The Care Quality Commission
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  • GP practice

Archived: Deben Road Surgery

Overall: Good read more about inspection ratings

2 Deben Road, Ipswich, Suffolk, IP1 5EN (01473) 741152

Provided and run by:
Deben Road Surgery

Important: The provider of this service changed. See new profile

All Inspections

5 December 2019

During an inspection looking at part of the service

We carried out a focused inspection at Deben Road Surgery on 5 December 2019. The inspection of this service was due to the length of time since the last inspection. Following our review of the information available to us, including information provided by the practice, we focused our inspection on the following key questions, safe, effective and well lead. Because of the assurance received from our review of information, we carried forward the ratings for the following key questions: caring and responsive.

The practice was previously inspected on 24 March 2015 and was rated good overall.

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 received 15 CQC feedback cards given to patients before and during the inspection. All but one of the comment cards were very positive about the services provided and the practice staff.

    We have rated this practice as good overall and good for all population groups.

    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 way the practice was led and managed promoted the delivery of high-quality, person-centre care.

  • The practice organised and delivered services to meet patients’ needs.

  • The practice had achieved World Health Organisation (WHO) for childhood immunisations.

  • They also met Public Health England target for cervical cancer screening.

  • The practice had acted to improve their risk management processes and we saw health and safety risk assessments had been carried out and action taken to mitigate the risks.

  • Medicines were stored securely, and cupboards and room doors were locked. Prescription paper was stored securely, and a log was maintained for this.

  • Non-clinical staff undertaking chaperone duties had received a Disclosure and Barring Service (DBS) check.

  • There was a clear leadership structure and staff felt supported by management.

  • Staff worked well together as a team and all felt supported to carry out their roles. There was a strong team ethos and culture of working together.

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

  • Review the level of sepsis training for clinical and non-clinical staff.

  • Review the level of dementia training all staff receive.

    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

24 March 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Deben Road Surgery on 24 March 2015. Overall the practice is rated as good.

The overall rating for this practice is good. We found the practice to be safe, effective, caring, responsive to people’s needs and well-led. The quality of care experienced by older people, by people with long term conditions and by families, children and young people is good. Working age people, those in vulnerable circumstances and people experiencing poor mental health also receive good quality care.

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

  • The practice was a, friendly, caring and responsive practice that addressed patients’ needs and that worked in partnership with other health and social care services to deliver individualised care.
  • The clinical and administrative team had a good understanding of the needs of their patient population. This was particularly the case in relation to those patients who were at most risk of poor health whose care was proactively managed through personalised care plans.
  • Staff were multi-skilled and could carry out a variety of roles.
  • 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.
  • 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 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.

However there were areas of practice where the provider needs to make improvements.

Importantly the provider must;

  • Ensure that safe and clinically supervised systems are in place for the review of all patient correspondence.

Importantly the provider should;

  • Ensure there are systems in place to monitor and assess health and safety risks on an on-going basis.
  • Prescription stationery was securely stored and some record keeping was in place, but there was scope to ensure that the audit trail was complete
  • Sustain its efforts to set up and maintain an active PPG so that patients are able to formally contribute to the development of the practice.
  • Ensure staff are able to see clearly see patients in the waiting area in the event of any sudden deterioration in a patient’s health or wellbeing
  • Ensure all staff are familiar with the practice business continuity plan and are familiar with whistleblowing procedures.
  • Ensure there is a systematic programme of clinical audit and that action is taken when

improvements are identified.

  • Ensure that all staff who chaperone are confident in their understanding of the role.
  • Review and strengthen the arrangements for staff meetings.
  • Ensure there is a culture of consultation and challenge in which all staff can contribute to the direction of the practice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice