Coulby Medical Practice

Updated 13 December 2017

Coulby Medical Practice, Middlesbrough, TS8 0TL, is situated on a housing estate on the outskirts of Middlesbrough and provides services under a General Medical Services (GMS) contract with NHS England, Durham, Darlington And Tees Area Team to the practice population of 8268, covering patients of all ages. The proportion of the practice population in the 65 years and over age group is slightly higher than the England average. The practice population in the under 18 age group is slightly higher than the England average. The practice scored five on the deprivation measurement scale which goes from one to ten, one being the lowest decile. People living in more deprived areas tend to have greater need for health services. The overall practice deprivation score is slightly higher than the England average, the practice is 25.3 and the England average is 23.6. The practice has four GP partners, three female and one male and a salaried female GP. There are two part time practice managers who job share, three part-time nurse practitioners, two practice nurses, one health care assistant and a phlebotomist. The practice has an administration manager, a reception manager and a team of secretarial, administration and reception staff. When the practice is closed patients use the NHS 111 service to contact the OOHs provider. The Out of Hours service is provided by ELM Alliance Limited as part of a GP federation. Information for patients requiring urgent medical attention out of hours is available in the waiting area, in the practice information leaflet and on the practice website. The practice is open between 8.30am to 6.00pm Monday to Friday, telephone lines are available from 8.00am. Appointments are from 9.00am to 5.30pm daily. The practice website can be accessed at https://coulbynewham.gpsurgery.net/

Updated 13 December 2017

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection August 2015– 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

The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Coulby Medical Practice on 1 November 2017. This was as part of our inspection programme.

At this inspection we found:

• The practice had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the practice learned from them and improved their processes.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

• Staff involved and treated people with compassion, kindness, dignity and respect.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

• The practice implemented service developments using input from clinicians to understand their impact on the quality of care.

• The information used to monitor performance and the delivery of care was accurate and useful. There were plans to address any identified weakness.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 12 November 2015

The practice is rated as good for the care of people with long-term conditions (LTCs). Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. Longer appointments and home visits were available when needed. All these patients had a named GP and a structured annual review to check that their health and medication needs were being met. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

There was a dedicated telephone line that patients with LTCs and other vulnerable patients could use to access advice and care quickly.

Updated 12 November 2015

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 had a high number of A&E attendances. The practice offered comprehensive vaccination programmes which were managed effectively. Immunisation rates were relatively high for all standard childhood immunisations. The practice monitored any non-attendance of babies and children at vaccination clinics and worked with the health visiting service to follow up any concerns.

The practice held quarterly meetings where they discussed all the children who had complex physical needs. This was attended by the practice staff and the health visitors.

Appointments were available outside of school hours and the premises were suitable for children and babies. We saw good examples of joint working with midwives, health visitors and school nurses. There was a midwife clinic held at the practice and patients’ care was shared between the midwife and GPs.

Updated 12 November 2015

The practice is rated as good for the care of older people. The practice was knowledgeable about the number and health needs of older patients using the service and actively reviewed the care and treatment needs of these patients. Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. Patients over the age of 75 had a named GP. The practice was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs.

Updated 12 November 2015

The practice is rated as good for the care of working-age people (including those recently retired and students). The needs of this population group 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 provided a range of options for patients to consult with the GPs and nurses. The practice was proactive in offering online services. Useful information was available in the practice and on the website as well as a full range of health promotion and screening that reflected the needs for this age group.

Updated 12 November 2015

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia). The practice maintained a register of patients who experienced mental health problems including dementia. The register supported clinical staff to offer patients an annual appointment for a health check and a medicines review. Data for 2013/2014 showed 79.6% of patients diagnosed with dementia had received a face to face review in the previous 12 months; this was 1.5% above the local CCG and 1.7% above the national average.

The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. Information was available for patients on counselling services and support groups. An in house counselling service was available for patients suffering from depression and a weekly alcohol support service.

Updated 12 November 2015

The practice is rated as good for the care of people whose circumstances may make them vulnerable. The practice held a register where necessary, of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability. The practice offered these patients longer appointments. We found that all of the staff had a very good understanding of what services were available within their catchment area, such as supported living services, care homes and families with carer responsibilities.

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. They had access to the practices’ policy and procedures and discussed vulnerable patients at the clinical meetings.