve the system in place to manage Patient Group Directives.
  • Take steps to ensure all meeting minutes include staff present and are dated appropriately.
  • Take action to improve the availability of information to patients and carers in relation to health information and support.
  • Take action to validate safeguarding registers with local authority information.

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

28 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Nettleham Medical Practice on 28 April 2016. Overall the practice is rated as outstanding.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. There was a coordinator in place for significant events who produced a regular significant event newsletter to ensure all staff were aware of recent incidents and ensured lessons learned were shared with all practice staff.
  • Risks to patients were assessed and well managed. The practice had an effective risk register in place and had carried out numerous risk assessments which were reviewed on a regular basis.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • The practice provided a memory clinic held in-house on a monthly basis for patients.This service was delivered by a community mental health nurse and a consultant in old age psychiatry.

  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • The practice achieved the highest dementia diagnosis rate within Lincolnshire West CCG of 94 patients diagnosed during 2014-15, with an increase in diagnosis to 122 patients during 2015-16.

  • If families had suffered bereavement, their usual GP sent a letter to the bereaved family member/s or carer of the deceased patient and offered an appointment at a convenient time and access to bereavement services. The practice had received numerous letters and cards of thanks for the support offered by staff at times of bereavement.

  • The practice provided health pods in the waiting area for patients which enabled them to check their own blood pressure reading and weight measurements.This system was available in numerous different languages and automatically updated the patient care record with this information. Patients could use this system at a convenient time to the patient.

  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

  • The provider was aware of and complied with the requirements of the duty of candour.

During our inspection we saw four areas of outstanding practice:

  • The practice worked in partnership with the patient participation group. A voluntary driver scheme was formed in 2009 in response to difficulties patients experienced in attending consultations at either practice.There were 13 dedicated voluntary drivers who had carried out 11,146 patient journeys for approximately 360 patients since the scheme began.

  • The practice provided a memory clinic held in-house on a monthly basis for patients.This service was delivered by a community mental health nurse and a consultant in old age psychiatry.The practice also had an effective alert system system in place within the patient care record to ensure clinicians carried out effective dementia screening for patients who required this. The practice had achieved the highest dementia diagnosis rate within Lincolnshire West CCG of 94 patients diagnosed during 2014-15, with an increase in diagnosis to 122 patients during 2015-16. This provided an early diagnosis for patients and enabled GPs to provide the most effective care, treatment and support to help them to manage their condition.

  • The practice carried out an on-going palliative care audit. Three full cycle audits had been carried out at the time of our inspection. The aim of this audit was to identify all patients who required palliative care and to review the levels of care delivered to these patients and those at end of life, and assessed whether appropriate end of life care planning had been provided. The practice aimed to ensure the best possible care was for provided to these patients at all times. As part of this audit process, the practice produced its own standards in line with the Department of Health 2008 end of life care strategy to ensure clinicians continually monitored and delivered high quality care for patients. The practice carried out a full review of all of these patients during multi-disciplinary meetings to ascertain whether these standards had been achieved and carried out a significant event analysis to identify where improvements could have been made in the delivery of care.

  • The practice provided an in-house leg ulcer clinic which provided holistic care for patients of the practice who suffered leg problems.This service had been introduced approximately 12 years ago. The practice had a higher than average elderly population who had increased risk of developing chronic oedema and other leg problems and the nearest specialist lymphedema clinic was approximately 40 miles away from the practice.14.1% of the practice patient population were over the age of 75 compared to the CCG average of 8.4% and national average of 7.5%.The aim of this service was to provide early intervention and long term management of patients, reducing costs to the NHS, reducing admissions to hospital and enhancing quality of life for patients. 2.71% of the practice patient population were being seen in this clinic at the time of our inspection. 88% of patients seen in this clinic had successfully healed venous leg ulcers. We saw numerous examples of case studies of patients whose treatment had been successful.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 April 2014

During a routine inspection

Nettleham Medical Practice provided primary medical services for approximately 11,200 patients living in Nettleham, Cherry Willingham and the surrounding villages. The practice provided dispensing services at both the main surgery and the branch surgery at Cherry Willingham. The practice had been established as a GP training practice for many years and provided training to medical students and GP Registrars. These are qualified doctors who wish to pursue a career in General Practice. The practice was associated with the Lincolnshire GP Vocational Training Scheme and was assessed by the East Midlands Deanery.

We carried out the inspection as part of our new inspection programme to test our approach. It took place over one day with a team that included three CQC inspectors, a GP and a nurse. We sought advice from a CQC pharmacy inspector.

Before our inspection we spoke with representatives from three residential and nursing homes where patients were registered with the practice.

During our inspection we spoke with eleven patients who used the service. We received and reviewed sixteen comments cards, which had been left for patients to complete, by the CQC. We spoke with seventeen members of staff.

The regulated activities we inspected were diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.

There were effective processes in place to ensure that learning from significant events, complaints and feedback from patients was shared in order to improve patient experience.

The practice had taken robust steps to ensure that all staff underwent a thorough and rigorous recruitment and induction process. However, there was scope to improve the level of completion of the training required by the practice for some subject areas.

There were appropriate arrangements in place for the obtaining, recording, handling, using, storage, dispensing and the disposal of medicines, which minimised the risks to patients which are associated with medicines. However, there was scope for improvement in ensuring there were procedures in place for dealing with uncollected prescriptions and dispensed medicines.

We found the practice was effective at meeting patient’s needs. The practice worked well with other health and social care services which ensured the best care and support for patients.

Patients told us that overall they were happy with the service provided. Patients said they were involved in decisions about their care and treatment and were treated with dignity and respect by staff. We observed patients being treated in a caring and helpful manner whilst their confidentiality was maintained. We found there was no information available that advised patients they could ask to speak confidentially to non-clinical staff members at reception, if they required.

We saw that the practice was aware of the different needs of patients and responded appropriately to meet these.

We found the practice was well led and managed by an enthusiastic and knowledgeable management team who were keen to continue to improve the service for the benefit of patients. The level of completion of the training required by the practice was recorded as being at a low level for some subject areas. The practice was aware of this and was taking steps to ensure staff completed the training they judged to be needed.