Whittington Moor Surgery

Updated 14 January 2016

Whittington Moor Surgery is situated approximately two miles from the centre of the town of Chesterfield. The practice is delivered from purpose built premises which has been extended on two occasions to accommodate growth.

The practice is run by a partnership of six female GPs who employ two part-time salaried female GPs (equivalent to 5.25 whole time equivalent GPs). The practice has four part time practice nurses and a health care assistant. The clinical team is supported by a practice manager, an assistant practice manager and a team of 14 administrative, secretarial, reception staff and an apprentice. As a training practice, GP registrars also work at the practice and at the time of our visit, two registrars were working at the practice. The practice also hosts members of the health visiting and district nursing teams, the community matron and the care co-ordinator employed by Derbyshire Community Health Services.

The registered practice population of 7,525 are predominantly of white British background, and are ranked in the fourth more deprived decile. Disease prevalence is mostly higher than the CCG and national average, indicating an increased demand for services. The practice age profile is broadly in line with national averages but has slightly higher percentages of patients aged 40 and over.

The practice opens from 8am until 6.30pm Monday to Friday. GP morning appointments times are available from 8.40am to 12.30pm and extended hours are offered from 7 to 8am each Wednesday to accommodate people who cannot easily attend during standard opening times for example, due to work commitments. Afternoon surgeries run from 2pm to 6pm on Monday and Tuesday; 2 to 5pm on Wednesday, and from 1.30 to 6pm on Thursday and Friday. The practice closes once a month on a Wednesday afternoon for staff training and development. In addition, the practice also offer extended hours every alternate Tuesday evening until 8pm, and open one Saturday morning each month with appointments available between 9 and 11am. When the practice is closed patients are directed to the out of hours’ service provided by Derbyshire Health United (DHU).

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 offered a range of enhanced services including joint injections as part of the minor surgery local enhanced service. They also provided four additional enhanced services including anti-coagulation, insulin initiation and support to care homes

Updated 14 January 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Whittington Moor Surgery on 5 November 2015. Overall the practice is rated as outstanding.

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

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

• There was an open and transparent approach to safety and a highly effective system was in place for reporting and recording significant events. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Opportunities for learning from incidents were maximised and inclusive of the whole practice team

• The practice worked with other organisations and with the local community in planning how services were provided to ensure that they met people’s needs. For example, the practice had contributed to the implementation of a telehealth service with a local care home to address high call outs by giving immediate telephone access to clinical advice.

• 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 member of the group had witnessed the reception staff dealing with an aggressive patient and when this was reported to the practice, staff were given training in dealing with confrontation and information was displayed in reception regarding unacceptable behaviour.

• The practice used clinical audits to review patient care and took action to improve services as a result. For example, the practice had audited its referrals to gynaecology and this helped to reduce the number of referrals through discussion on appropriate cases with the other GPs.

• 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, and learning was applied from complaints to improve services for patients.

• The practice had a clear vision which had quality and safety as its top priority. The partners had developed a robust strategy for business and clinical practice with lead areas of responsibilities for individual GPs. The supporting plans contained clearly defined goals and aspirations. The strategy to deliver this vision was regularly reviewed, and had been discussed with staff.

• Risks to patients were assessed and well managed in conjunction with the wider multi-disciplinary team.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

• High standards were promoted and owned by an enthusiastic and motivated practice team with evidence of highly effective team working.

We saw several areas of outstanding practice including:

• The practice demonstrated an exceptional approach to safety and had a designated lead GP for significant events who had undertaken additional training to support this role. Events were risk rated to identify those with more serious implications for patient safety to prioritise them for action. Positive events were also recorded to ensure these could be celebrated and shared as good practice with the team.

• The practice contracted a pharmacist to provide clinics within the practice for substance misuse and Warfarin monitoring. This enabled vulnerable patients to be seen locally and within a familiar environment, and also facilitated rapid communication regarding any identified concerns between the GPs and the pharmacist. The pharmacist had seen 32 patients for ongoing anticoagulation monitoring and seven patients for substance misuse issues over the last 12 months. The substance misuse service was quality-based to help keep patients stable on their medication regime, and the practice had audited patient satisfaction with the anticoagulation service in 2015 and this demonstrated positive feedback from patients.

• There was a high level of constructive engagement with staff and a high level of staff satisfaction. For example, the practice had undertaken a staff survey during October 2015. The whole team had all contributed to the development of the practice’s vision. Annual away days recognised the contribution made by staff to deliver practice achievements.All staff we spoke with told us they felt valued and that their work was appreciated.

• A comprehensive set of reception protocols had been developed as a reference document for staff to provide information on what to do in response to any issues they may encounter when dealing with patient queries or presenting issues.

• The practice had been involved in establishing a telehealth system at one of the care homes which gave care home staff access to immediate clinical support via an external nurse triage facility. If the problem could not be resolved by telephone advice, the triage service requested the GP to visit. The impact of the scheme was evidenced by a reduction of 33 GP visits per month to the care home.

• The practice ensured that any children at risk from actual or potential abuse who re-located to another area were followed up by arranging a discussion with the new GP practice to share any known concerns.

One area where the provider should make improvement is:

To review access to a male GP by working with other local practices

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 14 January 2016

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

• All patients with a long-term condition had a named GP and a structured annual review 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, and regular meetings were held to review and plan individual patient needs.

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

• The practice achieved 99.5% of available points via QOF in 2014-15. Key achievements for diabetes included 88% of newly diagnosed patients with diabetes being referred to a structured education programme within nine months. This was 13.7% above the CCG average and 21.7% above the national average.

• A podiatrist had attended the practice on a weekly basis since July 2015 to undertake an annual moderate and high-risk foot assessments on patients with diabetes. This ensured that patients, skin, blood circulation and sensation were reviewed to assess any impact from their diabetes, in order that they could receive appropriate treatment or advice. The practice were also considering hosting an independent podiatrist to provide toe nail cutting for diabetic patients.

• The practice provided initiation of insulin (teaching patients how to inject and manage their insulin regime) for type 2 diabetes as part of an additional enhanced service (type 2 diabetes occurs when the body doesn't produce enough insulin to function properly). 20 patients had received this service over the last 12 month period.

• The practice had developed a leaflet for patients with diabetes including information on pregnancy, driving, travel and administering insulin. Additionally, they had developed a template to record key information using an A-F easy guide – for example, ‘A’ included advice and albumin creatinine urine ratio (a method to monitor kidney disease used for patients with diabetes), ‘B’ for blood pressure and body mass index through to ‘F’ for feet, food, and flu vaccination.

• Longer appointments and home visits were available when needed. A home visit was provided for the patient’s annual review if they were housebound.

• The practice had developed a strategic management plan which identified a lead GP for specific long-term conditions and highlighted the priorities to be achieved. This was kept under regular review by the partners to monitor progress towards identified goals.

Updated 14 January 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 those who were at risk, for example, children who had a high number of A&E attendances. Monthly child safeguarding meetings were held with the health visitor and midwife, and the practice had undertaken work to establish good links with the school nursing service. The practice was proactive in following up any children at risk who re-located via communication with their new practice.

• Immunisation rates were high for all standard childhood immunisations (varying from 92.9% to 100%), and the practice had a robust process to follow up on non-attenders.

• 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. A child’s play area was available in reception.

• Nurse-led contraception clinics were held and the GPs fitted intra-uterine devices (coils) and implants

• Chlamydia testing kits were available in the patient toilets and in the main entrance to promote sexual health and well-being.

• Urgent appointments were available on the day for children, and routine appointments were available outside of school hours.

• School children from a local primary school had visited the practice to familiarise them with attending the doctor’s surgery and helped them to understand what the practice did.

Updated 14 January 2016

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

• Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people such as rheumatoid arthritis, osteoporosis and coronary heart disease. The practice had achieved 100% of the available points in all of these areas which was above both the CCG and national averages.

• It was responsive to the needs of older people and offered home visits, urgent appointments, and longer appointments times for those with acute or complex needs.

• The practice provided primary medical services to two local care homes. It undertook regular ward rounds at these locations to review patients, and also visited in-between these planned sessions if any urgent needs were identified. Named doctors provided input to the homes on a six monthly rotation to ensure continuity of care.

• The practice had been involved in establishing a telehealth system at one of the care homes. This was a process whereby care home staff had access to immediate clinical support via an external nurse triage facility. If the problem could not be resolved by telephone advice, the triage service requested the GP to visit. The impact of the scheme was evidenced by a reduction of 33 GP visits per month to the care home.

• The practice used the facilities of an adjacent church to encourage older patients to attend flu vaccinations on a Saturday during the flu vaccination season. This fostered social interaction and helped to protect older patients from developing flu. This event was supported by the patient participation group.

• The practice had regular meetings to review older people with complex needs. Communication regarding patient concerns were facilitated by the co-location of the care co-ordinator and district nursing team within the practice building. Care plans were in place for patients and the practice had signed up to the hospital admissions avoidance enhanced service.

• The practice used the single point of access (SPA) to address any identified needs which required input from the wider health and social care team allowing them to be met nearer to the patient’s own home. The practice also utilised the voluntary SPA to access voluntary services to provide support services to patients in the community such as the befriending scheme.

• The practice hosted a monthly abdominal aortic aneurysm screening programme. The screening is used to detect a dangerous swelling (aneurysm) of the aorta–the main blood vessel that runs from the heart, down through the abdomen to the rest of the body. The screening was targeted at men aged over 65 years old. Since August 2012, 168 patients from the practice had been screened, including 44 patients in the last 12 months. This accounted for 18.5% of all patients screened in the practice.

• Automatic entrance doors provided easy access for older patients and all the consulting rooms were situated on the ground floor. A wheelchair was available for use if required.

Updated 14 January 2016

The practice is rated as outstanding 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. For example, the practice offered extended hours for GP consultations which included an early morning surgery from 7-8am on one day each week. Late evening appointments were available until 8pm on alternate Tuesdays, and appointments were available on a Saturday morning once a month. Telephone consultations could also be booked by patients either on the day or booked in advance.

• The practice was proactive in offering online services to book appointments or order repeat prescriptions as well as a full range of health promotion and screening that reflected the needs for this age group.

Updated 14 January 2016

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

• 91.3% of people diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months. This was 7.7% above the CCG and 7.3% above the national averages

• 94% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive care plan documented in the preceding 12 months. This was in line with the CCG average and 5.7% above the national average.

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

• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations, and information was available within the practice.

• 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 GP would review the discharge summary and if the patient was not receiving care from the crisis team, a face to face appointment would be booked at the practice.

• Staff had a good understanding of how to support people with mental health needs and dementia, and we saw evidence of recent staff training in dementia awareness.

• The practice supported two local care homes which had a high number of patients with dementia. Managers at the homes told us that staff were listened to and involved in patient consultations, and relatives were provided with an opportunity to attend planned reviews being done by the GP.

• The practice was designated as ‘dementia friendly’, a programme focusing on improving inclusion and quality of life for people living with dementia.

• The practice had the highest rate of diagnosis of dementia patients in the CCG. This was aided for example by review of long-term condition patients which identified patients with memory loss for further assessment.

Updated 14 January 2016

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

• The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. For example, the practice contracted an independent prescribing pharmacist to attend the practice who reviewed patients who misused substances. Seven patients were monitored via this service over the last 12 months.

• It had told 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.

• The practice told us they had registered a homeless patient. The practice gave access to facilities on site and provided a drink if required for the homeless.

• The practice had invited all 34 patients on their learning disability register to attend for an annual review and 47% had been seen. Care plans were in place for all learning disability patients over 16 years of age. Longer appointments could be booked for patients with a learning disability.

• The practice liaised with a local learning disability day and residential unit for expert advice.

• The practice was a recognised ‘safe haven’ for members of the community who had a learning disability. This was a partnership development instigated by Derbyshire County Council and the police. The scheme aimed to stop the bullying and abuse of people with learning disabilities across Derbyshire and help them feel safe and confident when out in the community by having access to places which would support them. For example, by making a telephone call to carers or relatives to collect them if they were in difficulty.

• A practice nurse led on health reviews for patients with a learning disability. This allowed continuity for patients in establishing a rapport with the nurse. A resource file had been established for information, and letters sent to patients included pictures and simplified text when this was appropriate to the individual.

• Health checks were offered to the carers of all vulnerable patients. This checked how the carer was coping and gave an opportunity to provide information on the support services available, and it also promoted good health such as offering flu vaccinations.

• Staff had completed recent training in learning disability awareness