Archived: Rawdon Surgery Also known as Drs Sheard Mills and Clegg

Updated 24 June 2016

Rawdon Surgery is based in the West of Leeds and is part of the Leeds West Clinical Commissioning Group (CCG). The building consists of consulting rooms, large waiting area, disabled toilets and baby changing and breast feeding facilities. There is a patient room which has a weighing and blood pressure machine so patients can check their progress as part of their on-going health. There is easy access into and throughout the building with double automatic doors at the entrance of the building; to facilitate easier access for wheelchair users. There is a small car park on site and additional parking on nearby streets.

The practice is located in one of the least deprived areas of Leeds. It has a patient list size of 7773 with a higher than national average of patients who are aged between 35 to 50 years.

The practice is open Monday to Friday 8am to 6:30pm, extended hours are then provided at the Aire Valley Medical Group based at Yeadon with evening appointments from 6-8pm Monday to Friday and weekends 8-4pm.

There are four female GPs and two male GPs, an advanced nurse practitioner (male) and three practice nurses (female), health care assistant and phlebotomist. The practice is also staffed by the practice manager and a team of administration and reception staff.

The practice is also a GP training practice, providing support and guidance to trainee GPs.

Personal Medical Services (PMS) are provided under a contract with NHS England. The practice is registered to provide the following regulated activities; maternity and midwifery services, family planning, surgical procedures, diagnostic and screening procedures and treatment of disease, disorder or injury. They also offer a range of enhanced services such as influenza, pneumococcal and childhood immunisations.

Updated 24 June 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 15 March 2016. Overall the practice is rated as good for providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

Our key findings across all the areas we inspected were as follows:

• The practice was aware of and complied with the requirements of the duty of candour (being open and transparent with people who use the service, in relation to care and treatment provided). The partners encouraged a culture of openness and honesty, which was reflected in their approach to safety.

• All staff were encouraged and supported to record any incidents. There was evidence of good investigation, learning and sharing mechanisms in place.

• There was a clear leadership structure and a stable workforce in place. Staff were aware of their roles and responsibilities and told us the GPs and practice manager were accessible and supportive.

• Risks to patients were assessed and well managed. There were good governance arrangements and appropriate policies in place.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

• Information regarding the services provided by the practice was available for patients.

• The practice had good facilities and was well equipped to treat and meet the needs of patients.

• There was a complaints policy and clear information available for patients who wished to make a complaint.

• Patients said they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment.

• Patients were positive about access to the service. They said they found it easy to make both emergency and routine appointments.

• Longer appointments were given to those patients requiring interpreter services.

• The practice sought patient views how improvements could be made to the service, through the use of patient surveys, the NHS Friends and Family Test and their patient representative group (PRG).

• The ethos of the practice was to deliver good patient centred care.

We saw an area of outstanding practice:

• Collaboration with the local Aire Valley Medical Group a local ‘Hub’ of four practices in which Rawdon surgery is the lead practice. This had enabled seven day availability for appointments with both GPs and Nurses for all patients at the practices. It has also initiated a focus on the most vulnerable patients identified by putting in place three care coordinators and dedicated admin staff to ensure these patients are promptly and effectively supported with both their social and health care needs.

• The practice meets weekly with all staff to discuss and analyse incidents and significant events. This is called the ‘Huddle meeting’ and all staff were encouraged to raise any areas of concern. This ran alongside the sharing of safety events with other local practices via an electronic database. This shared learning, heightened awareness and increased transparency.

• Online systems used by the practice enabled patients to make appointments, order prescriptions, access their test results and the practice was piloting on- line access to patients records with 10% of patients presently accessing their medical information.

• A screening programme for impaired glucose tolerance (sometimes called pre-diabetes) had been initiated and run by the practice. This had identified additional patients in need of diabetic care and provided a programme of support.

• The practice worked in partnership with the Patient Empowerment Project (PEP) initiated by West Leeds Clinical Commissioning Group (CCG). This was to provide a link to services in the community which can provide support to the patients for instance with mental health, visual impairment problems and put them in touch with local based support groups.

However, there were areas of practice where they should make improvements:

• Ensure systems are in place for testing the on-going safety of electrical equipment and electrical and gas safety in the building.

• Review infection control throughout the building to ensure that audits are updated and action completed.

• Ensure all staff receive an annual appraisal.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 24 June 2016

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

• All these patients had a named GP and a structured annual review to check that their health and medicines needs were being met.

• Patients who were identified most at risk of hospital admission were identified as a priority.

• The practice worked with the care coordinators in conjunction with the local hub to reduce admissions to hospital.

• A diabetes pre-screening programme was initiated and run by the practice. This had identified additional patients in need of diabetic care and provided a programme of support.

• The practice delivered care for patients as part of the ‘year of care’. This NHS initiative enabled patients to have a more active part in determining their own care and support needs in partnership with clinicians. It was used with all patients who had diabetes, chronic obstructive pulmonary disease (a disease of the lungs) or coronary heart disease.

• Self-care/self-monitoring and remote diabetes monitoring.

• 88% of patients diagnosed with chronic obstructive pulmonary disease (COPD) had received a review in the last 12 months, compared to 90% nationally.

• Longer appointments and home visits were available when needed.

Updated 24 June 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 accident and emergency (A&E) attendances.

• Patients and staff told us children and young people were treated in an age-appropriate way and were recognised as individuals.

• Appointments were available outside of school hours and the premises were suitable for children and babies. All children who required an urgent appointment were seen on the same day as requested.

• The practice worked with midwives and health visitors to support the needs of this population group. For example, ante-natal, post-natal clinics and baby clinics.

• Immunisation uptake rates were high for all standard childhood immunisations, achieving 98% for many vaccinations.

• Sexual health and contraceptive and cervical screening services were provided at the practice.

• 86% of eligible patients had received cervical screening, compared to 83% both locally and nationally.

Updated 24 June 2016

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

• The practice provided proactive, responsive and personalised care to meet the needs of the older people in its population. Home visits and urgent appointments were available for those patients in need.

• The practice worked closely with other health and social care professionals, such as the care coordinators, district nursing and local neighbourhood teams, to ensure housebound patients received the care and support they needed.

• Care plans were in place for those patients who were considered to have a high risk of an unplanned hospital admission.

• Health checks were offered for all patients over the age of 75 who had not seen a clinician in the previous 12 months.

Updated 24 June 2016

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

• The needs of these patients had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

• Seven day opening, with weekend and evening appointments were provided by the practice via the Aire Valley Medical Group which is a collaboration of services provided by this practice and three other practices in the area.

The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group. For example, cervical screening, early detection of chronic obstructive pulmonary disease (a disease of the lungs) for patients aged 40 and above who were known to be smokers or ex-smokers.

Updated 24 June 2016

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

• The practice regularly worked with multidisciplinary teams in the case management of people in this population group, for example the local mental health team. Patients and/or their carer were given information on how to access various support groups and voluntary organisations, such as MIND and Mood Gym a self-help cognitive skills training programme.

• The practice were proactive with the pre-screening in dementia and had a GP lead in this area working with the NHS Year of Care initiative.

• 91% of patients diagnosed with dementia had received a face to face review of their  care in the last 12 months, compared to a national average of 84%

• 92% of patients who had a severe mental health problem had received an annual review in the past 12 months and had a comprehensive, agreed care plan documented in their record. This was comparable to both the local and national average of 88%.

• The practice worked in partnership with patient empowerment project (PEP) initiated by West Leeds Clinical Commissioning Group CCG. This was to provide a link to services in the community which can provide support to the patients for instance with mental health and local based support groups.

• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 24 June 2016

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

• The practice held a register of patients living in vulnerable circumstances and regularly worked with multidisciplinary teams in the case management of this population group.

• Longer appointments were given to those patients requiring interpreter services.

• The practice had identified a small number of vulnerable patients with complex needs, who were to be fast tracked for appointments and access to a clinician. All staff were aware of these patients.

• Staff knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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 could evidence the number of children who were on a child protection plan (this is a plan which identifies how health and social care professionals will help to keep a child safe).

• Those patients who had a learning disability were coded, which enabled additional support to be provided as needed.

• Information was provided on how to access various local support groups and voluntary organisations.

• As part of the blood borne virus screening programme, HIV, Hepatitis B and C testing were offered to all new patients aged between 16 and 65. Testing was also offered to those patients who were thought to be ‘at risk’.