Orchard Surgery

Updated 30 August 2016

Orchard Surgery provides medical care through a general medical services (GMS) contract commissioned by NHS England and Rushcliffe Clinical Commissioning Group (CCG). The practice is located in the centre of Kegworth village since 1835. It has a list size of approximately 8300, 9% of which are students due to the close proximity to the Sutton Bonington campus of the University of Nottingham. It is a semi-rural practice covering 19 villages, and in a less deprived area in comparison to national deprivation levels. It has a diverse population with 17% aged 18 and under and 17.8% aged over 65 years old.

The practice has a branch surgery located in Gotham, six miles from the Kegworth main site at Village Hall Surgery, Nottingham Road, Gotham, NG11 0HE. Approximately a third of its patients are seen at the branch surgery and medicines are dispensed at this site for eligible patients. The two practice sites incorporate areas across the counties of Nottinghamshire, Leicestershire and Derbyshire. We visited the practice’s branch surgery as part of the inspection to review the dispensary procedures.

The practice team comprises four GP partners, two salaried GPs, a GP Retainer, four practice nurses, two healthcare assistants/phlebotomists, a business manager, a practice manager, two deputy managers, a senior dispenser and the administrative/reception team. There are two female GPs and four male GPs. It is a teaching and training practice for medical students and doctors training to become GPs.

The practice in Kegworth is open between 8am and 6.30pm on Monday, Tuesday, Thursday and Friday, and 8am to 5pm on Wednesday. Appointment times vary throughout the day to meet demand, with the earliest appointment starting at 9am (8.30am on Wednesdays) and the latest appointment offered at 6pm daily. They are the only practice in the Rushcliffe area that offer extended hours appointments on alternate Saturdays from 8am to 11am with two GPs and a nurse available.

The practice in Gotham is open from 8.30am to 6.30pm on Monday to Friday. It is closed between from 1pm to 3.30pm daily with an emergency appointments telephone line is available during these times, and also closed on Thursday afternoons. Medicines dispensed at Gotham can be collected from 8.30am daily.

When the surgery is closed, patients are advised to dial NHS 111 and they will be put through to the out of hours service which is provided by Nottingham Emergency Medical Services.

Updated 30 August 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Orchard Surgery on 28 June 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events and near misses, and we saw evidence that learning was applied.

• The practice used proactive methods to improve patient outcomes. For example, education courses for patients with long term conditions such as diabetes and working with the local diabetes specialist nurse to improve the wellbeing of patients.

• There was easy access to appointments for patients with a range of appointments available including telephone consultations. The patient satisfaction with access was above average.

• Feedback from patients about their care was consistently positive. Data from the GP survey was consistently high and this included confidence in care provided by GPs and nurses.

• The practice planned and co-ordinated patient care with the wider multi-disciplinary team which included social services and Age UK, to deliver effective and responsive care to keep vulnerable patients safe. GPs were able to make direct referrals to these services and patients were made aware of the involvement of the services in discussing their care.
• 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 (PPG).

• The practice actively reviewed complaints to see if there were any recurrent themes, and identified issues where learning could be applied to improve patient experiences in the future.

• The practice actively planned their care services to meet the needs of their student population by meeting with student coordinators before the start of the academic year to discuss the number of students expected to enrol at the nearby university campus, and offering student clinics on Wednesday afternoons to coincide with the students’ free period.

• The practice had a clear vision which had quality and safety as its top priority. The education ethos of the practice was clear in how they supported all staff development, their training of doctors and leading in workforce development in their local Clinical Commissioning Group (CCG).
• The practice had strong and visible clinical and managerial leadership and governance arrangements, and staff told us that they were well-supported and felt valued by the partners.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 30 August 2016

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

• The practice had a recall system for patients with long term conditions, audited on a monthly basis to identify patients who were due for a review. There were high rates of reviews and attendance as well as extensive use of evidence based clinical templates, leading to high QOF achievement.

• QOF achievement on indicators for atrial fibrillation (an irregular heart rate) and chronic obstructive pulmonary disease were broadly in line with national averages. The practice achieved 100% on atrial fibrillation, compared to a CCG average of 99.5% and national average of 98.5%. The exception reporting rate was 11.9%, below the CCG average of 15.1% and in line with the national average of 11% They were proactive in carrying out routine checks at reviews, resulting in high identification and treatment of atrial fibrillation.

• All clinical staff had lead roles in specific disease areas and patients at risk of hospital admission were identified as a priority. Nursing staff were supported in undertaking additional training in rheumatology, diabetes and asthma to enhance their knowledge and skills in managing long term conditions.

• There was evidence of coordinated care with multi-disciplinary teams between the nursing staff and community matrons, diabetic specialist nurses and heart failure nurses to improve the outcomes for the patients.

• There were a large number of leaflets providing education and self-care advice and patients were directed to online resources. The practice actively encouraged patient education sessions for patients with conditions such as diabetes. A specialist diabetes nurse visited the practice monthly to review complex patients and provide support to the nursing staff with insulin initiation. The practice promoted self-referral to services such as podiatry, physiotherapy and psychological therapies, whose clinics were offered in the practice premises.

Updated 30 August 2016

The practice is rated as good for the care of families, children and young people.

• The practice worked closely with midwives, health visitors and family nurses attached to the practice. 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 or any children on a child protection plan at their clinical meetings.

• There were weekly baby clinics and drop in sessions for mothers and babies. The premises were suitable for children and babies. Baby changing facilities were available and the practice accommodated mothers who wished to breastfeed privately.

• Immunisation rates were broadly in line with the CCG averages for standard childhood immunisations. Vaccination rates for children under two years old ranged from 93.4% to 96.7% compared against a CCG average ranging from 96.7% to 97.2%. Vaccination rates for five year olds ranged from 84.1% to 98.4%, compared to the CCG average of 94.2% to 98.6%.The practice team worked closely with the health visitors to follow up non-attenders for routine immunisations.

• The practice offered flexible appointments, with longer appointments available if needed. Appointments were available outside of school hours with urgent appointments available on the day for children and babies. The practice computer systems were integrated with the health visiting and school nursing services to facilitate communication with ease.

• There was a full range of family planning services offered including fitting of intra-uterine devices (coil) and contraceptive implant fitting. Family planning clinics were offered on Tuesday mornings and afternoons, and they were also available on some Saturday mornings.

• The PPG had recently recruited a new mother to provide diverse representation on practice issues.

Updated 30 August 2016

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

• The practice had 17.8% of their patients aged over 65, slightly lower than the CCG average of 20.4% but in line with the national average of 17.1%. They offered proactive, personalised care to meet the needs of the older people in their population by offering home visits, same day telephone appointments and urgent appointments for those with enhanced needs. Phlebotomy home visits were offered where required. Longer appointments were available and offered if needed.

• Referrals were made to the community geriatrician service where appropriate, who provided holistic care and assessment to meet the needs of older people.

• The GPs worked effectively with multi-disciplinary teams on the care of patients with complex co-morbidities and frailty through the unplanned admissions register. Regular meetings were held with community teams to review patients on this register, including those receiving palliative care and on the district nursing case load to ensure patients were receiving coordinated care and their needs were met promptly. The practice engaged in an ongoing pilot scheme which included attendance of a social care representative and an Age UK outreach worker at the multi-disciplinary meetings to provide a holistic approach in the support given to patients.

• All over 75s had a named GP to facilitate continuity of care.

• Practice supplied data showed 2418 patients were given flu vaccinations, and 74% of these patients were aged 65 and over. Shingles vaccination clinics were provided to patients over 70 years old.

• The practice had good access for wheelchairs and height adjustable couches for patients who needed them. They had been awarded a five star rating by the Disabled Go website following modernisation of their reception area.

Updated 30 August 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. This included access to telephone appointments to fit around patient schedules.

• Flu clinics were offered on Saturdays for the convenience of working patients. Extended opening hours appointments were offered on alternate Saturdays from 8am to 11am with two GPs and a nurse available.

• The practice was proactive in offering online services such as online prescription requests, appointments, and accessing medical records. Appointments could be booked up to eight weeks in advance.

• Mobile phone text reminders were used for appointments, including the option to cancel an appointment via text.

• There was a full range of health promotion and screening information in the practice that reflected the needs for this population group. Services offered from the premises included phlebotomy, sexual health, minor surgery provided by the practice in-house, physiotherapy, diabetes education, and counselling provided by commissioned services.

• The practice’s uptake for cervical screening for eligible patients was 88.8%, which was in line with the CCG average of 88% and higher than the national average of 81.8%. Breast and bowel cancer screening data was broadly in line with CCG and national averages.

• The PPG had a virtual group to allow working patients to participate, and had recently recruited a student and a new mother to join the group in order to obtain more diverse views on the services provided by the practice.

• The practice met with the university student coordinator prior to the start of the academic year to plan the number of students expected, and held a talk during the induction week advising students on health promotion and how to access the practice. At the same time, they registered students, updated their vaccination records and booked follow up appointments for those identified as in need of further care.

• There was a dedicated page for students on the practice website with information for both local and international students, including a guide to NHS treatment, travel vaccines, cervical smear screening and health checks.

• A nurse clinic for students was offered on Wednesday afternoon to coincide with the free period students have on Wednesday afternoons. There was an active recall system for contraceptive services such as depo provera injections, particularly for students as they were more likely to require reminders due to their active lifestyles. The practice monitored its teenage pregnancy rate and observed low rates from 2014 to 2016 with nine pregnancies recorded for that period.

• The practice provided meningitis vaccinations for students going to university for the first time up to 25 years old.

• Patients were encouraged to self-refer to local counselling services that held a clinic in the practice on Wednesday mornings. Counselling services were available for students at the Sutton Bonington campus and referrals to this service were monitored.

Updated 30 August 2016

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

• 96.3% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is above the CCG and national averages of 88.5%.

• Practice supplied data indicated 89.2% of patients with severe mental illness had their care reviewed in a face to face meeting in 2015/16. Longer appointments were available and offered if needed.

• 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, for example community mental health support services and crisis support.

• Following a significant event in relation to mental capacity, the practice held in-house training on mental capacity to ensure staff were aware of what to do if they recognised patients experiencing cognitive decline.

• There were 14 patients registered with the practice who were resident in a local mental health unit specialising in patients with a diagnosis of Huntingdon’s disease. The practice provided general medical support by conducting weekly ward rounds to review patients by a named GP, and participating in regular multi-disciplinary meetings with healthcare staff at the unit in care planning. Feedback from the unit was positive about the care given to patients and the GP’s knowledge of all patients’ needs.

Updated 30 August 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 including those with a learning disability. One of the nurses had a lead role in carrying out annual reviews for patients with learning disabilities and tailored the reviews to meet the needs of the patients by offering longer appointments.

• Practice supplied data indicated there were 17 patients on their learning disabilities register, and 13 had been reviewed in a face to face appointment in 2015/16.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients. Formal multidisciplinary meetings were held monthly to discuss patients at high risk of admission to hospital to ensure their needs were met promptly. There was a dedicated telephone line for health professionals to speak to hospital staff and paramedics for vulnerable patients at risk of admission.

• The practice actively promoted the identification of carers to ensure they were given appropriate support for their health and wellbeing. There were carers information packs available and regular carers events held at the practice.

• 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. They had all received training to ensure 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.

• Staff told us they were aware of how to access interpreting and text talk services for deaf or deafened patients and an interpreter could be arranged for those who could not speak in English through Language Line. A hearing loop was available in the practice.