Theatre Royal Surgery

Letter from the Chief Inspector of General Practice

This practice is rated as Requires Improvement overall. (Previous inspection 12 November 2014- rated good overall and good for all domains.)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires improvement

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 – Requires improvement

People with long-term conditions – Requires improvement

Families, children and young people – Requires improvement

Working age people (including those recently retired and students – Requires improvement

People whose circumstances may make them vulnerable – Requires improvement

People experiencing poor mental health (including people with dementia) - Requires improvement

We carried out an announced comprehensive inspection at Theatre Royal Surgery on 28 November 2017. We carried out this inspection as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage safety incidents. When incidents did happen, the practice learned from them and improved their processes.

• The practice had systems and processes in place to ensure patients were safeguarded from harm.

• The practice did not have effective risk assessments in place relating to fire or legionella. Immediately following the inspection, the practice sourced a company to complete a fire risk assessment and a legionella risk assessment as these were last completed in 2010 and 2012.

• 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 had achieved 99.8% for the Quality and Outcomes Framework.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system was not always easy to use; however the management team were aware of this and had implemented a new phone system and upskilled staff to address this issue. Results relating to access from the GP Patient survey were lower than local and national averages.

• Management were visible, approachable and staff felt proud to work in the practice.

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

We saw one area of outstanding practice:

• The practice had set up a walking group for patients with diabetes to improve health outcomes such as lowering blood pressure and increasing physical activity. Due to the popularity, this group had expanded to all patient groups. The practice had found and provided evidence to show decreased social isolation including those recently bereaved and they had ensured the group was accessible for those with a disability, including visual impairment. The group walked every day and the practice staff assisted those with lower mobility, or disabilities so that they could still attend. The practice could demonstrate that patients health had improved since joining the group; for example, some patients no longer needed medicines to control their blood pressure.

The areas where the provider must make improvements are:

• Ensure that the practice assesses and mitigated the risks to the health and safety of service users and staff.

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.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice