The Care Quality Commission
  • Doctor
  • GP practice

Elmham Surgery

Overall: Good read more about inspection ratings

59 Holt Road, North Elmham, Dereham, Norfolk, NR20 5JS (01362) 668215

Provided and run by:
Elmham Surgery

All Inspections

6 July 2023

During a monthly review of our data

We carried out a review of the data available to us about Elmham Surgery on 6 July 2023. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Elmham Surgery, you can give feedback on this service.

28 March 2020

During an annual regulatory review

We reviewed the information available to us about Elmham Surgery on 28 March 2020. We did not find evidence of significant changes to the quality of service being provided since the last inspection. As a result, we decided not to inspect the surgery at this time. We will continue to monitor this information about this service throughout the year and may inspect the surgery when we see evidence of potential changes.

30 March 2017

During an inspection looking at part of the service

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Elmham Surgery on 12 April 2016. The overall rating for the practice was good with a rating of requires improvement for providing safe services. The full comprehensive report based on the 12 April 2016 inspection can be found by selecting the ‘all reports’ link for Elmham Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 30 March 2017 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 and also additional improvements made since our last inspection.

Overall the practice is rated as good. During the inspection on 12 April 2016 we found areas of practice where the provider needed to make improvements.

We found that the provider must:

  • Undertake infection control audits in order to protect patients and staff.

  • Ensure that Patient Group Directions are reviewed and in date and ensure that Patient Specific Directions are in place to protect both staff and patients.

Our key findings as a result of this desk-based review on 30 March 2017 were as follows:

  • The practice had implemented infection control audits to ensure that safe infection control measures were in place.
  • The Patient Group Directions (PGDs) and Patient Specific Directions (PSDs) had been reviewed and embedded into practice.

We found the provider should:

  • Improve the infection control action plans to identify the person responsible for each action and a target date for completion so that progress can be monitored.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

12 April 2016

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Elmham Medical Practice on 12 April 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.
  • There was scope to strengthen the management of some risks, including infection control, and risks associated with legionella.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and 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.
  • There had been recent change of partnership at the practice that required the new management structure to adapt in a short timeframe. We found they had done this and the evolving management structure was progressing well.

However there were areas of practice where the provider must make improvements:

  • Undertake infection control audits in order to protect patients and staff.
  • Ensure that Patient Group Directions are reviewed and in date and ensure that Patient Specific Directions are in place to protect both staff and patients.

There were also areas of practice where the provider should improve:

  • Action previously identified issues around the risks associated with legionella.
  • Complete clinical audit cycles in order to deliver and monitor improved outcomes for patients.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice