Archived: Cliffe Avenue Surgery

Updated 28 April 2016

Cliffe Avenue Surgery is a branch surgery to Windhill Green Medical Practice which serves the communities of Baildon, Shipley and Thackley and has been for over 50 years. The practice plays an active part in quality and health initiatives within the local area and nationally. The practice offers a full range of Primary Care Services and also additional services in the Emerald Suite, attached to Windhill Green Medical Centre.

Cliffe Avenue Surgery is situated within the Bradford District Clinical Commissioning group and is registered with CQC to provide primary medical services under the terms of a primary medical services contract, (PMS). This is a locally negotiated contract which allows NHS England to contract for services from non NHS bodies. The practice serves 12,516 patients across the two sites.

Cliffe Avenue Surgery is registered to provide diagnostic and screening procedures, treatment of disease, disorder or injury and maternity and midwifery services. They offer a range of enhanced services such as childhood immunisations. The practice offers drop in clinics for emergency cases and babies plus a range of advice, counselling and support services.

The practice offers services to an equal number of male and female patients.

The practice team consists of eight GP partners, four male, four female, four salaried GPs, a practice nurse team of seven supported by three health care assistants and 27 administration staff covering reception and all the backroom functions .

The practice is open between 8am and 6:30pm Monday to Friday with appointments available between these times.

On a Thursday Windhill Green Medical Practice is open between 8am and 8pm for extended hours appointments . Saturday opening was available from 8:30 to 11:30am with a telephone service available from 8:30 to 10:30am.

When the surgery is closed patients can use the NHS 111 service, which accesses after hours services from Local Care Direct.

Updated 28 April 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cliffe Avenue Surgery on 1 March 2016. Overall the practice is rated as outstanding.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

• The practice is part of a federation of practices, Trust Primary Care Ltd, developing new innovative services and part of One City, One Voice, Bradford Care Alliance CIC, a district wide collaboration of practices in a Community Interest Company which is a not for profit organisation delivering services.

• Feedback from patients about their care was consistently and strongly positive.
• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs. For example, the practice engages with the Clinical Commissioning Group and NHS England Area Team at CCG monthly meetings. Needs of the patients are discussed along with details of existing and new services, updates on service improvements and focussed schemes are developed to improve the health of the population.
• 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, providing improved car parking and installing water coolers and air conditioning in the waiting areas.
• The February 2016 friends and families test showed that 100% (117) would recommend this service to their friends and family.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Information about how to complain was available and easy to understand.
• The practice had a clear vision which had quality and safety as its top priority.
• The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

We saw several areas of outstanding practice including:

• The practice received the Bradford Healthy Hearts award 2016. This involves working closely with hospital consultants and other health professional, on the prevention, diagnosis and management of cardiovascular disease.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 28 April 2016

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

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

• The percentage of patients with diabetes, on the register, in whom the last blood

  pressure reading (measured in the preceding 12 months) was 81% with a national average of 78%.

• Longer appointments and home visits were available when needed.

• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

• The practice facilitates patient access to other healthcare, advice and support services for patients and plays a navigator/coordinator role e.g. through for instance their ‘Community 4’, Citizens Advice Bureau, Avoiding Unplanned Admissions, Chronic Disease Management, Diabetic clinics, and Virtual Wards.

• Bradford Healthy Hearts award 2016. The practice works closely with hospital consultants and other health professionals. GPs at the practice are reducing the number of people suffering from cardiovascular disease. Healthy Hearts is leading the way in the prevention, diagnosis and management of cardiovascular disease.

• Research which is currently being conducted at the practice includes taking part in ASPIRE (Action to Support Practices Implementing Research Evidence) research aiming to further improve the care of people with diabetes.

• The practice is in the top quartile and the fifth best practice in West Yorkshire relating to the Aspire project with regards to diabetes.

• The practice has taken part in the early Arthritis and Diabetes studies in the past few years as a member of the Primary Care Research Network and previous to this with the Medical Research Council.

Updated 28 April 2016

The practice is rated as outstanding 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. Immunisation rates were relatively high for all standard childhood immunisations.

• 83% of patients diagnosed with asthma, on the register, had an asthma review in the last 12 months compared to national average of 75%.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

• The percentage of women aged 25-64 whose notes record that a cervical screening test has been performed in the preceding 5 years was 89% compared to the national average of 82%.

• Appointments were available outside of school hours and the premises were suitable for children and babies.

• We saw positive examples of joint working with midwives, health visitors and school nurses.

• The practice used a proactive approach to reach out to young people in the form of WISH (a young person’s drop in clinic for registered and non-registered patients), Facebook, the practice website, (contraceptive and sexual health drop in clinics) for registered and non-registered patients, Citizens Advice Bureau sessions weekly in the practice, HALE – social prescribing within the practice.

• People were encouraged to participate in health promotion activities, such as breast screening, cytology, smoking cessation. Patients have been able to benefit from health and lifestyle projects such as educational and health screening tools

• Regular talks at PPG on health promotion by clinical staff.

• Women who fail to attend for their smear test; or those who have an abnormal result are followed up and closely monitored.

• Practice used a Facebook page to connect and engage with young people.

Updated 28 April 2016

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

• The practice offered proactive, personalised care to meet the needs of the older people in its population.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

• The practice ensures patient and carers receive appropriate coordinated, multi-disciplinary care (including those who move into a care home, or those returning home after hospital admission).

• The multidisciplinary team of ‘Community 4’ reviewed care packages to co-ordinate care. The practice is part of a service to ensure patients in nursing homes have care plans and regular reviews which includes sharing of records with nursing homes which has improved access to records for staff caring for patients in these nursing homes.

• Unplanned admissions and readmissions for this group regularly reviewed and improvements made. The practice has a lead GP for the avoiding unplanned admissions initiative. The GP regularly reviews the at risk patients and develops care plans together with the multidisciplinary team of Community 4.The team includes social workers, mental health workers, voluntary sector workers, health visitors, district nurses and GPs.

Updated 28 April 2016

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

• The needs of the working age population, those recently retired and students 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 was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

• Bradford Healthy Hearts award 2016. This involves working closely with hospital consultants and other health professionals, GPs at the practice are reducing the number of people suffering from cardiovascular disease. Healthy Hearts is leading the way in the prevention, diagnosis and management of cardiovascular disease.

• Patients had access to appropriate health assessments and checks. These included health checks for new patients and NHS health checks for people aged 40 plus.

Updated 28 April 2016

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

• 85% of patients diagnosed with dementia who had had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average.

• The percentage of patients with schizophrenia, bipolar affective disorder and

  other psychoses who have a comprehensive, agreed care plan documented in

  the record, in the preceding 12 months was 99% compared to the national average of 88%.

• The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia.

• The practice carried out advance care planning for patients with dementia.

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

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

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

• Staff will be undertaking Dementia Friendly training provided by the Alzheimer’s Society. The practice will be taking advice from the training providers on the new design of the reception areas to improve the dementia friendliness of the practice.

Updated 28 April 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 such circumstances including homeless people, travellers and those with a learning disability.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

• 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.