Pelham Medical Practice

Updated 25 October 2017

Pelham Medical Practice is located in a residential area of Gravesend, Kent and provides primary medical services to approximately 14000 patients.

The practice is based in a large Victorian house and there is an independent pharmacy attached to the surgery. The practice is not purpose built, but does have access for wheelchair users and disabled facilities. There is a car park for patient use.

There are four male GP partners at the practice and three female salaried GPs. The practice is registered as a GP training practice, for doctors seeking to become fully qualified GPs.

There are five female members of the nursing team; four practice nurses and a health care assistant (HCA). The practice also employs a female phlebotomist. GPs and nurses are supported by a practice manager and two surgery managers and a team of reception/administration staff.

The practice is open between 8.00am and 6.30pm Monday to Friday. Appointments are from 8.30am to 12.00pm every morning and 3.00pm to 6.30pm daily. Extended hours appointments are offered between 6.30pm and 8.00pm on Tuesday, Wednesday and Thursday. The practice is closed between 12.30pm and 1.30pm every day except Wednesday when it is closed from 12.30pm to 1.15pm. The phones are answered during this time. In addition to pre-bookable appointments up to six weeks in advance, urgent appointments are also available for people that need them.

The practice has a higher than average percentage of children from 0 to 19 years and is in an area of high deprivation. There are a significant number of people in the area who do not have English as their first language, with a large number of Polish and Punjabi speaking people.

The practice runs a number of services for its patients including; chronic disease management, new patient checks, minor surgery, family planning, anti-coagulation monitoring and immunisations. It also offers a free acupuncture service and a sleep apnoea clinic.

Services are provided from 17 Pelham Road, Gravesend, Kent, DA11 0HN and from St Gregory’s Medical Practice, 116 St Gregory’s Crescent, Gravesend, Kent, DA12 4JW, which is a branch surgery. The branch surgery was not inspected.

Updated 25 October 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pelham Medical Practice on 30 March 2016. The overall rating for the practice was requires improvement. The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Pelham Medical Practice on our website at www.cqc.org.uk.

We carried out an announced focused inspection on 4 January 2017 to see whether the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified on 30 March 2016. Although the practice had made some improvements these were not sufficient. Therefore we found a breach of legal requirements

and the practice was rated requires improvement overall. The practice was rated inadequate for providing well-led services, requires improvement for safe and effective services and good for providing caring and responsive services.

Following this inspection we issued a warning notice in relation to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014: Regulation 17, Good Governance, which stated that the practice must comply with the legal requirements in relation to the following:

• Ensure that safety alerts including those from the Medicines and Healthcare Products Regulatory Agency (MHRA) in relation to monitoring and managing safety in primary medical services were received and made available to relevant staff.
• Ensure embedded systems to prevent, detect and control the spread of infections, to patients and staff.
• Ensure the proper and safe management of medicines and their disposal when of out of date.
• Implement a system to ensure that staff members were trained, including safeguarding training at the appropriate level.
• Ensure a system and process for the timely sharing of patient information particularly in relation to a backlog of scanning at the practice.

This inspection was an announced focused inspection carried out on 3 May 2017 to confirm that the practice had carried out their plans to meet the legal requirements in relation to the breaches in regulations identified in the warning notice issued following our previous inspection on 4 January 2017. This report covers our findings only in relation to the requirements of the warning notice and will not result in reviewing the overall rating or the ratings of any individual key question or population group.

Our key findings at this inspection, 3 May 2017, were as follows:

• The practice had devised a new system to manage national patient safety alerts. They were able to demonstrate that alerts were being discussed at clinical meetings and that action was being taken in relation to receipt of alerts.

• Infection control audits had been carried out and there was evidence of action being taken where issues were highlighted.
• Medicines were managed safely and the expiry dates were subject to on-going audit.
• The practice were able to demonstrate that there was a system for identifying and implementing staff training. The practice were working with the Clinical Commissioning Group (CCG) to identify role and person specific training requirements. Safeguarding training had been carried out at the appropriate level.
• A new scanning protocol had been introduced. The practice was able to demonstrate that the process for receiving patient information and scanning this onto the patient record was carried out in a timely way.

We carried out an announced comprehensive inspection at Pelham Medical Practice on 12 September 2017. Overall the practice is now rated as good.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said that there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

• Continue to work to improve patient satisfaction, as reflected in the GP patient survey results.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 25 October 2017

At our previous inspection the practice was rated as requires improvement for the care of people with long-term conditions. The practice is now rated as good for the care of people with long-term conditions.

• GPs and nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.
• The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) was 140/80 mmHg or less was 64% compared with the clinical commissioning group and national average of 78%. This is considered to be comparable to other practices.
• The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.
• There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.
• The practice had a system for monitoring repeat prescribing for patients with long term conditions. For example, blood results were attached to prescriptions sent to the GPs for signing prior to disease modifying anti-rheumatic drugs (DMARD) being re-prescribed.
• All these patients had a named GP and there was a system to recall patients for 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 25 October 2017

At our previous inspection the practice was rated as requires improvement for the care of families, children and young people. The practice is now rated as good for the care of families, children and young people.

• We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk.

• Immunisation rates were relatively high for all standard childhood immunisations.
• Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• Baby and child clinics were held weekly and led by a GP and followed up with a nurse appointment if required.
• The practice provided post-natal checks and child health surveillance clinics.

Updated 25 October 2017

At our previous inspection the practice was rated as requires improvement for the care of older people. The practice is now rated as good for the care of older people.

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
• The practice offered proactive, personalised care to meet the needs of the older patients in its population.
• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
• The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.
• The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.
• Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible.
• The practice worked with Age UK to support older people. Where an older patient had two hospital admissions within a six month period a referral could be made to a key worker and a befriending scheme.

Updated 25 October 2017

At our previous inspection the practice was rated as requires improvement for the care of working age people (including those recently retired and students). The practice is now rated as good for the care of working age people (including those recently retired and students).

• The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended hour appointments were available on Tuesday at the branch surgery and Tuesday and Thursday at Pelham Medical Practice.
• 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.
• The practice used a text message service to remind patients of their appointments.

Updated 25 October 2017

At our previous inspection the practice was rated as requires improvement for the care of people experiencing poor mental health (including people with dementia). The practice is now rated as good for the care of people experiencing poor mental health (including people with dementia).

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

• 93% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is higher that the CCG and national average of 84%.
• The practice specifically considered the physical health needs of patients with poor mental health and dementia.
• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive, agreed care plan documented in the record, in the preceding 12 months was 77% compared to the CCG and national average of 89%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
• Patients at risk of dementia were identified and offered an assessment.
• The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.
• Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.

Updated 25 October 2017

At our previous inspection the practice was rated as requires improvement for the care people whose circumstances may make them vulnerable. The practice is now rated as good for the care of people whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
• The practice provided care and treatment for the residents of number of care homes for people living with a learning disability.
• Patients with learning disabilities were flagged on the IT system so that the appropriate level of care and length of appointment time could be offered.
• Annual reviews were carried out for patients with a learning disability and care plans which demonstrated updates to care and treatment were seen.
• The practice offered longer appointments for patients with a learning disability.
• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations. For example, an information leaflet devised by the patient participation group was available to patients.
• Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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.