Theatre Royal Surgery

Updated 30 November 2018

Theatre Royal Surgery provides services to approximately 8,971 registered patients in a semi-rural area in Dereham, Norfolk. The practice holds a general medical services contract with NHS England.

The practice is run by two male GP partners who hold financial and managerial responsibility for the practice. The partners are supported by one salaried GP (female) and a trainee GP (female). The practice employs one advance nurse practitioner, three practice nurses, an emergency care practitioner, two healthcare assistants and one phlebotomist. Other support staff include a team consisting of an operations manager, a finance manager and a number of administration, reception and secretarial staff.

The practice is a training practice and supports medical students training to become GPs. At the time of our inspection, there was one trainee GP at the practice.

The practice is open between 7am and 8pm on Monday and Tuesday, 7am to 6pm on Wednesday and 8am to 6pm Thursday and Friday. When the practice is closed patients are automatically diverted to the GP out of hour’s service provided by Integrated Care 24 through the NHS 111 service.

According to Public Health England information, the patient population aged 0 to 4 is below the practice average across England and it has an above average number of patients aged 65 and over compared to the practice average across England. Income deprivation affecting children and older people is above the practice average locally but below the practice average across England.

Updated 30 November 2018

This practice is rated as Good overall. At the previous inspection in November 2017 the practice were rated as requires improvement overall; they were rated as requires improvement for providing safe and responsive services and good for effective, caring and well-led services.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? - Good

We carried out an announced comprehensive inspection at Theatre Royal Surgery on 30 October 2018 to follow up on breaches of regulations.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
• At the previous inspection, the practice did not have effective risk assessments in place relating to fire or legionella. We observed at this inspection the practice had taken action in relation to this.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
• The practice invited relevant practitioners such as palliative care specialists, district nurses and social care practitioners to quarterly training meetings at the practice to enhance collaborative working.
• Childhood immunisation uptake rates were above the target percentage of 90% or above with a range of 97% to 98%.
• The most recent published Quality Outcome Framework (QOF) results were 100% of the total number of points available compared with the CCG average of 98% and national average of 96%.
• The practice proactively identified carers and supported them. The practice had identified 571 carers and provided support to them. This was approximately 6.4% of the practice population.
• The practices GP patient survey 2018 results were below local and national averages for all questions relating to access to care and treatment.
• Patients continued to express their dissatisfaction in relation to accessing the practice.
• The practice had created a ‘Who to see at Theatre Royal Surgery’ help sheet for patients. The help sheet identified a number of conditions and highlighted which clinician in the practice would be suitable to see.
• The practice had a virtual patient participation group, however at the time of out inspection this was not active.
• Staff we spoke with stated they felt respected, supported and valued. They were proud to work in the practice and felt well supported by the practice management team.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• Continue to assess and ensure improvement to patient satisfaction relating to access to appointments as seen in the national GP patient survey results and feedback from patients during the inspection.
• Continue to develop engagement with patients, such as through a Patient Participation Group.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Updated 30 November 2018

Updated 30 November 2018

Updated 30 November 2018

Updated 30 November 2018

Updated 30 November 2018

Updated 30 November 2018