Archived: Rosebank Surgery

Updated 22 January 2015

Rosebank Surgery operates from three sites. The first, Scale Hall, is in the north of the city. The second is in Galgate, three miles south of the city. The final is the main surgery, Rosebank, opposite the Royal Lancaster Infirmary. All three sites have been purpose-built and have access and facilities for disabled patients and visitors. It provides a weekday service for 10,820 patients in the North Lancashire area and is part of NHS Lancashire North Clinical Commissioning Group. 

Public Health England figures show that 31% of all patients at Rosebank Surgery are 65 years of age or over and the largest percentage of the practice population, 63.2%, are of working status either paid work or in full-time education.

Each practice site opens Monday to Friday from 8am with the exception of Scale Hall which opens at 08.30am. Galgate and Scale Hall sites close at 6pm and Rosebank at 6.30pm each weekday with the exception of the Scale Hall site which closes at 12.30pm on Wednesdays. The practice operates a system based upon "Advanced Access." To enable patients to see a member of the clinical team (this can be either a Nurse Practitioner or Support Pharmacist) within 24 hours and see a GP within 48hrs. When the practice is closed and in the out of hours (OOH) periods patients are requested to contact either the ambulance service for emergencies or telephone 111. The OOH service is operated by Bay Urgent Care.

The practice has nine GP partners, five male and four female, one Nurse Practitioner (NP) partner, a trainee NP, three Practice Nurses, a Healthcare Assistant and a phlebotomist. The practice staff team includes a research nurse, pharmacy manager, pharmacy technician and dispensing staff. The practice also has a practice director and deputy practice manager and all are supported by administration, reception and secretarial staff.

Rosebank Galgate site is situated in the rural village of Galgate and is a dispensing practice. They have dispensed from Galgate for over 25 years to meet the needs of their registered patients. They opened a pharmacy in January 2013 on site, to help extend services to their patients and local community.

The practice use the same locum GP, when required, for continuity of service and support for their patients. The majority of the GP partners who work at the practice have their professional details available for patients to read on the practice website. Clinics run by the practice include amongst others; child development, minor surgery, long term condition management which  includes a wide range of conditions, for example; diabetes, heart disease and hypertension (high blood pressure) and travel clinics.

The practice is registered with Care Quality Commission to provide the regulated activities: Treatment of disease, disorder and injury, diagnostic and screening procedures, family planning, maternity and midwifery services and surgical procedures.

Updated 22 January 2015

Letter from the Chief Inspector of General Practice

Rosebank Surgery operates from three sites. The first, Scale Hall, is in the north of the city. The second is in Galgate, three miles south of the city. The final is the main surgery, Rosebank, opposite the Royal Lancaster Infirmary. We visited Rosebank-Lancaster and Rosebank-Galgate sites as part of our inspection on 01 October 2014. 

We inspected this practice as part of our new focused, comprehensive, inspection programme. This practice had not been inspected before. We looked at how well the practice provided services for specific groups of patients. These included; older patients, patients with long-term conditions, families, children and young people, working age patients (including those recently retired and students), patients living in vulnerable circumstances and patients experiencing poor mental health (including people with dementia).

During our visit we spoke with staff including GPs, receptionists, administration staff, nurses, the dispensing pharmacy staff and with five patients who used the service. Patients spoken with and the 30 completed Care Quality Commission comment cards from the three sites were all extremely complimentary about the care and treatment being provided. Patients reported that all staff treated them with dignity and respect. They found the doctors and nurses delivered a very personalised service and had an excellent understanding of their needs.

We found that the leadership team was very visible. There were good governance and risk management measures in place. We found that the practice met the regulations and provided services that were caring, responsive, safe, well led and effective.

The overall rating for this practice was good.

Our key findings were as follows:

• The practice provided an effective service for all age groups. GPs, apart from having the overall competence to assess each person attending the service, had particular interest areas. For example one GP is the Cardiology Lead for the local Clinical Commissioning Group (CCG) and helps run the Community Heart Failure Service. Care and treatment was being delivered in line with current published best practice.

• The practice had systems in place that reflected best practice in end of life care and demonstrated an ethos of caring and striving to achieve a dignified death for patients. This was actively supported by practice staff and local community initiatives.
• We found that clinicians critically reviewed their practices and this had led to not only changes in their own working practice but also that of other organisations.
• Patients confirmed they were able to contact the practice and speak with a health practitioner and found the service provided was both timely and accessible. The practice operated an all-day triage system for appointment requests. Patients spoke positively about the system.  All the patients we spoke with confirmed they would be offered a same day appointment if there was an urgent need.

We saw several areas of outstanding practice including:

• One of the GP partners was appointed as the National Clinical Lead in palliative care by the Royal College of General Practitioners. The GP led a three year national programme working to improve end of life care in primary settings. The practice had systems in place that reflected best practice in this regard and demonstrated an ethos of caring and striving to achieve dignified death for patients. We were told and audits demonstrated that in appropriate cases patients were ‘offered’ conversations around end of life planning such as advance care plans, preferred care priorities and resuscitation but such discussions were never ‘imposed.'

• One GP partner is the Cardiology Lead for the local Clinical Commissioning Group and helps run the Community Heart Failure Service with remote support for their cardiac patients. This enabled patients to remain in the comfort of their own home whilst receiving appropriate monitoring of their condition.
• Staff were consistent in supporting patients to live healthier lives through a targeted and proactive approach to health promotion and the prevention of ill-health. There was for example a nurse led five year development plan in place with clear strategic vision. This included a nurse led initiative reviewing all patients at potential risk of the development of diabetes. The nurses invited patients to attend the practice in October 2014 as a group, for an education and health promotion event to improve the health of their registered population, of all ages.
• The practice had a clear vision and overall strategy regarding the practice and its development. We saw evidence that showed the practice worked with the CCG to share information, monitor performance and implement new methods of working to meet the needs of local people. There was evidence of a good learning culture and appropriate information sharing of significant events.
• The practice’s rural community dispensary and practice also provided the addition of a pharmacy in response to meeting the needs of their local community.

However, there were also areas of practice where the provider should make improvements. 

The provider should:

• Record the recruitment checks they had completed on staffs professional registration details as is appropriate.The practice was unable to provide evidence of some of the recruitment checks they had completed. The recruitment records did not always include all the information as specified in Schedule 3 of the Health and Social Care Act (2008) for the purposes of carrying on a regulated activity.
• Improve the arrangements for the reauthorisation of prescriptions for patients on medicines requiring regular blood tests.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 22 January 2015

The practice was knowledgeable about the number and overall health needs of patients with long term conditions. They worked with other health services and agencies to provide appropriate support. Public Health England found that 57.8% of the practice patients had a long-standing health condition.

We saw that clinical audits were completed and where appropriate, any actions following the findings implemented and reviewed. As an example, in November 2013 they completed an audit of hypertension diagnosis to see if the practice was complying with the 2011 National Institute for Health and Care Excellence (NICE) Hypertension guidelines and making appropriate use of the ambulatory blood pressure monitoring machines available. They found that 66% was reasonable compliance with use of ambulatory or home readings before making a diagnosis of hypertension but was short of the audit standard of 85%, they found that the diagnostics were readily available with short waiting times and not doing either should be an unusual exception. They put in place five learning points for staff to consider and implement following the audit which were implemented following the review.

Staff were skilled in specialist areas which helped them ensure best practice guidance was always being followed. There was a nurse led initiative reviewing all patients at potential risk of the development of diabetes. The nurses invited patients to attend the practice as a group for an education and health promotion event to improve the health of their registered population of all ages.

Updated 22 January 2015

The practice provided services to meet the needs of this population group. There were comprehensive screening and vaccination programmes which were managed effectively to support patients. 

We saw that an audit was conducted into paediatric referral ‘zero’ length of stay between 01 Jan-31 March 2013 of 0-16 year olds admitted to the Paediatric Admission Unit (PAU). PAU-Zero hours refers to patients admitted for six hours or less. Of those 20 admissions, 17 demonstrated appropriate use of the service and three of the 17 had direct access to ward. The remaining admission findings were that one attended via the out of hour’s service and the other via A&E. 

We saw that the cervical smear uptake percentage was at 82% and that for chlamydia screening the practice advertised the service at the three sites and took opportunity to encourage 15-25 year olds to consider this screening. 

There was literature available signposting patients to healthy activity programmes at the local YMCA, nearby drop in clinics for children and cancer care therapeutic groups for children aged 9 to 11 years who had experienced bereavement. 

Staff were knowledgeable about child protection and a named GP took the lead for safeguarding. 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.

Updated 22 January 2015

The practice was knowledgeable about the number and health needs of older patients using the service. They kept up to date registers of patients’ health conditions, carers’ information and whether patients were housebound. They used this information to provide services in the most appropriate way and in a timely manner. We found the practice worked well with other agencies and health providers to provide support and access specialist help when needed. 0.578% of the patients registered at the practice resided in nursing homes which the GPs attended.

There was a high percentage of patients aged 65 and older who had received a seasonal flu vaccination. They had a practice plan to reduce avoidable A&E attendance in all groups which included older people. An audit took place October 2012 and the action taken since the audit included: from January 2014 all day telephone triage, a phlebotomist was employed, increased pharmacy practitioner hours and an additional nurse practitioner employee. An audit of afternoon triage during the month of June 2014 demonstrated that 210 calls were received, eight of which the practice believed to have prevented an A&E attendance. A shingles audit was completed in 2014 for 70-79 age groups and they achieved respectively an 83% and 84% take up rate.

The practice had a complete register available of all patients in need of palliative care or support irrespective of age. The practice had regular monthly supportive care meetings to discuss all the patients on the palliative register. Following the inspection we requested the most recent audit on patients preferred choices around end of life planning such as advance care plans, preferred care priorities and resuscitation.  The findings from the audit conducted in July 2014 and reported in November 2014. demonstrated best practice with 98% of patients who should be on the palliative care register on the register. They found that 85% of patient’s had their preferred place of care documented. Of patients who sadly died 81% died outside of a hospital environment. All patients who died outside of the hospital setting had advanced directives regarding resuscitation in place. The practice devised actions to implement further improvements following this audit which included changing the palliative care register to that of a Supportive Care register to encourage further identification of the frail elderly and those with dementia who may benefit from a more palliative approach.

Updated 22 January 2015

The practice provided a range of services for patients to consult with GPs and nurses, including on-line booking and all day telephone consultations. The practice operated a system based upon "Advanced Access." To enable patients to see a member of the clinical team (this can be either a Nurse Practitioner or Support Pharmacist) within 24 hours and see a GP within 48hrs. Some patients were frustrated at the length of time they had to wait to see their named GP. All the patients we spoke with confirmed they would be offered a same day appointment if there was an urgent need.

63.2%, of the patient population registered at the practice were of working status either paid work or in full-time education. The practice kept their opening hours under review in order to meet the needs of the patient population registered at the practice.

Updated 22 January 2015

GPs worked with other services to review and share care with specialist teams. The practice maintained a register of patients who experienced mental health problems. The register supported clinical staff to offer patients an annual appointment for a health check and a medication review.

The practice had a named GP who was the Mental Health Lead. We saw evidence that quarterly mental health meetings were held. GPs expressed that there was good communication with the mental health therapists.

The practice also participated in the Local Enhanced Service for Dementia patients and records of patients at risk were identified and the practice reviewed the care, treatment and support they provided to patients in partnership with other health and social care professionals.

The practice participated in a national initiative seeking to develop caring communities. Representatives of Help Direct held a weekly clinic at the practice. Help Direct is a support and information service for adults that seeks to assist people with a wide range of issues. We were told that this might include assisting people with learning difficulties, mental health problems and those who had experienced bereavement.

Updated 22 January 2015

The practice made adjustments to how they provided the service in order to meet patients’ needs. For example, the practice offered longer appointment times for patients with a learning disability and for annual health checks. This helped to ensure patients were given time to be fully involved in making decisions about their health.

The practice maintained a register of patients aged 18 and over with learning disabilities and we saw that patients were invited to attend annual health check reviews. In the year ending March 2014, 67 % of those on the learning disability register attended for their check-ups. They invited patients to attend with their carers at least once annually with the aim for patients to have continuity of care with a named nurse and GP. Those who did not attend where followed up by the nursing staff and GP.

The practice had recorded and identified, via the new Direct Enhanced Service contract, vulnerable patients who were at potential risk of unplanned admissions to hospital, which represented 2% of the practice patient population.

Staff were knowledgeable about safeguarding vulnerable adults. They had access to the practice’s policy and procedures and had received training in the last 12 months.