Background to this inspection
Updated
12 August 2022
Cromwell Primary Care Centre is located in Grimsby at:
Cromwell Road
Grimsby
DN31 2BH
The practice has a branch surgery at: Laceby Village Surgery
6 Caistor Road
Laceby
North East Lincolnshire
DN37 7HX
The provider is registered with CQC to deliver the following Regulated Activities:
- Diagnostic and screening procedures
- Maternity and midwifery services
- Treatment of disease, disorder or injury
- Surgical procedures
- Family Planning
The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.
The practice is situated within the North East Lincolnshire Clinical Commissioning Group (CCG) and delivers Personal Medical Services (PMS) to a patient population of about 4602. This is part of a contract held with NHS England.
The practice is part of a wider network of GP practices. The group of eight practices is known as Panacea Primary Care Network (PCN) and work together to provide access to additional services such as a pharmacist, and First Contact physiotherapist.
Information published by Public Health England shows that deprivation within the practice population group is in the fourth lowest decile (four of 10). The lower the decile, the more deprived the practice population is relative to others.
According to the latest available data, the ethnic make-up of the practice area is 1.3% Asian, 97.5% White, 0.2% Black, 0.8% Mixed, and 0.2% Other.
The age distribution of the practice population closely mirrors the local and national averages.
The practice’s clinical team is led by the provider (principal GP) and supported by a salaried GP and regular locums who provide cover at both practices. The nursing team consists of two nurse prescribers, a practice nurse and a health care assistant. The practice manager and a team of reception and administrative staff undertake the day to day management and running of the practice.
The main surgery is open between 8 am to 6.30 pm on Monday, Tuesday, Wednesday and Fridays, with extended access on Monday and Tuesday evenings until 7.45 pm. The surgery closes at 1pm on Thursdays. On Saturdays, every fourth week, the main surgery is open from 8.30 am to 12 noon.
The branch surgery is open in the mornings between 8 am and 12.00 pm Monday - Friday and in the afternoons between 2.30pm and 6.30 pm on Monday, Tuesday and Fridays. On Thursdays the branch surgery is open from 1pm to 6.30 pm. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.
When the practice is closed, extended access is provided locally by the Primary Care Network (PCN), where late evening and weekend appointments are available. Out of hours services are accessed via the NHS 111 service.
Updated
12 August 2022
We carried out an announced inspection at Cromwell Primary Care Centre on 22 and 28 June 2022. Overall, the practice is rated as Good.
Safe - Requires Improvement
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Why we carried out this inspection
This inspection was a comprehensive inspection. It was the first inspection since a change in registration in November 2019.
How we carried out the inspection
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 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 Good overall
We found that:
- The practice had not always provided care in a way that kept patients safe and protected them from avoidable harm. Recruitment policies were not always fully implemented, there were some gaps in aspects of blank prescription security and management and the lead GP had not completed safeguarding training to the required level.
- Patients received effective care and treatment that met their needs.
- Staff treated patients with kindness, compassion, and respected their privacy and dignity. Staff helped patients to be involved in decisions about their care and treatment.
- The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment through a variety of routes and at a choice of preferred venue.
- Appropriate standards of cleanliness and hygiene were met.
- Data showed good levels of patient satisfaction with the service.
- The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
- The leadership team demonstrated an open and transparent leadership style.
We found one breach of regulations. The provider must:
- Ensure recruitment procedures are established and operated effectively to ensure only fit and proper persons are employed.
Although not a breach of regulations, the provider should:
- Embed practice policies and procedures for distribution and monitoring of pre-printed blank prescription stationary with staff and monitor compliance.
- Continue to encourage patient uptake in cervical cancer screening.
- Maintain the action plan put in place for structured medication reviews.
- Complete level 4 safeguarding training as safeguarding lead.
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