The Care Quality Commission
  • Doctor
  • GP practice

Archived: Toftwood Medical Centre

Overall: Good read more about inspection ratings

2 Chapel Lane, Dereham, Norfolk, NR19 1LD (01362) 691196

Provided and run by:
Elmham Surgery

All Inspections

17 June 2020

During an inspection looking at part of the service

At our last inspection on 25 April 2019 the practice was rated as good with a rating of requires improvement for providing safe services. This was because actions from fire risk assessments had not been actioned, the stock of emergency medicines was not in line with national guidelines, and Patient Group Directions (PGD) used by nurses to administer vaccinations were not clearly authorised by all staff. The full comprehensive report based on the 25 April 2019 inspection can be found by selecting the ‘all reports’ link for Toftwood Medical Centre on our website at .

This inspection was a desk-based review carried out on 17 June 2020 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection. This report covers our findings in relation to those requirements

We found that the practice was now meeting those requirements and we have amended the rating for this practice accordingly. The practice is now rated Good for the provision of safe services. We previously rated the practice as Good for providing Effective, Caring, Responsive and Well Led services.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we carried out our desk-based review
  • 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 have rated Safe as Good because:

  • The practice had instructed a professional specialist provider who had undertaken a full fire risk assessment. All actions identified were completed; one action was limited by the building structure, so a risk assessment had been undertaken.
  • Emergency medicines were stocked in line with guidance recommendations. The practice had identified an alternative emergency medicine that had been fully risk assessed.
  • The PGDs had been reviewed and correctly authorised the practice had embedded this process.

We found the provider should:

  • Continue to monitor immunisation uptake data to ensure national and international targets are met in all areas.
  • Continue to monitor and improve prescribing performance.
  • Ensure fire risk assessments and fire drills are undertaken when Covid lockdown is eased.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of General Practice

25 Apr 2019

During a routine inspection

We carried out an announced comprehensive inspection at Toftwood Medical Centre on 25 April 2019 as part of our inspection programme. This was the first inspection of this location.

This practice is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

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 rated the practice as requires improvement for providing safe services because:

  • The provider did not ensure the premises were safe for their intended use: The provider did not have an up to date fire risk assessment and had not taken all of the recommended actions to address risks identified in the last risk assessment.
  • At the time of inspection, the service did not have all of the recommended emergency medicines or a risk assessment mitigating the absence of some medicines. Following the inspection, the provider ensured these medicines were available.

However, we also found that:

  • The practice otherwise 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.
  • The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
  • The way the practice was led and managed promoted the delivery of high-quality, person-centred care.

The areas where the provider must make improvements are:

  • Ensure care and treatment is provided in a safe way for service users.

We identified areas where the provider could improve and should:

  • Monitor and review the process for authorising staff to administer medicines under patient group directions.
  • Continue to monitor immunisation uptake data to ensure national and international targets are met in all areas.
  • Continue to monitor and improve prescribing performance.

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