This practice is rated as Good overall. (Previous rating May 2016 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Dr I P Tolley and Partners, known as Hellesdon Medical Practice, on 18 October 2018 as part of our inspection programme.

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.
• 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.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Patients found the appointment system easy to use and reported that they could access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

There were areas where the practice could improve and should:

• Continue to monitor and review prescribing and where possible reduce the use of antimicrobial medicines in line with local and national guidelines.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

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

Letter from the Chief Inspector of General Practice

 We carried out an announced focused inspection of Dr J K Mathews and Partners on 8 April 2016. This inspection was undertaken to follow up a requirement notice we issued to the provider at our previous inspection of 3 November 2015 as they had failed to comply with the law in respect of providing safe care and treatment for patients, specifically in respect of safeguarding service users from abuse and improper treatment. We undertook this focused follow up inspection to check that they had followed their action plan to achieve compliance with the regulations and to confirm that they now met legal requirements. This report only covers our findings in relation to this requirement. You can read the report from our last comprehensive inspection, by selecting the ‘all reports' link for on our website at www.cqc.org.uk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at DR J K Mathews and Partners on 3 November 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• The practice offered a wide range of services to meet patients’ needs

• The practice had a very good skill mix which included advanced nurse practitioners who were able to see a broader range of patients than the practice nurses.

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

• Risks to patients and staff were assessed and well managed.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance a clinical staff had the skills, knowledge and experience to deliver effective care and treatment. However there was no formal system in place to ensure that clinicians were kept up to date with the latest guidance.

• Information about services and how to complain was available and easy to understand.

• Patients said they found it easy to make an appointment and that 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 was one where the provider must make improvement:

• Ensure that only trained staff who have been risk assessed regarding the need for a DBS check undertake chaperone duties. Ensure that a sign is clearly on display in each consulting or treatment room offering chaperone service if required.

The areas where the provider should make improvement are:

• Ensure there is a system is in pace to monitor that all relevant medicines and healthcare product regulatory safety updates are actioned.

• Produce written protocols on how to deal with patients on high risk medicines, especially those who have not attended for a blood test.

• Put systems in place to ensure all clinicians are kept up to date with national guidance and guidelines.

• Improve the training for reception and administrative staff to ensure they have the knowledge and skills for their role.

• Keep a record of recruitment interviews conducted with all potential employees

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Most people we spoke with told us they were happy with the service they received. They told us appointments were usually thorough, that the doctor took time to explain things, that appointments were of sufficient length and not rushed. People told us that they felt well informed about their healthcare needs by doctors, nurses and other staff and that there was ample information about the health care available within the practice building. One person we spoke with told us that the reception staff knew them well, were always kind and polite and that the doctor and nursing team knew their medical history well.

People informed us that they were generally satisfied with the healthcare and treatment they received. One person said "I have been registered with the practice a very long time and have no complaints. I usually have to wait for two or three days for an appointment but I don’t mind. I have confidence in the GP and the Practice Nurses. The prescription service is very good too".

Staff that we spoke with all confirmed that they felt supported in their jobs, had sufficient training and were familiar with the practice policies and procedures. This was confirmed by checking staff records.

The premises were clean, bright and easily accessible. There was ample parking at the surgery and we noted an assistance call system in place for those wishing to enter the building with mobility problems.

We noted that the professional registration for GPs and nurses was current.