The Care Quality Commission
  • Doctor
  • GP practice

Dr Jones & Partners

Overall: Good read more about inspection ratings

15 Dereham Road, Mattishall, Dereham, Norfolk, NR20 3QA (01362) 850227

Provided and run by:
Dr Jones & Partners

All Inspections

16 January 2024

During a routine inspection

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

13 December 2022

During an inspection looking at part of the service

We carried out an announced focused inspection at Dr. Jones and Partners on 13 December 2022. Overall, the practice is rated Inadequate.

Safe - Inadequate

Effective - Inadequate

Well-led – Inadequate.

Following our previous inspection in February 2018, the practice was rated good and for all key questions.

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

Why we carried out this inspection

This inspection was a focused inspection in response to concerns reported to us. The inspection focused on specific areas of the following key questions:

  • Are services safe?
  • Are services effective?
  • Are services well-led?

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

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.
  • A short site visit.

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 Inadequate overall.

We found that:

  • The practice leadership had failed to ensure the practice was led and managed in a way that promoted the delivery of high-quality, person-centre care.
  • The practice did not provide care in a way that always kept patients safe and protected them from avoidable harm.
  • Not all patients received safe and effective care and treatment that met their needs.
  • The practice did not ensure that all medicines were prescribed safely to all patients.
  • The practice did not have clear oversight that staff had received appropriate competency assessments.

We found breaches of regulations. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements:

  • Encourage patients to attend their appointments for the national cervical cancer screening programme.
  • Improve involvement of and engagement with the patient population to gain feedback in order to monitor and review the service.
  • Encourage staff to report and improve knowledge regarding the reporting of significant events, with a no-blame culture.
  • Review the system for NHS health checks for patients to improve uptake.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement, we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

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

23 January 2018, 31 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (October 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 Dr Jones and Partners on 23 January 2018 and 31 January 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. This included a risk stratification tool which gave management an ongoing oversight of all documented risks in the practice.

  • The practice had systems in place to safeguard patients against abuse. The practice regularly reviewed all documentation for children that were not brought for appointments. There was a clear audit trail to show that letters had been reviewed and discussed in meetings. However, the practice did not always document this in the patient’s notes for children that did not attend hospital appointments.

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided through clinical audit. It ensured that care and treatment was delivered according to evidence based guidelines.

  • The practice had achieved 100% performance for the Quality and Outcomes Framework.

  • Staff involved and treated patients with compassion, kindness, dignity and respect. Results from the national GP Patient Survey reflected this.

  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

  • The practice responded to complaints in a timely and open manner.

  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

  • There was a positive culture within the practice and staff reported the management team were supportive and approachable.

The areas where the provider should make improvements are:

  • Review the system for the documentation of children that were not brought for hospital appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

30 September 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Jones & Partners on 9 February 2016. At this time we noted that improvement was required to increase the security of medicines and blank prescription stationery held in the practice. Furthermore, we found that there was scope to improve the systems and processes in place for the ordering and collection of repeat prescriptions.

After the comprehensive inspection, the practice wrote to us to say what they would do to meet legal requirements in relation to ensuring robust processes were in place.

We undertook this focused inspection to check that they had followed their plan and to confirm that they now met legal requirements. This report only covers our findings in relation to those requirements.

The overall rating for the practice is good. You can read our previous report by selecting the ‘all reports' link for on our website at www.cqc.org.uk

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

9 February 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Jones and Partners on 9 February 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • 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.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Improve the arrangements for the security of blank prescription forms to ensure that they are only accessible to authorised staff.

  • Risk assess the systems in place for the ordering and collection of repeat prescriptions.

The area where the provider should make an improvement is:

  • Ensure that dispensing errors are investigated as significant events in order to ensure continuous learning.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice