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Care Quality Commission

The Care Quality Commission (CQC) monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and publish what they find, including performance ratings to help people choose care.

They ask 5 key questions of all the care services they inspect:

Are they safe?

Safe: you are protected from abuse and avoidable harm.

Are they effective?

Effective: your care, treatment and support achieves good outcomes, helps you to maintain quality of life and is based on the best available evidence.

Are they caring?

Caring: staff involve and treat you with compassion, kindness, dignity and respect.

Are they responsive to people's needs?

Responsive: services are organised so that they meet your needs.

Are they well-led?

Well-led: the leadership, management and governance of the organisation make sure it's providing high-quality care that's based around your individual needs, that it encourages learning and innovation, and that it promotes an open and fair culture.  

Theatre Royal Surgery was inspected on Tuesday 28th November 2017 and awarded a requires improvement rating for the services we provide.

Theatre Royal Surgery CQC Report - Nov 2017

Please see a statement from the Partner’s below in response to our CQC Inspection November 2017:

Obviously we are very disappointed with the outcome of our recent Care Quality Commission (CQC) report as we do not feel that this accurately reflects the service we offer or the hard work of the staff at the practice.

We are pleased that in the areas of effective, caring and well-led we were rated as good. CQC recognised that staff treated patients with compassion, kindness, dignity and respect and that the practice had a strong focus on continuous learning and improvement at all levels of the organisation. CQC also highlighted one area of outstanding practice, the walking group set up for patients with diabetes to improve health outcomes such as lowering blood pressure and increasing physical activity.

CQC highlighted two areas that need improvement. So what have we been doing to address these areas?

1) The practice needs to continue to assess and ensure improvement to patient satisfaction relating to access to appointments as seen in the national GP patient survey results.

The report highlighted that the practice “has a larger number of patients aged 65 to 85 compared to the national average”, we also have an above average number of care homes. Historically our 9000 patients had 5.25 Full Time Equivalent (FTE) GP’s but in recent years this has steadily decreased and since November 2016 we have 2.75 FTE GP’s for the same number of patients. Our list size per GP is almost TWICE the national average.

It has proved impossible to recruit and retain salaried doctors, therefore we decided to employ other health professionals such as our Emergency Care Practitioner (ECP) and in June 2017 we also employed our Minor Illness Nurse, which has greatly improved patients access to a healthcare professional. Between the two practitioners they are both able to offer on the day and pre-bookable appointments. We have, since the CQC visit, also added additional GP appointments and same day appointments to increase the overall access to a healthcare professional.

In October we were fortunate enough to recruit Dr Pettigrew who is available to work a couple of sessions per week and Dr Sarah Stevens continues to offer locum cover as and when. We have also managed to recruit a new salaried GP, Dr Krupa Patel, who started on the 18th December 2017 working three days per week to replace one of our GP’s who has now moved to Australia.

Despite our access issues we are proud to see our excellent ratings to provide a caring and effective service in the context of such a high patient list size.

2) The practice did not have effective risk assessments in place relating to fire or legionella and needs to assess the risks to the health and safety of service users and staff

Immediately following the inspection we sourced a company to complete a fire risk assessment and a legionella risk assessment. We have also put in place regular checks for water temperature and a system to annually update our fire risk assessments.

Dr Marinus Rosbergen

Senior Partner & CQC Lead

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