The Care Quality Commission
  • Doctor
  • GP practice

Taverham Surgery

Overall: Requires improvement read more about inspection ratings

Sandy Lane, Taverham, Norwich, NR8 6JR (01603) 867481

Provided and run by:
Marriott's Medical Practices

Important: The provider of this service changed - see old profile

All Inspections

26 April 2023

During a routine inspection

We carried out an announced inspection at Taverham Surgery on 26 April 2023. Overall, the practice is rated as requires improvement.

Safe - Requires improvement.

Effective - Requires improvement.

Caring - Good.

Responsive – Requires improvement.

Well-led – Requires improvement.

We previously inspected Taverham Surgery on 24 August 2022, report published 11 October 2022 and the practice was rated inadequate overall and placed in special measures. As a result of the concerns identified, we issued a Section 29 warning notice on 30 August 2022 in relation to a breach of Regulation 12 Safe Care and Treatment, requiring them to achieve compliance with the regulation by 18 October 2022. We undertook a focused inspection on 26 October 2022 to check that the practice had addressed the issues in the warning notice and now met the legal requirements.

We carried out this comprehensive inspection on 26 April 2023 and have rated the practice as requires improvement overall and for providing safe, effective, responsive and well led services. We have rated the practice as good for providing caring services.

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

Why we carried out this inspection.

We carried out this comprehensive inspection to follow up on breaches of regulation from a previous inspection, report published 11 October 2022.

  • Key questions inspected were safe, effective, caring, responsive and well led.
  • Areas followed up including any breaches of regulations or ‘shoulds’ identified in previous inspection.

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.
  • 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:

  • We found the practice had made significant improvements and the trajectory of the practice action plan was positive.
  • Although we identified some improvements, the systems and processes that were implemented needed further embedding, and monitoring to ensure they were sustainable and effective.
  • We found the GP partners had strengthened their leadership and worked with the management team. Evidence we saw showed there was clear clinical leadership and better cohesive working and was resulting in improved systems and processes and working practices. There was greater knowledge of the areas where risks were identified, and the actions required.
  • Processes to enable monitoring and oversight had been improved. The management team had developed clearer roles and responsibilities to ensure quality checks and improvements were monitored appropriately.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • There was some negative feedback in respect of access to care and treatment in a timely way.

We found a breach of regulations. The provider must:

  • Further establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

In addition, the provider should:

  • Continue to review and monitor feedback from patients to improve access to the practice.

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

I am taking this service out of special measures. This recognises the improvements that have been made to the quality of care provided by this service.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services

26 October 2022

During an inspection looking at part of the service

We previously inspected The Taverham Surgery on 24 August 2022 and the practice was rated inadequate overall and place in special measures. As a result of the concerns identified, we issued a Section 29 warning notice on 30 August 2022 in relation to a breach of Regulation 12 Safe Care and Treatment, requiring them to achieve compliance with the regulation by 18 October 2022.

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

Why we carried out this inspection

We undertook a focused inspection on 26 October 2022 to check that the practice had addressed the issues in the warning notice and now met the legal requirements. This report only covers our findings in relation to those requirements and will not change the ratings.

At the inspection, we found that not all the requirements of the warning notice had been met.

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 work remotely without conducting a site visit. 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

Our findings

  • The practice had improved their recruitment process to ensure staff are recruited safely, we found improvements in Disclosure and Barring Service (DBS) checks, however, the practice were still in progress of obtaining immunisation status of their staff.
  • The practice had undertaken infection prevention and control audit and had identified areas needing action, the practice had not produced an action plan to ensure all improvements were made and progress monitored safely.
  • The practice had improved their system to manage patient safety alerts.
  • We found the practice were still prescribing medicines outside of guidelines.
  • The practice had a backlog of fully summarising medical records and for managing electronic tasks and therefore staff may not have all the information they needed to deliver safe care and treatment.
  • The practice had improved their structured medicine reviews to include all medications.
  • We found processes for monitoring patients with long-term conditions had improved, however, we found the systems and processes needed further embedding and monitoring to be fully effective and to ensure they would be sustained.

We found a breach of regulation. The provider must:

  • Ensure care and treatment is provided in a safe way to patients.

For further information see the requirement notice at the end of this report.

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

24 August 2022

During a routine inspection

We carried out an announced inspection at Taverham Surgery on 24 August 2022. Overall, the practice is rated as inadequate.

Safe - Inadequate

Effective - Requires improvement

Caring - Good

Responsive – Requires improvement

Well-led - Inadequate

We previously inspected The Taverham Partnership in December 2017 and the practice was rated good overall. In May 2022 the practice changed provider and inherited the regulated history and ratings of the previous location, and is now called Taverham Surgery. The provider has two locations both of which were inspected due to concerns relating to both locations.

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

Why we carried out this inspection

This inspection was a comprehensive inspection in response to concerns raised with CQC in relation to patient safety and the premises.

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 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 Inadequate overall

We found that:

  • The practice did not provide care in a way that kept patients safe and protected from avoidable harm.
  • Not all patients received effective care and treatment that met their needs.
  • The practice did not have clear oversight to ensure all staff were recruited safely.
  • The practice did not ensure that all medicines were prescribed safely to all patients.
  • Medicine reviews were not always effective or completed in a timely manner.
  • The practice did not have clear oversight that staff had received appropriate competency assessments.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. However, patients could not always access care and treatment in a timely way.
  • The practice did not engage with the practice population for feedback to improve their services.
  • The management and leadership of the practice did not promote the delivery of high-quality, person-centre care.
  • The practice did not operate effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

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.

In addition there were areas the provider could improve and should:

  • Continue to identify, contact and assess patients who are eligible for NHS health checks.
  • Review and improve the system and process to gain feedback from patients.

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 any 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.

As a result of the concerns identified we issued a Section 29 warning notice in relation to a breach of Regulation 12 Safe Care and Treatment.

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