Pulborough Medical Group

Updated 17 March 2017

Pulborough Medical Group is situated in the small town of Pulborough, in West Sussex. The practice serves approximately 13,000 patients living in the town and surrounding areas.

There are six GP partners and four salaried GPs. Five of the GPs are male and five are female. There is a practice manager who is a managing partner and an advanced practitioner nurse who is also a partner. The practice also employs five practice nurses and two health care assistants. There is a finance team leader, a patient services manager and a team of secretarial, administrative and reception staff. The practice is a training practice and provides placements for student nurses and trainee GPs.

Data available to the Care Quality Commission (CQC) shows the practice serves a higher than the local and national average number of patients over the age of 65. The proportion of patients with a long standing health condition is 68% which is above the local and national average. Income deprivation is relatively low for both children and older people. The population is largely rural and there are small areas of significant deprivation. The ethnicity of the practice population is largely white British.

The practice is open from 7am until 6.30pm on Monday, Tuesday and Friday. On Wednesday and Thursday it is open from 8am until 6.30pm. Appointments can be booked over the phone, on line or in person at the surgery. When the practice is closed, patients are advised on how to access the out of hour’s service on the practice website, the practice leaflet or by calling the practice. Out of hours calls are handled by an out of hours' provider (Care UK).

The practice provides a wide range of NHS services and clinics for its patients including minor surgery and vasectomy services, a nurse led minor injuries service, asthma, diabetes, cervical smears, childhood immunisations, travel immunisations, family planning and new patient checks. It is a yellow fever vaccination centre. The practice is located in a primary care health centre which hosts a variety of other health care services and specialist clinics including community nursing, psychiatry, dermatology, ear nose and throat, aortic aneurysm screening, audiology, speech and language therapy, osteopathy, podiatry, counselling and physiotherapy. A welfare and benefits advice clinic is provided monthly by the Citizens Advice Bureau.

The practice provides services from the following location:-

Pulborough Primary Care Centre

Spiro Close

Pulborough

West Sussex

RH20 1FG

Updated 17 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pulborough Medical Group on 5 January 2017. Overall the practice is rated as outstanding

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• The practice used innovative and proactive methods to improve patient outcomes. For example as a result of a review of venous leg ulcer management the practice was able to demonstrate a significant improvement in healing rates
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Feedback from patients about their care was consistently positive.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had worked proactively with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs. As a result of this work patients had access to a wide range of services including mental health services, specialist dermatology, ear nose and throat, podiatry, audiology physiotherapy and citizens advice.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group, Pulborough Patient Link group (PPL). For example, as a result of feedback from the PPL the practice had installed additional phone lines and increased the number of call centre staff.
• The practice had strong and visible clinical and managerial leadership and governance arrangements. The partnership included the practice manager and the advanced nurse practitioner. The practice had a clear vision to deliver health care in a flexible and innovative way to meet patient choice and to improve access to services for its largely elderly, rurally based population. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed.
• The provider was aware of and complied with the requirements of the duty of candour.

We saw several areas of outstanding practice

• The practice had taken the lead on working with other organisations and its patient participation group to ensure services were more accessible to its predominantly elderly, rurally based population and also to those who were vulnerable or suffering deprivation. By providing providers with space and facilities the practice had significantly increased the range and frequency of services available to its patients within its premises so that patients did not have to travel. As a result of the practice’s proactive approach to providers, services had expanded over the years to include consultant led mental health services, counselling, cognitive behavioural therapy, hearing aid provision, ear, nose and throat services, podiatry, alcohol and drug addiction support, consultant paediatrics and citizens advice.
• The practice had been proactive in ensuring that the mental health needs of its patients were met. It had identified that 35% of its work was mental health related and that these patients had to travel outside the area to receive the specialist help they required.In recognition of the fact that travel for these patients could be challenging the practice sought to provide a better option. The practice approached the local community trust and worked with them to establish a ‘mental health hub’ at the primary care centre and ensure that a counselling service for patients was provided on a daily basis. Following the success with this, the practice was asked to extend this service all patients in West Sussex to support the wider rural area
• The practice used innovative and proactive methods to improve patient outcomes. After identifying that demand for leg ulcer management clinics was increasing and that healing rates were declining the practice undertook a review of venous leg ulcer management. This led to the introduction of a new protocol and integrated approach which included the establishment of a specialist leg ulcer clinic. This was run by a practice nurse who had been especially recruited by the practice and supported by them to train as a specialist in compression and wound management. The practice had also invested in specialist equipment to aid assessment and diagnosis. As a result the practice was able to show that healing rates had increased from 60% in 2014 to 85% in 2016.
• The practice had identified 532 patients as carers (About 4% of the practice list). Written information was available to direct carers to the various avenues of support available to them. There was a dedicated page on the practice’s website providing information and advice for carers.

The areas where the provider should make improvement are:

• Review exception reporting rates for the quality and outcomes framework and ensure appropriate action is taken to reduce rates where they are above the local and average.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 17 March 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
• One of the practice nurses specialised in diabetes and met weekly with the GP lead for diabetes to discuss care plans for patients.
• A diabetes specialist nurse from the local hospital held a monthly clinic on site with the practice nurse for patients with more complex needs. There was input also from a specialist diabetes dietician.
• The practice held regular pre-diabetes clinics for patient identified at risk of developing the disease.
• Practice performance against indicators for the management of long term conditions was comparable the local and national averages. For example the percentage of patients on the diabetes register, in whom the last blood pressure reading (measured in the preceding 12 months) was 140/80 mmHg or less was 82% compared to the clinical commissioning group (CCG) average of 79% and the national average of 78%.
• The percentage of patients with chronic obstructive pulmonary disease (COPD) who had had a review undertaken by a healthcare professional, including an assessment of breathlessness, in the preceding 12 months was 92% compared to the CCG average of 88% and the national average of 90%.
• The practice held regular clinics for patients with respiratory disease. Combined clinics were held for patients with more than one long term condition to avoid them having to attend multiple appointments.
• Longer appointments and home visits were available when needed.
• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named practice worked with relevant health and care professionals to deliver a multi-disciplinary package of care.

Updated 17 March 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.
• The practice provided a comprehensive family planning service which included the fitting of implants and coils.
• The number of women aged between 25 and 64 who attended cervical screening in 2015/2016 was 81% compared to the CCG average of 84% and the national average of 82%.
• The practice ensured that children under five were seen straight away and the duty doctor was informed immediately of their arrival.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• Fortnightly midwife clinics were held in the primary care centre which helped facilitate good communication between them and the GPs.
• The paediatric lead GP had regular meetings with the health visitor to discuss children and families of concern. The health visitor often attended the practice’s weekly multi-disciplinary meeting.
• Case conferences to discuss families and children of concern were held at the practice and the GPs attended.
• The health visiting team was also based in the primary care centre which helped the GPs maintain close links with the service.
• The practice had received an award from the clinical commissioning group as part of an improvement programme for practices providing primary care services to children, young people, their families and carers. This was in recognition of the work they had undertaken to develop a dedicated page on their website for children and young people, patient engagement, refreshed child safeguarding policies and procedures, a training video for non-clinical staff and the development of a care template for sick children.

Updated 17 March 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

• As part of the clinical commissioning group’s (CCG) ‘pro-active care’ initiative the practice identified and registered older patients at high risk of hospital admission. They worked with multi-disciplinary teams to develop care plans for these patients so that unnecessary and unplanned hospital admissions were avoided.
• There were weekly multidisciplinary meetings to discuss and review these patients. Care plans were reviewed every three months and were shared with the ambulance service and out of hour’s providers.
• The ‘pro-active care’ team and the community nursing team were based in the same primary care centre as the practice which enabled good communication about patients being cared for.
• The practice provided care to older patients who lived in care homes and nursing homes within the locality. The GPs carried out regular reviews of the care being provided to these patients and had regular meetings with the homes’ managers.
• All patients over the age of 75 had a named GP. Each named GP worked with a group of GP worked in a group of GPs within the practice to provide and ensure continuity of care for patients who were unable to see their named GP.
• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

Updated 17 March 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
• Extended access appointments from 7am until 8 am were available three days a week. This included practice nurse, phlebotomy and GP appointments.
• Patients could contact the practice via phone, email or fax.
• The practice was pro-active in offering online services which included on line appointment booking and the ordering of repeat prescriptions.
• It provided a full range of health promotion and screening that reflected the needs for this age group.
• The practice enabled students returning from university in the holidays to be registered a temporary resident for that period.

Updated 17 March 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. Comprehensive care plans were put in place and updated annually.
• 95% of patients with a severe and enduring mental health problem had a comprehensive, agreed care plan documented in the record, in the preceding 12 months compared to the clinical commissioning group (CCG) average of 82% and the national average of 89%.
• 82% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was comparable to the CCG average of 81% and the national average of 84%.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• In recognition of the fact that travel for these patients could be challenging the practice had led discussions with local trusts to ensure that a wide range of mental health services were available for patients at the primary care centre. This included consultant led psychiatry, a daily counselling service, cognitive behavioural therapy and addiction and alcohol counselling.
• The GPs were able to communicate directly about patients with consultant psychiatrists who held clinics at the primary care centre.
• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 17 March 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

• The practice offered longer appointments for patients with a learning disability and those with more complex needs.
• There were weekly multi-disciplinary meetings at the practice where vulnerable patients were identified and discussed.
• The practice was a centre for distribution of food-bank vouchers. This helped ensure its vulnerable patients could access essential resources.
• The practice had approached the Citizens Advice Bureau and now provided them with space and facilities for a monthly clinic so that patients received advice on benefits, housing debt management, law and citizens’ rights
• The practice provided financial support for a subsidised community transport scheme which enabled patients who would have difficulties doing so, to get to the primary care centre and the local hospitals to attend appointments.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.