Dr Jones & Partners

Updated 9 February 2024

Dr Jones & Partners also known as Mattishall Surgery is located in Dereham at:

15 Dereham Road

Mattishall

Dereham

Norfolk

NR20 3QA.

There is a hybrid pharmacy/dispensary at this site.

The practice has a branch surgery in the nearby village of Lenwade, which also has a dispensary, at: Lenwade Surgery, The Street, Lenwade, Norwich, Norfolk, NR9 5SD. Both of these sites were inspected as part of this inspection. Patients can access services at either surgery.

The provider is registered with CQC to deliver the Regulated Activities:

• Diagnostic and screening procedures

• Maternity and midwifery services

• Treatment of disease, disorder or injury

• Surgical procedures

• Family planning services.

The practice is situated within the Norfolk and Waveney Integrated Care Board (ICB) and delivers General Medical Services (GMS) to a patient population of about 8,650. This is part of a contract held with NHS England. The practice is part of a wider network of GP practices, Mid Norfolk PCN.

Information published by Public Health England shows that deprivation within the practice

population group is in the seventh lowest decile (7 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 99% White and 1% Mixed.

There is a team of 3 GPs partners and 4 Salaried GPs who provide cover at both practices. The practice has a team of nurses who provide nurse led clinics for long-term conditions at both the main and the branch site. The GPs are supported at the practice by a team of reception/administration staff. The practice manager is based at the main location to provide managerial oversight. There is also a team of dispensary staff.

The practice at 15 Dereham Road is open between 8.30am to 6pm Monday to Friday. They also provide extended access on a Thursday evening opening until 8pm and on a PCN Practices rotational basis providing extend access every four weeks on a Friday evening until 8pm and a Saturday between 9am – 5pm. Lenwade Surgery is open on Mondays between 8.30am and 1pm and between 2pm and 6pm, and on Tuesdays, and Thursdays between 8.30am and midday, and on Fridays between 8:30am to 1pm and 2pm to 5:30pm.

The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Out of hours services are provided by IC24.

Updated 9 February 2024

We previously carried out an announced comprehensive inspection at the practice on 13 December 2022. The practice was rated as inadequate overall and placed into special measures. As a result of the concerns identified, we issued the practice with a warning notice relating to a breach of Regulation 12, Safe Care and Treatment on 15 December 2022. We carried out an inspection on 17 April 2023 to ensure the provider had made improvements to mitigate the risks identified in the warning notice.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Dr Jones & Partners on our website at www.cqc.org.uk.

Why we carried out this inspection.

We undertook a comprehensive inspection on 16 January 2024 to verify that the practice had addressed the issues identified in the previous inspection 13 December 2022.

How we carried out the inspection

This included:

• 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.

• Onsite 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 found that:

• The practice leaders and management team had undertaken a full review of the issues identified at our last inspection. They had identified clear roles and responsibilities, had made the improvements required and implemented systems and processes to monitor these to ensure they were sustained. Additional staff had been recruited and further recruitments were in progress.
• The practice had taken action to engage staff and improve communication. Monthly whole practice meetings were in place.

• 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.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• They practice was in line with the England percentages for patient satisfaction in respect of access. However, some patients reported long delays in getting through on the telephone.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

• Continue to improve and monitor systems and process to follow up patients with a diagnosis of asthma prescribed 2 more courses of steroids within an appropriate time.
• Monitor the risk assessment and actions taken following the recent review of the dispensary delivery service.
• Review the system and process in place for patient safety alerts so that the practice is assured all actions required have been completed.
• Continue to encourage patients to attend their cervical cancer screening appointments.

I am taking this service out of special measures and the conditions that were imposed on the provider’s registration will be removed. This recognises the significant 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 Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Health Care