The Care Quality Commission
  • Doctor
  • GP practice

Dr I P Tolley and Partners Also known as Hellesdon Medical Practice

Overall: Good read more about inspection ratings

343 Reepham Road, Hellesdon, Norwich, Norfolk, NR6 5QJ (01603) 486602

Provided and run by:
Dr I P Tolley and Partners

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Dr I P Tolley and Partners on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Dr I P Tolley and Partners, you can give feedback on this service.

19 April 2023

During a routine inspection

We carried out an announced comprehensive inspection at Dr I P Tolley and Partners (known as Hellesdon Medical Practice) on 19 April 2023. Overall, the practice is rated as good.

Safe - good

Effective – good

Caring – good

Responsive – good

Well-led – good

Following our previous inspection published on 14 |November 2018, the practice was rated good overall and for all key questions.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr I P Tolley and Partners on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this inspection to follow up on concerns reported to us.

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 short site visit.
  • 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.

We found that:

  • 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. The practice was aware of a back log of annual reviews that had developed during the COVID-19 pandemic. The action plan they were working with ensured the the backlog was being addressed appropriately and within a timely manner.
  • The practice undertook regular quality improvements audits such as ensuring patients with a learning disability received appropriate proactive care to live healthier lives.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

  • Monitor risk assessments to take actions as required to mitigate risks to patients and staff.
  • Continue to monitor the systems in place including the coding of medical conditions to ensure all patients receive appropriate reviews in the appropriate timeframes.
  • Implement a system to formally record the reflective learning sessions to evidence that supervision and oversight of non clinical medical prescribers is in place. In addition, monitor the plan to implement whole team meetings to discuss and review significant events and complaints and to share any learning outcome and actions taken.
  • Continue to monitor and reduce the backlog of medical records to fully summarise.

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 Hospitals and Interim Chief Inspector of Primary Medical Services

18 October 2018

During a routine inspection

This practice is rated as Good overall. (Previous rating May 2016 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr I P Tolley and Partners, known as Hellesdon Medical Practice, on 18 October 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they could access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

There were areas where the practice could improve and should:

  • Continue to monitor and review prescribing and where possible reduce the use of antimicrobial medicines in line with local and national guidelines.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

8 April 2016

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

 We carried out an announced focused inspection of Dr J K Mathews and Partners on 8 April 2016. This inspection was undertaken to follow up a requirement notice we issued to the provider at our previous inspection of 3 November 2015 as they had failed to comply with the law in respect of providing safe care and treatment for patients, specifically in respect of safeguarding service users from abuse and improper treatment. We undertook this focused follow up inspection to check that they had followed their action plan to achieve compliance with the regulations and to confirm that they now met legal requirements. This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection, by selecting the ‘all reports' link for on our website at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

3 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at DR J K Mathews and Partners on 3 November 2015. Overall the practice is rated as good.

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

  • The practice offered a wide range of services to meet patients’ needs

  • The practice had a very good skill mix which included advanced nurse practitioners who were able to see a broader range of patients than the practice nurses.

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

  • Risks to patients and staff were assessed and well managed.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance a clinical staff had the skills, knowledge and experience to deliver effective care and treatment. However there was no formal system in place to ensure that clinicians were kept up to date with the latest guidance.

  • Information about services and how to complain was available and easy to understand.

  • Patients said they found it easy to make an appointment and that 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.

  • 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 was one where the provider must make improvement:

  • Ensure that only trained staff who have been risk assessed regarding the need for a DBS check undertake chaperone duties. Ensure that a sign is clearly on display in each consulting or treatment room offering chaperone service if required.

The areas where the provider should make improvement are:

  • Ensure there is a system is in pace to monitor that all relevant medicines and healthcare product regulatory safety updates are actioned.

  • Produce written protocols on how to deal with patients on high risk medicines, especially those who have not attended for a blood test.

  • Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.

  • Improve the training for reception and administrative staff to ensure they have the knowledge and skills for their role.

  • Keep a record of recruitment interviews conducted with all potential employees

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

4 February 2014

During a routine inspection

Most people we spoke with told us they were happy with the service they received. They told us appointments were usually thorough, that the doctor took time to explain things, that appointments were of sufficient length and not rushed. People told us that they felt well informed about their healthcare needs by doctors, nurses and other staff and that there was ample information about the health care available within the practice building. One person we spoke with told us that the reception staff knew them well, were always kind and polite and that the doctor and nursing team knew their medical history well.

People informed us that they were generally satisfied with the healthcare and treatment they received. One person said "I have been registered with the practice a very long time and have no complaints. I usually have to wait for two or three days for an appointment but I don't mind. I have confidence in the GP and the Practice Nurses. The prescription service is very good too".

Staff that we spoke with all confirmed that they felt supported in their jobs, had sufficient training and were familiar with the practice policies and procedures. This was confirmed by checking staff records.

The premises were clean, bright and easily accessible. There was ample parking at the surgery and we noted an assistance call system in place for those wishing to enter the building with mobility problems.

We noted that the professional registration for GPs and nurses was current.