Glebe Surgery

Updated 5 October 2023

Glebe Surgery is located in Storrington, West Sussex at:

The Glebe

Storrington

Pulborough

RH20 4FR

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

The practice is situated within the NHS Sussex Integrated Care System (ICS) and delivers General Medical Services (GMS). This is part of a contract held with NHS England. There are approximately 13,300 registered patients.

The practice is part of a wider network of local GP practices who work collaboratively to provide primary care services.

Information published by Office for Health Improvement and Disparities 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 98% White, 1% Mixed, 0.8% Asian, 0.2% Black.

There are 9 GPs (6 GP partners and 3 salaried GPs), 1 advanced nurse practitioner, 4 practice nurses, 5 health care assistants and a team of reception/administration staff. The practice manager and business manager provide managerial oversight.

The practice is open Monday to Friday 8.30am to 6.30pm. The telephone lines were also open from 8am to 8.30am for emergencies. The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

Evening and weekend appointments were also offered through the GP access hub. These were held at Glebe Surgery as well as other practices in the local area. Out of hours services are provided by 111.

Updated 5 October 2023

We carried out an announced comprehensive inspection at Glebe Surgery from 11 July 2023 to 13 July 2023. Overall, the practice is rated as good.

Safe - good

Effective - good

Caring - good

Responsive - good

Well-led - good

We carried out an announced comprehensive inspection of Glebe Surgery in August 2022. At this inspection the practice was rated inadequate and placed in special measures. We issued two warning notices against Regulation 12 (Safe care and treatment) and Regulation 17 (Good governance) because the quality of the care they were responsible for, fell below what is legally required.

This inspection in July 2023 was a comprehensive inspection to check the practice has made sufficient progress to improve. We also followed up on the warning notices. We found the practice had addressed all of our concerns and made significant improvements. The provider was compliant with the two warning notices and the rating has moved from inadequate to good.

The full comprehensive report and reports for previous inspections can be found by selecting the ‘all reports’ link for Glebe Surgery on our website at www.cqc.org.uk.

Why we carried out this inspection

This inspection was carried out to confirm whether the provider continued to meet the legal requirements of regulations and to ensure enough improvements had been made in the areas identified at previous inspections.

The focus of our inspection included:

• All key questions
• To follow up on breaches of regulation 12 (safe care and treatment) and 17 (good governance)
• Areas we said the provider should improve;
  -Take action to address the fire risk assessment by creating a documented action plan.
  -Improve the uptake of cervical screening.
  -Improve the systems for the identification of carers and ensure the information available allows carers to self-identify, to ensure all carers are provided with support.

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 on site and 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 staff questionnaire.
• A site visit.

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:

• The provider had made improvements and had fully addressed all the areas of concern raised by our last inspections.
• Risks to patients, staff and visitors were assessed, monitored and managed effectively. This included child and adult safeguarding processes, staffing including recruitment and supervision, medicines management, health and safety, and information governance.
• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff treated patients with kindness and respect and involved them in decisions about their care.
• Patients could access care and treatment in a timely way.
• The way the practice was led and managed promoted the delivery of high-quality, person-centred care.
• Staff told us they were happy with the level of support and communication provided by their management team.
• The practice encouraged staff development and gave staff the opportunities to further their career.
• The provider was fully engaged and committed to completing and embedding improvement actions. Governance systems and processes were improving, evolving, and embedding.

Whilst we found no breaches of regulations, the provider should:

• Review systems and processes to improve uptake of cervical screening.
• Provide formal training to non-clinical staff on sepsis and serious infection.

I am taking this service out of special measures. This recognises the significant improvements that have been made to the quality of care provided by this service.

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 Health Care