We carried out an announced comprehensive inspection at Sudbury Primary Care Centre (also known as Sudbury Surgery) on 2 November 2017. The overall rating for the practice was Requires Improvement. The full comprehensive report on the 2 November 2017 inspection can be found by selecting the ‘all reports’ link for Sudbury Primary Care Centre on our website at www.cqc.org.uk.

This inspection, on 13 December 2018, was an announced comprehensive inspection to confirm that the practice had carried out their plan to meet the requirements that we identified in our previous inspection on 2 November 2017.

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 good overall and good for all population groups.

We found that:

• The practice had been proactive and addressed all the findings of our previous inspection.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice organised and delivered services to meet patients’ needs.
• The way the practice was led and managed promoted the delivery of high-quality, person-centre care.

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

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

Letter from the Chief Inspector of General Practice

This practice is rated as requires improvement overall.

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The provider was rated as requires improvement for safe, effective and well-led. The issues identified as requiring improvement overall affected all patients in all population groups. However, there was evidence of some good practice.

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 Sudbury Primary Care Centre (also known as Sudbury Surgery) on 2 November 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns. However, the practice could not demonstrate that all staff were trained in safeguarding children to a level appropriate to their role.
• The systems for managing medicines, including vaccines, medical gases, and emergency medicines and equipment minimised risks. However, the practice did not have a process in place to monitor the use of prescription pads for controlled drugs.
• There was an effective system to manage infection prevention and control.
• The practice had 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. There was a system for receiving and acting on safety alerts.
• We found that some patient outcomes were below expectations compared with similar services and antibiotic prescribing was significantly higher than the national average.
• The practice ensured that care and treatment was delivered according to evidence-based guidelines.
• Staff had the skills, knowledge and experience to carry out their roles.
• Staff involved and treated patients with compassion, kindness, dignity and respect.
• Results of the national GP patient survey, comments cards we received and patients we spoke with showed patients felt they were treated with compassion, dignity and respect and were involved in decisions about their care and treatment.
• The practice team told us their aim was to provide high quality care and good patient outcomes. However, there was no supporting written strategy or business plan to support this.
• There was a leadership structure and staff felt supported by corporate management and the principal GPs.

The areas where the provider must make improvements as they are in breach of regulations are:

• 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.

The areas where the provider should make improvements are:

• Review the NICE Guidelines NG51: Sepsis Recognition, Diagnosis and Early Management to ensure the practice can appropriately assess all patients, including children, with suspected sepsis.
• Record the immunisation status for employees involved in direct patient care in line with guidance.
• Consider including the long-term locum GPs and practice nurses in the appraisal programme.
• Review the requirements of the Accessible Information Standard.
• Review how patients with caring responsibilities are identified and recorded on the clinical system to ensure information, advice and support is made available to all carers registered with the practice.
• Review how practice opening times, including access to the surgery by telephone, are advertised to patients to ensure they are consistent and in line with contractual requirements.
• Consider recording verbal complaints to enable all patient feedback to be captured and any trends identified.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice