Archived: The Barn Surgery

Updated 13 April 2017

The Barn Surgery is situated within Christchurch Medical Centre, Christchurch, Dorset. The practice provides personal medical services to patients living in the Christchurch area of Dorset and is part of NHS Dorset clinical commissioning group.

Christchurch Medical Centre hosts other GP practices and The Barn Surgery has a contractual arrangement to share some staff for both management and clinical support.

The practice is located in an area of relatively low social deprivation compared to the national average. At the time of the inspection, there were approximately 6300 patients on the practice list. The majority of patients are from a white British background. The practice does have some patients with Polish, Pakistani, Indian and Russian backgrounds and uses translation services and information in different languages where needed. The Barn Surgery has more than double the number of patients over 75 years (17% of the practice list) compared with the national average of 8%. Approximately 60% of patients at the practice have a long-term condition compared to the national average of 54%.

The practice has three whole time equivalent GP partners, two are male and one is female. The nursing team consists of three female nurses, one of whom is a non-medical prescriber. Since our last inspection, Christchurch Medical Centre has employed two female nurse practitioners who are able to diagnose, advise and one is also able to prescribe for minor illness. The nurse practitioners work approximately two days per week at The Barn Surgery. The Barn Surgery is managed by a team shared with the other two practices at Christchurch Medical Centre lead by a strategic business manager. A practice support manager is based at The Barn Surgery along with a team of administrative and reception staff.

The practice is open 8.30am to 6.30pm Monday to Friday. Phone lines are open from 8am until 6.30pm hours with the out of hours service picking up phone calls outside of these times. GP appointment times are from 8.30am to 12pm and 3pm to 6pm every weekday. Since our inspection in May 2016, the practice no longer offers extended hours appointments to reduce any potential risks for patients resulting from a shortage of GPs. Information about opening times and appointments are listed on the practice website and in the patient information leaflet.

The practice shares a large car park for patients with the neighbouring practices. The practice is located over two floors. Care is provided to patients on the ground floor in a variety of clinical areas including a treatment room. The first floor of the practice houses management and administration staff offices. Corridors and doorways are accessible to patients using wheelchairs and pushchairs.

Opening hours of the practice are in line with local agreements with the clinical commissioning group. Patients requiring a GP outside of normal working hours are advised to contact the out of hours service provided by the NHS 111 services in Dorset.The practice closes for two days a year for staff training. Patients are notified about practice closures well in advance.

At this inspection we inspected The Barn Surgery which is located at:

1 Purewell Cross

Christchurch

BH23 3AF

Updated 13 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Barn Surgery on 14 February 2017 to assess the improvements made at the practice. Overall the practice is now rated as Good. 

We had previously inspected the practice during 17, 18 and 19 May 2016 when we rated the practice as inadequate overall. Specifically, the practice was rated as inadequate for safe and for well-led, requires improvement for effective, and good for caring and responsive.

Areas which did not meet the regulations following our inspection in May 2016 were:

• Patients were at risk of harm because systems and processes were not being followed to keep them safe. For example, appropriate fire drills and some training was not undertaken by all staff. The practice did not have assurance that infection control practice followed current guidance. Not all staff had received training in infection control, chaperone duties for those staff undertaking this role, basic life support and the Mental Capacity Act (2005).

• There was no evidence of consistent wider learning and effective communication with staff regarding incidents, near misses and concerns.

• Patient outcomes were low in some areas compared to the locality and nationally. No clinical audits had been carried out, so there was no effective system to manage performance and improve patient outcomes.

• Significant staff shortages across the GP team was leading to longer waits for routine appointments and delayed appointments at the practice.

• The practice had insufficient GP leadership capacity and limited formal governance arrangements.

On 14 February 2017, our key findings across all the areas we inspected are as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to the safe care of patients were now clearly monitored and managed.
• Patients who attended the practice had their needs assessed and care was delivered in line with current evidence based guidance.
• Staff had the skills and experience to deliver effective care and treatment, but not all had received the training they needed to perform their roles effectively. For example, there were still gaps in training undertaken for infection control and The Mental Capacity Act (2005).
• Information about services and how to complain was available and easy to understand. Complaints were investigated appropriately and in a timely manner.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Clinical audits focussing on safe prescribing had been completed.
• There was a clear leadership structure and most staff felt supported by management.
• The practice proactively sought feedback from staff and patients, which it acted on. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The provider was aware of and complied with the requirements of the Duty of Candour.

However, there remain areas where the provider must make improvement. The practice must:

• Ensure staff complete all training the practice considers to be mandatory at the required frequency, to enable them to undertake their role safely and effectively.

The areas where the provider should make improvement are:

• Review process for team meetings to ensure all staff attend relevant meetings.
• Continue to identify carers so they can receive appropriate care and support.

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

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 13 April 2017

The provider was rated as good for people with long-term conditions.

• One of the practice nurses had qualified as an independent prescriber and was able to prescribe medicines for patients as part of long-term condition reviews.
• Not all patients with long-term conditions had their care and treatment needs regularly reviewed for safety and appropriateness. However, the practice had devised an action plan to address this and unverified data demonstrated some improvement for the care and treatment of patients in these groups.
• Nationally reported data showed that 76% of patients diagnosed with asthma had received an annual health check review compared to clinical commissioning group (CCG) average of 77% and the national average of 75%. Exception reporting for this indicator was below CCG and national averages.
• 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. For example, a practice nurse worked with a diabetes nurse specialist to ensure care for these patients was optimal. For example, by running joint clinics approximately every six weeks.

Updated 13 April 2017

The provider as rated as good for people with long-term conditions.

• 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.
• 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 practice’s uptake for the cervical screening programme was 78%, which was lower than the CCG average of 83% and the national average of 81%.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• The practice worked with other professionals, such as health visitors and midwives, to ensure the needs of this group were met.

Updated 13 April 2017

The provider was rated as good for older people.

• The Barn Surgery has a high proportion of older patients. Approximately 17% of patients are over 75 years compared to the national average of 8%. This patient group can be associated with a higher prevalence of illness along with risks of isolation and increased vulnerability resulting in increased care needs.
• Every patient at the practice including older patients aged over 75 years had a named GP.
• 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.
• Patients at risk of hospital admission were identified as a priority. They were supported by the AMBER team. Patients had comprehensive care and support plans in place. Data for the period October 2016 to January 2017, showed that 87 patients registered with The Barn Surgery were supported by the team. Of these, 10 patients were assessed as being high risk and vulnerable. During the three month timespan, there had been three unplanned hospital admissions for patients registered at The Barn Surgery.

Updated 13 April 2017

The provider was rated as good for 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.
• The practice offered telephone consultations to meet the needs of this group.

Updated 13 April 2017

The provider was rated as good for people experiencing poor mental health (including people with dementia).

• 91% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is comparable to clinical commissioning group (CCG) of 86% and the national average of 84%.
• Performance for mental health related indicators was comparable to the national average. For example, 88% of patients with schizophrenia, bipolar affective disorder and other psychoses had a blood pressure recorded in the preceding 12 months, compared to a CCG average of 89% and national average of 90%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice carried out advance care planning for patients with dementia.
• The practice had told 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.

Updated 13 April 2017

The provider was rated as good for people whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
• The practice had 25 patients registered who also had a learning disability. At the time of our inspection, 20% of these had received an annual health check.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• The practice had a carers lead, who 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.