The Pulteney Practice

Updated 9 March 2017

The Pulteney Practice is a GP practice serving mainly the Bath and Bathampton area, that has good local public transport links. One practice is in Great Pulteney Street near the centre of Bath and a branch surgery is a short distance away in the village of Bathampton. The inspection focused on the main Great Pulteney Street location and the branch site was not visited. The addresses are:

The Pulteney Street Surgery

35 Great Pulteney Street

Bath BA2 4BY

Bathampton Surgery

29 Holcombe Lane

Bathampton

Bath BA2 6UL

The practice supports approximately 11,500 patients who are able to attend either surgery. There is a lower than average younger patient population (under 20 years old) and a higher than average older patient population (65 years of age and over; and especially 85 years of age over). There are very few patients in nursing or residential homes; and the practice sees a relatively high numbers of tourists and other temporary residents including canal boat dwellers.

The practice offers a range of services including childhood and pneumococcal immunisations, health screening, travel clinics, asthma and diabetes advice and extended hours access. The main practice occupies several floors of a Grade I listed building, which it shares with a separate pharmacy business. Access is via stone steps from the pavement to a ground floor waiting area and reception. There is one ground floor consulting room available for disabled access. The practice has no access to a disabled toilet or a lift. There is no car parking available at the main site, however, the branch surgery has a separate car park and occupies a single story building with full disabled access and toilet facilities. The branch site is shared with another pharmacy and a dental practice.

The practice has eleven GPs, comprising 5 partner GPs, 5 salaried GPs and 1 locum GP providing 7.12 WTE (whole time equivalent) doctors. Five GPs are male and six are female. There is a team of eight nursing staff, comprising a nurse practitioner, 5 practice nurses, a research nurse and phlebotomist, providing 5.26 WTE staff. One of the nursing team is male and all others are female. The clinical staff are supported by a practice manager and an administrative team.

The practice is in the BANES area (Bath and North East Somerset) Local Authority and Clinical Commissioning Group (CCG). The practice had a Personal Medical Services (PMS) contract with NHS England (a locally agreed contract negotiated between NHS England and the practice).

The Pulteney Street practice is open Monday to Friday from 8.15am to 6pm with extended hours on Tuesday from 6pm to 8pm and every Saturday morning 9am to 12noon (for pre bookable appointments). The Bathampton practice is open Monday to Friday from 8.15am to 5.30pm closing earlier on Fridays at 2pm. The practice has opted out of providing Out of Hours services to their own patients. When the surgeries are closed patients are directed, via NHS 111 to clinical services from the Out of Hours provider or to 999 for life threatening emergencies, via answerphone message.

The practice undertakes clinical research studies as part of the local BARONET group of practices.

The practice had previously been inspected by Care Quality Commission in November 2013 and was judged as having met the standards at that time. At that inspection some areas were identified for the practice to follow up. These included infection control and access for the disabled.

Updated 9 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of The Pulteney Practice on 19 January 2016. We did not inspect the branch surgery at Bathampton (address: 29 Holcombe Lane, Bathampton, Bath BA2 6UL). During this inspection an overall rating of good was made, with the effective, caring and well led areas all being rated as good and the responsive domain as outstanding. Following the inspection we issued a requirement notice. The notice was issued due to a breach of Regulation 12 of The Health and Social Care Act (Regulated Activity) Regulations 2014, relating to safe care and treatment.

The issues were:

• The provider must ensure all appropriate emergency medicines were available, and stored for easy access. Regular checks were required to confirm these medicines were in date and what were safe to use.

• The provider must ensure that all medicines in the GP’s home visit bags and the controlled drugs held at the practice were in date and were accounted for.
• The provider must ensure out of date medicines are disposed of appropriately, in line with guidance from the Royal Pharmaceutical Society.
• The provider must ensure that requirements for the management of prescription paper security are met at all times.
• The provider must ensure that they reviewed and updated the practice fire evacuation procedures, maintain an appropriate frequency of fire alarm testing and fire drills, and update fire safety documentation appropriately.

In addition the provider should:

• Ensure that spill kits are available to deal with breakages so that guidelines on the cleaning of hazardous substances and samples are met.
• Assess its compliance with the Equality Act 2010, with respect to disabled access to the premises and any deficiencies should be addressed where possible.

The full comprehensive report on the 19 January 2016 inspection can be found by selecting the ‘all reports’ link for The Pulteney Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 24 January 2017 to confirm that the practice had carried out their action plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 19 January 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection. Overall the practice is now rated as good.

Our key findings across all the areas we inspected during this inspection, were as follows:

• We saw that the practice had policies in place for the storage of medicines, including controlled drugs and for checking emergency drugs in the practice. All appropriate emergency medicines and equipment were present, including emergency medicines for the management of diabetic conditions and also for some heart conditions. We found that all medicines in the GP home visit bag were accounted for, in date and safe to use.

• When we spoke to the practice they informed us that controlled drugs were no longer kept on site and showed us records to confirm that. All out of date medicines were disposed of appropriately, in line with guidance from the Royal Pharmaceutical Society.

• We saw evidence that prescription paper security was safely managed.
• We saw evidence that the provider had reviewed fire evacuation procedures, including updating information on fire alarm testing and records of fire drills.

Our findings regarding actions that the provider should take as a result of our last inspection were as follows:

• We saw that spill kits were available to deal with breakages so that guidelines on the cleaning of hazardous substances and samples were met, with up to date records.
• The provider had carried out an assessment of its compliance with the Equality Act 2010, with respect to disabled access to the premises and addressed deficiencies regarding access. This included assessing the premises for safe evacuation in the event of a fire from the first floor building.

Following this inspection the practice was rated overall as good across all domains.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 11 May 2016

The practice is rated as good for the care of people with long-term conditions.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

• The treatment of patients with diabetes was comparable to that provided by other practices.

• 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 GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 11 May 2016

The practice is rated as good for the care of families, children and young people.

• 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 were at risk of domestic violence or had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.

• 82% of patients diagnosed with asthma, on the register, had had an asthma review in the last 12 months, compared to a Clinical Commissioning Group (CCG) average of 78% and a national average of 75%.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

• 85% of eligible female patients had had a cervical screening test performed in the last 5 years compared to a Clinical Commissioning Group (CCG) average of 83% and a national average of 77%.

• Appointments were available outside of school hours and the premises were suitable for children and babies.

• We saw positive examples of joint working with midwives and health visitors.

Updated 11 May 2016

The practice is rated as outstanding for the care of older people.

• The practice offered proactive, personalised care to meet the needs of the older people in its population. We saw that the practice supported older people to remain independent in their own homes, with very few older patients in care or residential homes.

• The practice was responsive to the needs of older people, with proactive monitoring, communication and holistic support; including home visits and urgent appointments for those with enhanced needs.

• The practice had a higher than average population of older patients and provided effective services to support them, coordinated with other organisations. These included the Hale & Hearty scheme and a Social Prescribing Champion. Consistently positive feedback was seen from patients supported by these initiatives.

• GPs, supported by personal assistants, were pro-active in identifying and supporting ‘off-radar’ patients; avoiding unplanned hospital admissions; and supporting discharge.

• Pro-active, coordinated and holistic care was evident from multi-disciplinary team meetings.

Updated 11 May 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

• 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.

• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

• Extended hours were available for patients that were unable to attend the practice during working hours.

Updated 11 May 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

• 89% of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive agreed care plan documented in the record in the preceding 12 months, compared to the Clinical Commissioning Group (CCG) average of 87% and a national average of 88%.

• The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia.

• The practice carried out advance care planning for patients with dementia.

• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• Staff had a good understanding of how to support patients with mental health needs and dementia. The Blue Triangle scheme was used for dementia screening and these patients were supported by a medicines champion. Consistently positive feedback was seen from patients supported by these initiatives.

Updated 11 May 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

• The practice was actively supporting groups of patients whose circumstances may make them vulnerable. These included very transient patients and those at risk of domestic violence.

• The practice held a register of patients living in vulnerable circumstances temporary residents, transient patients, homeless people, and those with a learning disability.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.

• 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.