14 September 2022
Andaman Surgery is located at:
303 Long Road,
The provider is registered with the CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury and surgical procedures. These are delivered from this site.
The practice is situated within Norfolk and Waveney Integrated Care Systems (ICS) and delivers General Medical Services (GMS) to a patient population of about 6,600. This is part of a contract held with NHS England.
The practice is part of a wider network of seven GP practices called Lowestoft Primary Care Network (PCN).
Information published by UK Health Security Agency (formerly Public Health England) shows that deprivation within the practice population group is in the fifth lowest decile (five 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 97.9% White, 0.7% Asian, 1% Black, 1% Mixed, and 0.1% Other.
The age distribution of the practice population closely mirrors the local and national averages. There are more female patients registered at the practice compared to males.
There is a team of three GPs who provide deliver services at the practice. The practice has a team of three nurses who provide nurse led clinics for long-term conditions. The GPs are supported at the practice by a practice manager and a team of reception/administration staff.
The practice is open from 8am to 6.30pm 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 Suffolk GP+, where late evening and weekend appointments are available. Out of hours services are available through the NHS 111.
14 September 2022
We carried out an announced comprehensive inspection of Andaman Surgery on 9 August 2022. Overall, the practice is rated as good.
Safe - Requires improvement
Effective - Good
Caring - Good
Responsive - Good
Well-led - Good
Following our previous inspection on 10 November 2015, 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 Andaman Surgery on our website at www.cqc.org.uk
Why we carried out this inspection
We undertook this inspection as part of a random selection of services rated good and outstanding to test the reliability of our new monitoring approach.
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.
- 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.
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 been responsive to the challenges that the COVID-19 restrictions had imposed. The practice had returned to offering all patients a face to face appointment, unless the patient requested telephone advice.
- The practice was addressing areas where backlogs had occurred, such as long-term condition review appointments.
- Patients told us the practice was led and managed in a way that promoted the delivery of person-centred care.
- We found gaps in the practice system for the appropriate and safe use of medicines.
- The practice risk assessments had not fully identified and mitigated risks to ensure patients and staff were always kept safe from harm.
- Although the practice and staff told us there was clinical supervision, this was not always formally recorded for future and proactive learning.
- Staff treated patients with kindness and respect and involved them in decisions about their care.
- The practice sought feedback from patients from regular meetings, including those with their patient participation group.
We found a breach of regulations. The provider must:
- Ensure care and treatment is provided in a safe way to patients.
In addition, the provider should:
- Continue to improve the uptake of cervical screening.
- Continue to provide details of the Parliamentary and Health Service Ombudsman (PHSO) in all complaint responses.
- Continue to review and improve the prescribing of antibiotics in line with local and national guidelines.
- Embed the reviewed system for clinical oversight of managing pathology results in a timely manner.
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