• Doctor
  • GP practice

Church Hill Surgery

Overall: Good read more about inspection ratings

Station Road, Pulham Market, Diss, Norfolk, IP21 4TX (01379) 676227

Provided and run by:
Dr Farrook Ahmed Mondol

Important: The provider of this service changed - see old profile

Latest inspection summary

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Background to this inspection

Updated 24 March 2022

Church Hill Surgery is located in Pulham Market.

Station Road,

Pulham Market

Diss,

Norfolk.

IP21 4TX.

The practice provides services for approximately 4500 patients. It holds a General Medical Services contract and is a teaching practice for medical students from the University of East Anglia. The practice dispenses medicines to those patients eligible to receive this service. We inspected the dispensary 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 and surgical procedures.

The practice is part of a wider primary care network (PCN) of GP practices South Norfolk health Improvement Partnership (SNhIP).

Information published by Public Health England shows that the practice population has a higher than average number of patients aged 45 and over and lower than average number of patients aged under 40 years. The practice is in a rural area with a low level of deprivation. Income deprivation affecting children and adults is below the local and national averages.

The lead male GP (sole provider) is supported by a salaried (Male) GP, two locum GPs who provide regular sessions at the practice and an Advanced Nurse Practitioner (female). The practice has a practice nurse and a health care assistant. The practice manager and deputy practice manager are supported by a team of administration and reception staff. There is a lead dispenser who is supported by the team of dispensers.

Due to the enhanced infection prevention and control measures put in place since the COVID-19 pandemic and in line with national guidance, most GP appointments are telephone consultations. If the GP needs to see a patient face-to-face then the patient is offered an appointment.

Extended access was provided locally by the PCN practices, but this was paused during the COVID-19 pandemic so that the practice could deliver the COVID-19 vaccination programme. Out of hours services are provided by Integrated Care 24.

Overall inspection

Good

Updated 24 March 2022

We carried out an announced comprehensive inspection at Church Hill Surgery on 17 February 2022. Overall, the practice is rated as good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led – Requires improvement

Following our previous focused inspection on 29 July 2021 the practice was rated Inadequate overall and for safe, effective and well led key questions, but caring and effective remained good as these were not inspected. As a result of these findings, we placed the practice into special measures and imposed urgent conditions on the registration of the provider.

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

Why we carried out this inspection

This inspection was a comprehensive inspection of all key questions and to follow up on breaches of regulations.

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
  • 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 have rated this practice as Good overall

We found that:

  • The practice had with the support of the CCG and with additional external support from a GP and practice manager made significant improvements to provide care in a way that kept patients safe and protected them from avoidable harm.
  • These systems were newly implemented and required further embedding to ensure the practice would be able to sustain and make further improvements to ensure they were effective.
  • The practice had been challenged with some staff changes and difficulties in recruiting employed GPs and nurses, however, they used locums who provided sessions on a regular basis. The practice had an active recruitment drive in place and had recently employed a new nursing team member.
  • We found the practice’s system for managing patient and medicines safety alerts ensured medicines were prescribed safely.
  • We reviewed patient consultation records and found examples of appropriate clinical coding, ensuring that accurate information was available for any health professional that required it.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • 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.
  • The process for recording, investigating and learning from significant events ensured safe care and treatment.
  • The practice had an effective system in place for recalling, monitoring and treating patients with a potential diagnosis of diabetes and chronic kidney disease. This ensured these patients received proactive care and advice to make informed choices and lifestyle changes to prevent further deterioration of their health.
  • The practice operated effective systems and processes to ensure good governance in accordance with the fundamental standards of care. However, these systems and processes were not fully embedded to ensure they would be sustained.
  • Although the practice and staff told us there was supervision and competency checks for all staff, we did not see this was always formally recorded for future and proactive learning.
  • The practice did not evidence that all staff inductions were tailored to the staff members role to ensure they were confident to deliver the service.

The practice had engaged with the findings of our last report, had worked with the CCG and an external team to identify the recovery plan, make the changes, monitor and ensure those improvements were sustainable. Relationships had been made with the external team to strengthen the leadership, and feedback from staff was positive about the changes and future. However, where improvements had been made the practice needed to ensure they are fully embedded, monitored and sustained.

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

  • Improve the system and process in place to provide regular feedback, competency and supervision checks in a way that will support learning and improvements for all clinical staff.
  • Continue to embed, further improve and sustain the newly implemented systems and processes to provide safe and effective safe.
  • Continue to monitor and improve prescribing of antibacterial drugs.
  • Consider implementing a system and process to provide new staff with a tailored induction specific to their role.

I am taking this service out of special measures and the conditions that were imposed on the practice will be removed. This recognises the improvements that have been made to the quality of care provided by this service.

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