Debenham Group Practice

Updated 19 December 2022

Debenham Group Practice is located at:

20 Low Road

Debenham

Stowmarket

Suffolk

IP14 6QU

The practice has branch surgeries at:

Chapel Road

Otley

Ipswich

Suffolk

IP6 9NT

20 Charles Avenue

Grundisburgh

Woodbridge

Suffolk

IP13 6TH

The practice has a dispensary at all 3 sites. We did not inspect the branch sites as part of this inspection.

The provider is registered with CQC to deliver the Regulated Activities; diagnostic and screening procedures, maternity and midwifery services, treatment of disease, disorder or injury, family planning and surgical procedures These are delivered from all sites.

The practice is situated within the Suffolk and North East Essex Integrated Care System (ICS) and delivers Personal Medical Services (PMS) to a patient population of about 9,200 patients. This is part of a contract held with NHS England.

The practice is part of a wider network of GP practices called East Suffolk Primary Care Network.

Information published by Public Health England shows that deprivation within the practice population group is in the second highest decile (9 of 10). The lower the decile, the more deprived the practice population is relative to others.

According to the latest available data, the ethnic make-up of the practice area is 05% Asian, 98.3% White, 0.2% Black, 0.9% Mixed, and 0.1% Other.

The age distribution of the practice population shows there is a higher number of older people and a lower number of younger people.

There is a team of 8 GPs (4 partners, 3 salaried GP’s and a GP Retainer) who provide cover at all 3 practices. The practice has a team of 3 nurses, 1 apprentice nurse associate and 3 health care assistants who provide nurse led clinics for long-term conditions, using both the main and the branch locations. The GPs are supported at the practice by a team of reception/administration/dispensary staff. Through the PCN, they share 3 paramedics within the locality group and have access to a central clinical pharmacy team. The business manager and operations manager are based at the main location to provide managerial oversight.

The practice is open between 8.00am to 6.30pm Monday to Friday. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Extended access is provided locally by GP+ (Suffolk GP Federation), where late evening and weekend appointments are available. Out of hours services are provided by Suffolk GP Federation.

Updated 19 December 2022

We carried out an announced comprehensive inspection at Debenham Group Practice on 18 October 2022. Overall, the practice is rated as Good.

Safe - Good

Effective - Good

Caring - Good

Responsive - Good

Well-led - Outstanding

When this service registered with us, it inherited the regulatory history and ratings of its predecessor. This is the first inspection of Debenham Group Practice under the registered provider Suffolk Primary Care who became the provider from April 2020. Following our previous inspection and under the previous provider, the practice was rated as good overall. Suffolk Primary Care is a partnership of 9 GP surgeries covering a population of 115,000 patients across Suffolk. We inspected 8 of the 9 practices within a period of four weeks.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for Debenham Group Practice on our website at www.cqc.org.uk

Why we carried out this inspection

We carried out this comprehensive inspection to provide a rating of the location under the new provider and in line with our inspection priorities.

How we carried out the inspection

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site.

This included:

• Conducting staff interviews using video conferencing.
• Completing clinical searches on the practice’s patient records system (this was with consent from the provider and in line with all data protection and information governance requirements).
• Reviewing patient records to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• A short site visit.
• Staff questionnaires.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We found that:

Suffolk Primary Care is a partnership of 9 GP surgeries covering a population of 115,000 patients across Suffolk. There are 28 GP partners and around 500 staff working across the practices. Whilst each practice retains oversight of their demographics and patients’ needs and priorities, there is a centralised head office which provides a single governance structure with clear engagement from all partners. There are key roles such as a management board consisting of a chair, medical directors, business director and finance directors. In addition, there are other teams such as an executive team with delegated decision-making authorisations, information governance and Information Technology (IT), human resources (HR), finance, research, estates, procurement, complaints and governance. There are clinical and administration teams who manage patient safety alerts and the quality audit programme. In addition, there are various manager and lead roles including head of operations, website management and business intelligence. Many of the centralised functions support the practices with surges of demand such as medicines management and background services such as patient recall for patients with long term conditions.

There are several functions that are centrally carried out by the provider (SPC) for the practices. These include maintenance of human resources (HR), estates and equipment, risk assessments and safety. Management of the various teams such as the pharmacy team which consisted of pharmacists and pharmacy technicians (some of these are also based in the individual practice) and physiotherapists. The provider and practice demonstrated clear and cohesive joint working and sharing of resources in particularly different staff skill mix including clinical and non-clinical staff.

Within the Suffolk Primary Care (SPC) organisation there were 10 approved GP trainers and a further 6 associate trainers. Across the practices there was support and teaching/supervision and oversight for the employed clinical staff such as non-medical prescribers as well as GP registrars, foundation year doctors and medical students.

We found;

• There was compassionate, inclusive and effective leadership at all levels. Leaders at all levels demonstrated the high levels of experience, capacity and capability needed to deliver excellent and sustainable care. There was a deeply embedded system of leadership development and succession planning, which aimed to ensure that the leadership was comprehensive and included successful leadership strategies to ensure and sustain delivery and to develop the desired culture. Leaders had a deep understanding of issues, challenges and priorities in their service, and beyond.
• The strategy and supporting objectives and plans were in place at provider level and at practice level. They were stretching, challenging and innovative, while remaining achievable.
• There was strong collaboration, team-working and support across all functions and a common focus on improving the quality and sustainability of care and people’s experiences.
• Governance arrangements were proactively reviewed and reflected best practice. A systematic approach was taken to working with the other practices within the group, the local primary care network and the provider to improve care outcomes.
• There was a demonstrated commitment to best practice performance and risk management systems and processes. The provider and practice reviewed how they functioned and ensured that staff at all levels had the skills and knowledge to manage those systems and processes effectively. Problems were identified and addressed quickly and openly.
• The service invested in innovative and best practice information systems and processes. The information used in reporting, performance management and delivering quality care was consistently found to be accurate, valid, reliable, timely and relevant. There was a demonstrated commitment at all levels to sharing data and information proactively to drive and support internal decision making as well as system-wide working and improvement.
• There were consistently high levels of constructive engagement with staff and people who use services, including all equality groups.
• There was a fully embedded and systematic approach to improvement, which made consistent use of a recognised improvement methodology. Improvement was seen as the way to deal with performance issues and for the organisation to learn. Improvement methods and skills were available and used across the organisation, and staff were empowered to lead and deliver change.
• The provider had been informed they had been short listed for a national award given by the Health and Safety Journal in the patient safety category. The nomination was in relation to the significant work the provider and practice had undertaken in the monitoring and management of medicines, including patient safety alerts and high-risk medicines. They told us they were very proud of becoming a finalist and planned a celebration with the staff.

Whilst we found no breaches of regulations. The provider should:

• Continue to monitor and further improve the systems and processes in place for safe prescribing of medicines including those relating to structured medicines reviews.
• Continue to monitor the recovery of backlog improvement plan already in place so that patients requiring follow up or annual reviews are seen in a timely way. This should include improving the uptake of the national childhood immunisation programme.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Sean O’Kelly BSc MB ChB MSc DCH FRCA

Chief Inspector of Hospitals and Interim Chief Inspector of Primary Medical Services