We visited the provider's headquarters to look at records and meet with the registered manager and four staff members. Following this we visited the Head Office location where a cardiology clinic was being held on the afternoon of our inspection.

We spoke with two people who were attending appointments at the cardiology clinic. We also spoke with two people's relatives. People told us that they were happy with the information that they had received during their appointment. One person said, "They were very informative and have put my mind at ease." Another person said, "We were given the information that we needed."

People told us that they were provided with information about their appointments and where they were being held. One person said, "I thought I would have had to go to the hospital, but I was happy to come here as it is much closer to home." Another person showed us their appointment letter which included the time and address of their appointment.

People said that they were not kept waiting for their appointment. One person said, "We were seen straight away." Another person said, "I came in early and thought I would have to wait, but they called me straight in."

We found that staff were provided with the training that they needed to meet the needs of the people who used the service. The provider had an effective system to regularly assess and monitor the quality of service that people received.

This service is rated as Requires improvement overall. (Previous inspection October 2013, the provider was compliant with the regulations but was not rated at this inspection.)

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

• We carried out an announced comprehensive inspection at the Suffolk GP Federation C.I.C. as part of our inspection programme on 21, 22, and 29 January 2019. Suffolk GP Federation C.I.C is a community interest company and is the registered provider of three other locations and services are provided from various sites across Suffolk and North East Essex. Suffolk GP Federation C.I.C. holds contracts with Ipswich and East Suffolk, West Suffolk and North-East Essex Clinical Commissioning Groups (CCGs).

At this inspection we found:

• The Suffolk GP Federation C.I.C was a clinically led organisation and leaders had the capacity and skills to deliver high-quality, sustainable care. We found at senior level the leadership was clear, organised and proactive but this did not always ensure that the leadership at local levels was effective for example we identified risks to patients at the minor injuries unit.
• We found the records of some patients seen at the minor injuries unit did not contain sufficient detail to evidence that patients had been fully assessed. The management team took immediate action and reviewed the records, contacted patients as appropriate and told us they would implement new systems to address this issue.
• The service had systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes. The service used various ways to communicate with both regular and sessional staff such as regular emails, newsletter and electronic notifications and staff were responsible for reading communications issued to them. However, not all staff we spoke with during our inspection were aware of the learning shared.
• We found the service had systems and processes to manage risks to patients but not all of these were fully known or understood by staff working in the local sites where services were delivered. For example, not all staff working at the various locations we inspected were clear about the IPC process and their responsibilities.
• Although the provider had risked assessed the provision of emergency medicines to ensure they were easily available to staff in the event of a medical emergency, the medicines in stock were not in line with the current guidelines and the mitigation of risk for some medicines was insufficient to ensure patients would receive emergency treatment in a timely manner. The Suffolk GP Federation C.I.C. reviewed their assessment immediately and updated to provide additional medicines.
• The emergency department streaming service provided care and treatment within service guidelines and timescales. The provider worked closely with emergency department partners to continually evaluate and improve the service, including effective safety protocols in place to manage patients who needed to be referred back into the emergency department.
• The GP+ service provided patients with timely access to evidence based care and treatment based on their needs. Staff felt well supported and there was good cross site working to effectively manage capacity and demand.
• The service routinely reviewed the effectiveness and appropriateness of the care it provided; however, we found in the minor injuries unit these reviews did not always address issues in the way care and treatment was recorded.
• We found that staff were knowledgeable about their service but the provider did not have clear and easy oversight that all staff were competent to do their role. We found in some areas such as the minor injuries unit and the cardiology clinic there was a lack of oversight to be assured that all staff had been fully assessed as competent to do their roles.
• Staff involved and treated people with compassion, kindness, dignity and respect.
• Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
• Patients we spoke with and the results from the friends and family test gave positive feedback about the care and treatment they had received.
• There was a strong focus on continuous learning and improvement at all levels of the organisation. We saw examples of clinical and non- clinical staff having access to further development including leadership programmes.

We saw areas of outstanding practice:

• In October 2018, the north-east Essex diabetes services (NEEDS) had won a national award in recognition of its clinical excellence at the recent Quality in Care Diabetes award, winning the category for the best adult diabetes education programme. The Suffolk GP Federation C.I.C was also highly commended in the ‘Best Practice and Sustainability’ category for their integrated approach which had improved patient outcomes. The provider continuously and proactively monitored the diabetic service they offered. Regular reports and audits were shared with the North Essex CCG who confirmed they had no concerns about the high level of service offered. Regular audits had been completed such as the number of patients completing the patient education programmes and the monitoring of patients’ blood test results. The CCG analysed the progress of the diabetes quality and outcome (QOF) indicators for the North-East Essex practices comparing 2015/2016 data to 2016/2017 data. This concluded an improvement was seen in eight of the ten QOF indicators. The service saw an average of 1000 patients per month through the year January to December 2018.
• The falls and fragility service is a small service offered by specialist’s nurses in the community. It was set up six years ago to ensure patients across West Suffolk had equitable access to advice and support. The service gave patients a personalised service with a long term aim to reduce fractures in the age group of over 60 years old. CCG data showed that from April 2018 to November 2018 the service had seen 332 patients. Nationally published data showed that as a result of their approach and follow up the patients they saw were more compliant with their medicines with an 80% compliance compared with the national average of 32%.

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.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice