This practice is rated as Good overall. At the previous inspection in November 2017 the practice were rated as requires improvement overall; they were rated as requires improvement for providing safe and responsive services and good for effective, caring and well-led services.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? - Good

We carried out an announced comprehensive inspection at Theatre Royal Surgery on 30 October 2018 to follow up on breaches of regulations.

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.
• At the previous inspection, the practice did not have effective risk assessments in place relating to fire or legionella. We observed at this inspection the practice had taken action in relation to this.
• 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 invited relevant practitioners such as palliative care specialists, district nurses and social care practitioners to quarterly training meetings at the practice to enhance collaborative working.
• Childhood immunisation uptake rates were above the target percentage of 90% or above with a range of 97% to 98%.
• The most recent published Quality Outcome Framework (QOF) results were 100% of the total number of points available compared with the CCG average of 98% and national average of 96%.
• The practice proactively identified carers and supported them. The practice had identified 571 carers and provided support to them. This was approximately 6.4% of the practice population.
• The practices GP patient survey 2018 results were below local and national averages for all questions relating to access to care and treatment.
• Patients continued to express their dissatisfaction in relation to accessing the practice.
• The practice had created a ‘Who to see at Theatre Royal Surgery’ help sheet for patients. The help sheet identified a number of conditions and highlighted which clinician in the practice would be suitable to see.
• The practice had a virtual patient participation group, however at the time of out inspection this was not active.
• Staff we spoke with stated they felt respected, supported and valued. They were proud to work in the practice and felt well supported by the practice management team.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

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 and feedback from patients during the inspection.
• Continue to develop engagement with patients, such as through a Patient Participation Group.

Professor Steve Field CBE FRCP FFPH FRCGPChief 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

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

Letter from the Chief Inspector of General Practice

Theatre Royal Surgery has a practice population of approximately 9300 patients.

We carried out a comprehensive inspection at Theatre Royal Surgery on 12 November 2014.

We have rated each section of our findings for each key area. The practice provided a safe, effective, caring, responsive and well led service for the population it served. The overall rating was good and this was because the practice staff consistently provided good standards of care for patients.

Our key findings were as follows:

• Practice staff worked together as a team to ensure patients received the standards of care they needed.

• There were safe systems in place for ensuring patients received appropriate treatments and prescribed medicines were regularly reviewed to check they were still needed.

• Patients were protected against the unnecessary risks of infections because staff adhered to appropriate hygiene practices and regular checks were carried out.

• The practice was able to demonstrate a good track record for safety. Effective systems were in place for reporting safety incidents. Untoward incidents were investigated and where possible improvements made to prevent similar occurrences.

• Patients were treated with respect and their privacy was maintained. Patients informed us they were very satisfied with the care they received and the access to the practice. The feedback we received from patients was without exception positive.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

The practice had policies in place for activities that helped to promote patients' human rights, dignity and independence. For example, we read the policy on assistance dogs, the chaperone policy and the 'patient dignity and respect' policy. Patients and their relatives told us that they were informed about treatments and tests. They also said that they were involved in decisions about their care. One patient told us that their usual GP "...makes sure I understand. They're very good that way."

The representative of the Patient Participation Group (PPG) told us that access to routine appointments had been patients' major concern in the 2013-2014 survey. However, responses had indicated that there was a high degree of satisfaction with the practice. One patient said "I've never had any problems." Two patients explained that they were pleased that the practice offered late appointments. They told us that this meant that they could attend the surgery without taking time off work.

The practice had made reasonable adjustments to meet patients' needs. The premises were accessible to patients with mobility problems. The building was fitted with electronic entrance doors and all public areas were on the ground floor.

The practice assessed the quality of its services. For example, significant events were discussed at practice training days so that staff could use them as a means of improving their work and the quality of the service provided.