26 June 2023
Taverham Surgery is located in Norwich at Sandy Lane Taverham Norwich NR8 6JR. Taverham Surgery provides a dispensing service on site and this was visited as part of this inspection.
The provider is registered with CQC to deliver the Regulated Activities, diagnostic and screening procedures, maternity and midwifery services and treatment of disease, disorder or injury, family planning and surgical procedures.
The practice is situated within the Norfolk and Waveney Integrated Care Systems (ICS) and delivers General Medical Services (GMS) to a patient population of about 8,323.
This is part of a contract held with NHS England. The practice is part of a wider network of GP practices called West Norwich Neighbourhood.
Information published by Public Health England shows that deprivation within the practice population group is in the highest decile (tenth out of ten). The higher the decile, the least deprived the practice population is relative to others. According to the latest available data, the ethnic make-up of the practice area is 1% Asian, 96% White, 1% Black, 1% Mixed, and 1% Other. The age distribution of the practice population closely mirrors the local and national averages. There are more male patients registered at the practice compared to females.
There is a team of 3 GPs who work at the practice. The practice has a physician’s associate, an advanced nurse practitioner, a team of 4 nurses, a health care assistant, 2 phlebotomists and a clinical pharmacist. The GPs are supported at the practice by a team of reception and administration staff. The practice manager and business manager provide managerial oversight.
The practice is open between 8:30am to 6:00pm Monday to Friday.
The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments. Extended access is provided locally by OneNorwich Practices, where late evening and weekend appointments are available. Out of hours services are provided by Integrated Care 24 (IC24).
26 June 2023
We carried out an announced inspection at Taverham Surgery on 26 April 2023. Overall, the practice is rated as requires improvement.
Safe - Requires improvement.
Effective - Requires improvement.
Caring - Good.
Responsive – Requires improvement.
Well-led – Requires improvement.
We previously inspected Taverham Surgery on 24 August 2022, report published 11 October 2022 and the practice was rated inadequate overall and placed in special measures. As a result of the concerns identified, we issued a Section 29 warning notice on 30 August 2022 in relation to a breach of Regulation 12 Safe Care and Treatment, requiring them to achieve compliance with the regulation by 18 October 2022. We undertook a focused inspection on 26 October 2022 to check that the practice had addressed the issues in the warning notice and now met the legal requirements.
We carried out this comprehensive inspection on 26 April 2023 and have rated the practice as requires improvement overall and for providing safe, effective, responsive and well led services. We have rated the practice as good for providing caring services.
The full reports for previous inspections can be found by selecting the ‘all reports’ link for Taverham surgery on our website at www.cqc.org.uk
Why we carried out this inspection.
We carried out this comprehensive inspection to follow up on breaches of regulation from a previous inspection, report published 11 October 2022.
- Key questions inspected were safe, effective, caring, responsive and well led.
- Areas followed up including any breaches of regulations or ‘shoulds’ identified in previous inspection.
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.
- 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.
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:
- We found the practice had made significant improvements and the trajectory of the practice action plan was positive.
- Although we identified some improvements, the systems and processes that were implemented needed further embedding, and monitoring to ensure they were sustainable and effective.
- We found the GP partners had strengthened their leadership and worked with the management team. Evidence we saw showed there was clear clinical leadership and better cohesive working and was resulting in improved systems and processes and working practices. There was greater knowledge of the areas where risks were identified, and the actions required.
- Processes to enable monitoring and oversight had been improved. The management team had developed clearer roles and responsibilities to ensure quality checks and improvements were monitored appropriately.
- Staff dealt with patients with kindness and respect and involved them in decisions about their care.
- There was some negative feedback in respect of access to care and treatment in a timely way.
We found a breach of regulations. The provider must:
- Further establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
In addition, the provider should:
- Continue to review and monitor feedback from patients to improve access to the practice.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
I am taking this service out of special measures. This recognises the improvements that have been made to the quality of care provided by this service.
Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA
Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services