Cleveland Surgery

Updated 14 January 2022

Cleveland Surgery is located at Vanessa Drive, Gainsborough, Lincolnshire, DN21 2UQ.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, family planning, maternity and midwifery services and treatment of disease, disorder or injury and surgical procedures.

Cleveland Surgery has a patient list of around 12,500 patients under the terms of a General Medical Services (GMS) contract. A GMS contract is a contract between general practices and NHS England for delivering primary care services to the local community. More than 200 of the patients live in residential and nursing care homes.

A GP partner is also the registered manager and there is one other partner. The provider also has four other GPs. The clinical team also includes two advanced nurse practitioners, six nurses, an emergency care practitioner and two healthcare assistants. An assistant manager and practice manager are supported by the reception and administration team.

The practice is open from 8am until 8pm (pre-bookable extended hours appointments from 6.30pm-8pm only) and 9am to 12pm on Saturday and Sunday (pre-bookable extended hours appointments only). When the practice is closed, out of hours cover for emergencies is provided by the 111 service.

Information published by Public Health England shows that deprivation within the practice population group is in the second lowest decile (two of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the estimated ethnic make-up of the practice area is 97.8% White, 0.9% Asian, 0.8% Mixed, 0.4% Black and 0.1% Other.

Updated 14 January 2022

We carried out an announced inspection at Cleveland Surgery on 23 November 2021. This was the first inspection of this provider at this location.

Overall, the practice is rated as Good.

Safe – Good

Effective – Requires improvement

Caring – Good

Responsive – Good

Well-led - Good

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

Why we carried out this inspection

This inspection was a comprehensive inspection to rate this provider at this location.

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 telephone and 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 to be submitted electronically.
• A short site visit.
• To ensure we gathered staff feedback we used a questionnaire which was sent to staff electronically via email.

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.

The practice is rated as good overall. The practice is also rated as good for providing safe, caring, responsive and well-led services. However, the service has been rated as requires improvement for providing effective services.

The service is rated as requires improvement for providing effective services because:

• Most patients received effective care and treatment that met their needs, however, some patients with long term conditions or potential long-term conditions had not received up to date monitoring or their diagnosis had not been identified.

We also found that:

• The service provided care in a way that kept patients safe and protected them from avoidable harm.
• Staff treated patients with kindness and respect and involved them in decisions about their care.
• The practice organised services to meet patients’ needs. Patients could access care and treatment in a timely way. This had continued during the Covid-19 pandemic.
• Systems and processes were in place to ensure good governance in accordance with the fundamental standards of care. However, we identified some areas where processes could be strengthened.

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

• Continue to monitor the support available to reception staff.
• Continue to strengthen processes for supporting and identifying people with long term conditions.
• Continue their work to improve uptake of childhood immunisations and cervical screening.
• Continue their work to improve patient satisfaction in the areas identified in the GP Patient Survey.
• Continue to review and monitor assurance processes to identify issues and improve performance.

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