Coltishall Medical Practice

Updated 29 March 2022

Coltishall Medical Practice is located at: St John’s Close, Rectory Road, Coltishall, Norwich, Norfolk, NR12 7HA. There is a dispensary at the Coltishall site, and we inspected this as part of our inspection.

The practice has a branch surgery at: 20, St Peter’s way, Spixworth, Norwich, Norfolk. NR10 3NS. This site was not visited as part of this inspection.

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

The practice offers services from both a main practice and a branch surgery. Patients can access services at either surgery.

The practice is situated within the NHS Norfolk & Waveney Clinical Commissioning Group (CCG) and delivers General Medical Services (GMS) to a patient population of approximately 8,787. This is part of a contract held with NHS England.

The practice has four GP partners (three male, one female) and four salaried GPs (one male and three female). There is an advanced nurse practitioner, three practice nurses, two health care assistants (assistant practitioners) and a phlebotomist. The practice also employs a business manager, practice manager, an IT & Data Quality Manager, a reception manager, a dispensary manager and a team of reception, administration and dispensary staff as well as secretaries and medical summarisers and coders.

The practice main site at Coltishall is open from 8am to 6.30pm Monday to Friday. Extended hours appointments (for pre-booked GP telephone appointments) are available between 6.30pm to 7.15pm Monday to Friday. In addition, appointments with assistant practitioners are available between 7.15am to 8am on alternate Wednesdays and Fridays. The branch site at Spixworth is open between 8am and 5pm Monday to Friday, closing every day between 1pm and 1.30pm for lunch. The dispensary opening hours are Monday to Friday from 8.30am and 6pm.

The practice was a training (for qualified doctors training to become GPs) and teaching practice (for medical students). The practice had reduced capacity to support trainees and medical students during the pandemic and to allow capacity to focus on driving improvements identified in previous inspections. The practice currently has one GP trainee but had not restarted teaching for medical students.

According to Public Health England, the patient population had a lower number of patients aged 0 to 40 and a higher number of patients aged 45 and over in comparison to the practice average across England. It had a higher proportion of patients aged 60 to 74 compared to the practice average across England. Income deprivation affecting children and older people was lower than the practice average in the area and across England.

Extended access is provided locally at the Improved Access Hub managed by North Norfolk Primary Care, where late evening and weekend appointments are available at one of the four Primary Care Network (PCN) practices. Patients are able to access these appointments at any one of the locations on each day. The service is hosted at the Spixworth branch surgery every fourth Tuesday and Thursday of the month from 6.30pm to 8.30pm and every fourth Saturday of the month from 9am to 1pm. Out of hours services are provided by Integrated Care 24.

Updated 29 March 2022

We carried out an announced focused inspection at Coltishall Medical Practice on 1 and 9 March 2022. Overall, the practice is rated as Good.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

Following our previous focused inspection on 5 May 2021 the practice was rated as requires improvement overall and for providing safe and well-led services. We did not inspect caring or responsive services.

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

This inspection was a focused inspection to follow up on:

• The key questions inspected: are services safe, effective and well-led.
• Any breaches of regulations and areas we identified where the provider should make improvements identified in the previous inspection.

During this inspection we also considered the management of access to appointments.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with all data protection and information governance requirements.

This included

• Conducting staff interviews using video conferencing
• Completing clinical searches on the practice’s patient records system and discussing findings with the provider
• Reviewing patient records to identify issues and clarify actions taken by the provider
• Requesting evidence from the provider
• A short site visit

We undertook this inspection at the same time as CQC inspected a range of urgent and emergency care services in Norfolk and Waveney. To understand the experience of GP providers and people who use GP services, we asked a range of questions in relation to urgent and emergency care. The responses we received have been used to inform and support system wide feedback.

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 have rated this practice as Good overall and Good for providing Safe, Effective, and Well-led services.

We found that:

• The practice had undertaken DBS checks for all staff.
• Formal and comprehensive risk assessments had been undertaken when required, for example in relation to the safe storage and management of medicines in the dispensary.
• Record keeping for the safe management of medicines storage had been improved.
• Standard operating procedures (SOPs) had been amended and acknowledged by staff.
• Evidence provided demonstrated systems and protocols for significant and learning events had been strengthened and embedded.
• Patients received effective care and treatment that met their needs.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• Governance structures had been strengthened and there were clear responsibilities, roles and systems of accountability to support good governance and management.
• There was evidence to demonstrate the new partnership had continued to develop and improve the service.
• The practice demonstrated a cohesive approach to the use of developed systems and processes. Staff remained positive about working at the practice and the improvements made.

In addition, we found the provider should:

• Continue to monitor, develop and drive forward the improvement plan, ensuring regular monitoring of improvement to ensure they are safe and effective.

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

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care