Cartmel Surgery

Updated 7 June 2022

Cartmel Surgery is the registered provider and provides primary care services to its registered list of 3000 patients at the time of the inspection. It is also a dispensing practice. The practice delivers commissioned services under the General Medical Services (GMS) contract and is a member of Morecambe Bay Clinical Commissioning Group (CCG).

The GMS contract is the contract between general practices and NHS England for delivering primary care services to local communities. The practice is registered with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures, surgical procedures, family planning, maternity and midwifery services, and treatment of disease, disorder and injury.

Regulated activities are delivered to the patient population from the following address:

Haggs Lane

Cartmel

Grange-over-sands

LA11 6PH

The practice has a website that contains information about what they do to support their patient population and the in house and online services offered:

https://cartmelsurgery.co.uk/

There are two GPs working at the practice to cover all clinical sessions (female and male GPs) and two GP registrars. There are two practice nurses, an assistant practitioner and a healthcare assistant. There is a practice manager and supporting administration staff. The practice also has a Primary Care Network (PCN) pharmacist, dispensary manager and two dispensers. The practice is a teaching and training practice for doctors and medical students.

The average life expectancy and age profile of the practice population is broadly in line with the CCG and national averages. Information taken from Public Health England placed the area in which the practice is located in the ninth least deprived decile (from a possible range of between 1 and 10). In general, people living in more deprived areas tend to have greater need for health services. According to the latest available data, the ethnic make-up of the practice area is 99% White, and 1% Other.

Patients requiring a GP outside of normal working hours are advised to contact the surgery and they will be directed to the local out of hours service which is provided through NHS 111 and delivered by Cumbria Health on Call (CHOC).

Due to the enhanced infection prevention and control measures put in place since the pandemic and in line with the national guidance, most GP appointments were telephone or online consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment at the practice.

Updated 7 June 2022

We carried out an announced inspection at Cartmel Surgery on 10 May 2022. Overall, the practice is rated as Outstanding with the following key question ratings:

Safe - Good

Effective - Good

Caring - Outstanding

Responsive - Outstanding

Well-led - Outstanding

Following our previous inspection on 19 April 2016 the practice was rated Outstanding overall and for the key questions caring and responsive. Since that inspection the practice had made changes to its registration.

Why we carried out this inspection

This was a full comprehensive inspection due to changes to the registration of the practice.

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.

This inspection included:

• A site visit by the lead inspector.
• Conducting staff interviews remotely and on site.
• Completing clinical searches remotely on the practice’s patient records system and discussing findings with the provider.
• Reviewing patient records remotely to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• Gaining feedback from staff by using staff questionnaires.

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.

Our findings

We have rated this practice as outstanding overall.

We rated the practice as outstanding for providing caring services because:

• The practice had achieved outstanding results in the national GP Patient survey. The practice was rated fifth overall for all practices in England and had maintained this high positive level of patient feedback for several years.
• The practice provided numerous examples of how they had supported vulnerable individuals to access health and social care, and how they had worked with other organisations to support patients.
• Patients were truly respected and valued as individuals and were empowered as partners in their care, practically and emotionally, by an exceptional and distinctive service.
• The practice adopted a holistic approach to caring by addressing all the needs of the patient, including their physical, mental, and emotional health, while taking social factors into consideration.
• The practice demonstrated a truly patient-centred culture and staff were committed to delivering excellent care to meet the needs of individuals.

We rated the practice as outstanding for providing responsive services because:

• The practice had achieved outstanding results in the national GP Patient survey. The practice was rated fifth overall for all practices in England and had maintained this high positive level of patient feedback for several years.
• Services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• 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 rated the practice as outstanding for providing a well-led service because:

• The practice management team were motivating, forward thinking, organised and innovative with a sensible approach and clear goals. Staff told us they received excellent support and encouragement from the leadership team to do this. The practice management team were compassionate and caring. Quality and integrity were a high priority resulting in a caring culture within a strong practice. There were opportunities provided for all staff for their personal development.
• The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care.
• There was strong collaboration across all staff and a common focus on engaging with patients and other services to improve quality of care and the patient experience.
• The practice embraced social prescribing for the community to ensure patients received timely intervention when they needed it most, signposted them to services that could help them and ensured support was offered locally so the patient population could easily attend appointments.
• The practice took the lead in the Primary Care Network and ensured best practice was shared amongst the members.

We have rated this practice as good for providing safe and effective services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.

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