Archived: Apple Tree Medical Practice

Updated 4 February 2016

Apple Tree Medical Practice is situated in the village of Burton Joyce in the Gedling district of Nottinghamshire. The practice is in a renovated and extended property which was purposely refurbished to provide primary care medical services and has housed the practice since 2000.

The practice is run by a partnership of two part-time GPs (one male and one female), who also employ three part-time female salaried GPs, and two part-time practice nurses. The clinical team is supported by a practice manager and a team of eight administrative, secretarial and reception staff.

The practice also dispenses medications to approximately 450 of its registered patients. This service is only available for patients who reside a mile or more from a local pharmacy. Three members of the reception team provide input into the dispensing service.

Patients reside predominantly within Burton Joyce and the surrounding villages of Lowdham and Lambley. The registered practice population of 3,471 are predominantly of white British background, and are ranked in the lowest 10% level of deprivation across England. The practice age profile demonstrates higher percentages of patients over the age of 40 in comparison to England averages, and this is more significantly defined for patients over the age of 60. For example, the percentage of patients aged 65 and over is 28.8% compared to the England practice average of 16.7%. There are lower percentages of children and younger adults registered at the practice in comparison to England as a whole due to the local demographics.

The practice opens from 8.30am until 1pm in the morning, and from 2pm to 6.30pm Monday to Fridays, apart from Thursday afternoons when the surgery is closed. GP morning appointments times are available from 8.30am (a doctor is on call between 8 and 8.30am) and the session runs until approximately 11.30am, although this can run later dependent on the number of urgent appointments required to be seen. Afternoon GP surgeries run from 3pm, the last scheduled appointment varies each day, the latest being at 5.10pm. The GP will continue to see any patients requesting a later appointment or an emergency appointment after this time until the practice closes. When the practice is closed patients are directed to Nottinghamshire Medical Services (NEMS) via the 111 service.

The practice holds a Personal Medical Services (PMS) contract to provide GP services which is commissioned by NHS England. A PMS contract is one between GPs and NHS England to offer local flexibility compared to the nationally negotiated General Medical Services (GMS) contract by offering variation in the range of services which may be provided by the practice and the financial arrangements for those services. The practice also offered some enhanced services commissioned by the CCG including minor surgery and anti-coagulation.

Updated 4 February 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Apple Tree Medical Practice on 2 December 2015. Overall the practice is 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 an effective system in place for the reporting and recording of significant events. People affected received support and an apology where this was appropriate.

• Feedback from patients about their care was consistently positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• Risks to patients were assessed and well managed with involvement from the wider multi-disciplinary team and external agencies.
• Clinical outcomes were good and the practice had achieved 99.8% of the total for the Quality and Outcome Framework (QOF) in 2014.15, with an overall exception reporting rate of 8.8% (consistent with national and local average percentages).
• Urgent appointments were available on the day they were requested. Access to routine appointments could be difficult with waiting times between three to six weeks observed on the day of our visit. The practice were undertaking a review of their appointment system to increase the availability of non-urgent appointments.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. This was kept under review by the practice which used audit as a mechanism of ensuring that patients received safe and effective care.
• Staff had the skills, knowledge and experience to deliver effective care and treatment. Staff undertook training appropriate to their roles, and had received an annual appraisal with any further training needs identified and supported by the practice.

• Information about services and how to complain was available and easy to understand.
• There was a clear leadership structure and staff felt supported by management.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example, a self check-in system had been installed in response to comments about lengthy waits at reception.
• The practice had a dedicated carers’ champion to help support the identified carers of patients registered with the practice.
• The practice worked with other local practices and engaged with their Clinical Commissioning Group (CCG) to improve services.
• Disabled access was restricted in terms of access to the main entrance and the main reception desk. The practice were in the process of reviewing this issue.

The areas where the provider should make improvement are:

• Improve the availability of non-urgent appointments for patients.

• Review disability access to the site in accordance with the requirements of the Equality Act

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 4 February 2016

The practice is rated as good for the care of people with long-term conditions.

• GP partners had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

• All long term condition patients had a structured annual review (sometimes more frequently subject to each patient’s own needs) to check that their health and medicines 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.

• In 2014-15, the practice achieved 100% of its Quality and Outcomes Framework (QOF) targets for long term condition indicators including asthma, diabetes, chronic obstructive pulmonary disease and hypertension. Its overall exception reporting was in line with local and national averages.

• The practice achievement within some clinical indicators demonstrated high exception reporting. For example, the percentage of patients newly diagnosed with diabetes in the preceding year that had a record of being referred to a structured education programme within nine months achieved 100%, but with an exception reporting figure of 46.2%. This was over 40% higher than local and national averages for exception reporting on this particular indicator. The practice were able to explain this by saying that patients had been offered the programme but had chosen not to attend. However, other indicators demonstrated a low exception reporting rate, for example, with regards to patients with asthma

• A diabetes nurse specialist attended the practice on a monthly basis to provide initiation of insulin (teaching patients how to inject and manage their insulin regime) for type 2 diabetes ( type 2 diabetes occurs when the body does not respond to the hormone insulin as it should)

• Longer appointments and home visits were available when needed to accommodate more complex needs.

Updated 4 February 2016

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. Multi-disciplinary team meetings were held including GPs, health visitors and school nurses to monitor the needs of vulnerable children.

• Antenatal care was shared between midwives and the GPs. An antenatal pack had been developed for patients providing advice on matters such as screening and calcium supplements. It also contained literature including some leaflets specifically designed by the practice. This pack had won a practice development award with a previous healthcare commissioner organisation.

• All new mothers were contacted in the immediate postnatal period and reviewed by a telephone call, with the offer of a home visit or an appointment at the surgery  where appropriate with the doctor. A home visit was offered for all first born children.  

• Immunisation rates were relatively high for all standard childhood immunisations for children aged 12 months and five years. Rates for those aged two years were slightly lower.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and this was evidenced within the comments cards.

• Same day appointments were always available for children. Routine appointments were available outside of school hours and the premises were suitable for children and babies.

• The practice provided contraception services and the GPs fitted intra-uterine devices (coils) as part of a family planning service available to patients.

• Cervical screening rates were high at 87.6% compared locally with a figure of 86.2% and a national average of 81.88%

Updated 4 February 2016

The practice is rated as good for the care of older people.

• The age profile of patients at the practice was higher for older people, and the practice had the highest percentage of older patients across the 21 practices within the CCG. The services available reflected the needs of this group.

• It was responsive to the needs of older people and undertook home visits when this was applicable. Longer appointments were available although some patients with multiple long term conditions were reviewed over two to three appointments, to ensure there was sufficient time allocated to review each presenting problem. Urgent appointments were available for those presenting with enhanced needs.

• The practice had identified a named GP for all patients aged 75 and over.

• A medicine dispensing service was available at the practice for those who lived more than one mile from a pharmacy.

• Older patients with multiple health issues received an annual (or more frequent if required) medicines review to re-assess their condition and ensure the medicines remained suitable for their needs.

• The practice provided care to some older patients residing in three local care homes. The manager of one of the homes told us that the GPs were very responsive to their needs and would visit as required and also re-assess patients as part of a medication review. The manager told us that the GPs took account of mental capacity assessments and treated their residents with dignity and respect.

• Seasonal flu vaccinations for patients aged over 65 demonstrated an uptake of 80.81% compared against a national average of 73.24%

• Established links between the practice and a consultant for older patients provided an expert opinion when this was required. The consultant undertook some home visits for the practice’s patients to assess their needs.

• The practice proactively used electronic systems to identify vulnerable patients at risk of unplanned hospital admissions, and developed care plans to ensure they were supported to stay in their own homes.

• Any older patients who had been in hospital had their discharge summaries reviewed within three days, and any medicines changes were updated. Incoming correspondence relating to hospital discharges were flagged as a priority to ensure rapid follow up was arranged.

• Patients who were at risk of falling were identified and where necessary referred for further tests or commenced on appropriate medicines.

• A named carer was identified where this was appropriate. The carer then received appropriate information on support services as well as linking into the practice’s identified carers’ champion.

Updated 4 February 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

• The practice had attempted to adjust the services it offered to improve access to routine appointments, but there were no extended opening hours available for working people.

• Urgent appointments were available on the day.

• Telephone calls could be booked to consult with the doctor.

• The practice was proactive in offering online services to book appointments or order repeat prescriptions.

• It offered a full range of health promotion and screening that reflects the needs for this age group. This included the promotion of health checks for 40-75 year olds, smoking cessation support and advice on weight management.

Updated 4 February 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

• 79% of people diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months. This was 8.3% below the CCG and 4.5% below the England averages. However, exception reporting for this indicator was very low at 2.2%, which was over 6% below CCG and national averages.
• Achievements for mental health indicators was 100%. However, there were high exception reporting rates across the seven indicators measured in this clinical domain. For example, the practice achieved 100% of patients with schizophrenia, bipolar disorder and other psychoses having a comprehensive and agreed care plan documented in their records in the preceding 12 months. However, exception reporting was 46.2% which was 27.6% above the CCG and 33.6% above the England averages.

• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

• The practice actively promoted the Improving Access to Psychological Therapies (IAPT) programme offering psychological therapies for conditions including depression and anxiety.

• It had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• The practice organised a successful awareness and advice event in May 2015 as part of the national dementia week. A dementia outreach worker attended the event.

• The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. The practice was a dementia-friendly practice and all practice staff were signed up to become dementia friends. The practice had also involved their PPG in raising awareness of dementia.

• It carried out advance care planning for patients with dementia.

• An audit had commenced on the reappraisal of long-term anti-psychotic medications for patients with dementia. This will be completed and reviewed as a full cycle audit next year.

• The practice had developed their own dementia carers leaflet

Updated 4 February 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

• The practice worked with multi-disciplinary teams in the case management of vulnerable people. Adult safeguarding was incorporated into the monthly multi-disciplinary meetings held at the practice.

• All staff had received training in adult and child safeguarding and knew how to recognise any signs of potential abuse. 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.

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability. It carried out annual health checks for people with a learning disability, although the practice only had two patients on their register.

• The reception team had received some training to help them understand the needs of patients with a learning disability.

• Leaflets for female patients with a learning disability were available to provide information on cervical screening

• It had told vulnerable patients and their carers about how to access various support groups and voluntary organisations.

• Patients who were newly diagnosed with cancer were contacted by telephone and invited in for a consultation and cancer care review.

• The practice had a detailed palliative care check-list incorporating all aspects of required care, for example, special notes, anticipatory medications, and discussions on end of life wishes. GPs and nurses participated in monthly Gold Standards Framework meetings

• A wide variety of information was displayed within the waiting area to help provide information and signpost to support services for vulnerable patients and their carers.

• The practice had developed a resource leaflet for staff providing information on local and national cancer and bereavement services, providing a comprehensive overview of available support.