The Care Quality Commission
  • Doctor
  • GP practice

Andaman Surgery

Overall: Good read more about inspection ratings

303 Long Road, Lowestoft, Suffolk, NR33 9DF (01502) 517346

Provided and run by:
Andaman Surgery

All Inspections

9 August 2022

During a routine inspection

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.

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 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

15 November 2017

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection report published 7 January 2016 - Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Andaman Surgery on 15 November 2017 as part of our regulatory functions.

At this inspection we found:

  • The practice had good systems to manage risk so that safety incidents were less likely to happen. When they 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. The clinical team met regularly to keep updated, share learning and review patients. Support and monitoring was in place for the nursing staff, although the monitoring of the work undertaken by the nurse practitioner was primarily informal.
  • The practice engaged with the Clinical Commissioning Group and worked with a group of local practices to improve the service for patients.
  • Staff involved and treated people with compassion, kindness, dignity and respect. All staff had received equality and diversity and dementia awareness training.
  • Patients found the appointment system easy to use and reported that they were able to access care at the right time. Patient feedback on access to appointments was positive, this was supported by a review of the appointment system and data from the latest national GP Patient Survey.
  • Information on the complaints process was available for patients at the practice and on the practice’s website. There was an effective process for responding to, investigating and learning from complaints. Responses to patients were timely, however they did not all detail information about the Parliamentary and Health Service Ombudsman.
  • Staff told us they were happy to work at the practice, received training for their role and were encouraged to raise concerns and share their views.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation. The practice was a training practice for qualified doctors training to become GPs.

The areas where the provider should make improvements are:

  • Review the work undertaken by the nurse practitioner to obtain assurance of the quality of their work.
  • Continue to engage with the local Clinical Commissioning Group in relation to improving performance on antibiotic prescribing and radiology referral rates.
  • Information about the Parliamentary and Health Service Ombudsman should be included in all complaint response letters.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

10 November 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Andaman surgery on 10 November 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good for providing safe, effective, caring, responsive and well-led services. It was also good for providing services for older people; people with long-term conditions; families, children and young people; working age people; people whose circumstances may make them vulnerable and people experiencing poor mental health.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP 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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice