Trinity Surgery

Updated 24 June 2016

Trinity surgery provides Personal Medical Services to approximately 12,000 patients and comprises a full range of socio-economic groups including some affluent areas and some deprived council wards. Wisbech is the most deprived ward in Cambridge. The practice area covers the town and the immediately surrounding area. Trinity is situated close to the North Cambridge Hospital in a purpose built building and provides services including weekly midwifery and counselling services. The surgery was purpose built in 2006. Over 25% of the patient population do not have English as their first language. Translation services are available on the practice website and information in other languages is available on the electronic book in screen and in leaflets in the practice. We saw notices in the reception areas informing patients this service is available.

The practice area includes the most deprived ward in Cambridgeshire; however the deprivation index was varied across the practice area. There is significant rural deprivation with the main employment being manual (landwork) and food-packaging. The practice has seen a dramatic increase in the number of births in the area with a high number of ‘at risk families and children of concern.

The practice provides treatment and minor surgery rooms, consultation rooms, a comfort room for distressed patients and a blood pressure self monitoring area on two floors with ramp and lift access and automatic doors. On the second floor there are a number of administration offices, a library, a staff rest room and a meeting room. Parking is available across the hospital car parks.

According to information taken from Public Health England, the patient population has a higher than average number of patients aged 0-9 years and 20-34 years and a lower than average number of patients aged 54- 85+ years compared to the practice average across England.

The practice has a team of six GPs. All six GPs are partners which mean they hold managerial and financial responsibility for the practice. There is a team of practice nurses, which includes four nurse practitioners, three practice nurses and two healthcare assistants who run a variety of appointments for long term conditions, minor illness and family health. All four nurse practitioners and one of the practice nurses are qualified to prescribe.

There is a practice manager who is supported by an assistant practice manager. In addition there is a team of non-clinical administrative, secretarial, scanning and prescription clerks and reception staff who share a range of roles, some of whom are employed on flexible working arrangements.

The practice is open between 8am and 6.30pm Monday to Friday. Appointments are available from 8.30am to 1pm and 2.00pm to 6.30pm daily. On the third Thursday of each month the practice is open from 8.30am to 12.30pm and then reopens from 5pm to 6.30pm. In addition to pre-bookable appointments that can be booked up to four weeks in advance, urgent appointments are also available for people that need them.

The practice offers a range of appointment options which include; pre-bookable appointments follow up appointments, on-line access, and telephone consultations. These are supported by telephone access to a GP for those patients who do not require a face to face consultation. The appointment system is continually reviewed by the management team to establish any increase in demand and to warrant an increase in access.

The practice does not provide GP services to patients outside of normal working hours such as nights and weekends. During these times GP services are provided via the 111 service provided by Integrated Care 24.

Updated 24 June 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Trinity Surgery on 21 April 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.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said there were urgent appointments available on the same day and continuity of appointments, however some patients told us they did not always find it easy to make an appointment with a named GP.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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.
• The provider was aware of and complied with the requirements of the duty of candour.

We saw one area of outstanding practice:

• The practice worked closely with three other practices in Wisbech to provide a community eye service, Anglia Community Eye Services (ACES). This initial concept was developed by four Wisbech practices and provided the services of consultant ophthalmologists out of hospital into the community. In addition the practices joined to provide out of hospital DEXA scan provision for the community.

The areas where the provider should make improvement are;

• Ensure patients waiting for their appointments in all areas of the practice can be clearly seen by staff to ensure patients whose health might deteriorate can be observed.
• Ensure that medical consumables are in date.
• Ensure records of all clinical meetings are maintained and shared with staff to ensure learning outcomes.
• Establish an effective process for monitoring requests and the collection of repeat prescriptions for vulnerable and high risk patients.
• Continue to monitor clinical exception reporting process within the practice to ensure reviews of patient health and medication are undertaken where appropriate.
• Continue to monitor patient feedback and implement changes to practice when required.
• Continue to encourage and improve the uptake of bowel and breast screening for patients.

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.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. They were supported by GP clinical leads for long term conditions who worked closely with the nurse practitioner and the nursing team.
• The practice used the information collected for the Quality and Outcomes Framework (QOF) to monitor outcomes for patients (QOF is a system intended to improve the quality of general practice and reward good practice). Data from 2014/2015 showed that performance for diabetes related indicators was 100%, which was above the CCG average by 10.5% and the national average by 10.8%.
• 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.
• Nurses provided spirometry, chronic obstructive pulmonary disease and asthma reviews and worked closely with the GPs to highlight any concerning results. In addition to this, the practice had a process in place where they would contact any patient following an admission to hospital for an asthma exacerbation or if the patient had contact with the out of hours service as a result of an asthma exacerbation. Patients in the community with chronic obstructive pulmonary disease were provided with rescue packs containing medications to prevent an exacerbation of their condition.
• The practice offered in-house diagnostics to support patients with long-term conditions, such as blood pressure machines, electrocardiogram tests, spirometry checks, blood taking, district nursing, family planning and midwifery, health screening, health visitor, minor injuries and minor surgery.

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 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 83%, which was above 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 offered the fitting and removal of long term contraception devices. In addition the practice encouraged chlamydia testing for the under 24 age group. Referrals were also made to a local outreach sexual health service. Emergency contraception was available at the practice. The practice took part in the C Card system which provided free condoms to patients between the ages of 13 -24.

Updated 24 June 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 would contact all vulnerable patients after their discharge from hospital to address any concerns and assess if the patient needed GP involvement at that time.
• The practice offered health checks for patients aged over 75.

• The practice reviewed all home visit requests to facilitate earlier visits where hospital admission may be an outcome.
• Nationally reported data showed that outcomes for patients for conditions commonly found in older people including heart failure and rheumatoid arthritis were above local and national averages.

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 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 uptake for patients aged 60-69, screened for bowel cancer in last 30 months was 48 %; this was below the CCG average of 59% and the national average of 58%. The practice uptake for female patients screened for breast cancer in the last 36 months at 60% was also below the CCG and national average of 72%.
• One GP had a special interest in dermatology and the practice offered in house dermatology services to patients from other local practices including cryotherapy for warts verruca and some skin lesions. The waiting list for this service was for two weeks and the practice had seen an increase in use from 300 referrals in 2010/2011 to over 600 this year.

Updated 24 June 2016

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

• 76% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months (01/04/2014 to 31/03/2015), which is below the national average of 84%.
• 93% of patients experiencing poor mental health had their care reviewed in a face to face meeting in the last 12 months (01/04/2014 to 31/03/2015), which is above the national average of 88%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. The practice liaised with the mental health link workers and other professionals to aid the management of those with mental health needs and those with chronic illnesses. In addition the practice worked with a local drug addiction support group and shared the care of ex drug abusers, monitoring medicines and general health.
• The practice carried out advance care planning for patients with dementia.Staff had attended training from the Alzheimers Society and had signed up as Dementia Friends.
• 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 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 including homeless people, travellers and those with a learning disability. Clinicians undertook both planned and opportunistic vaccinations when patients attended the practice to ensure patients received appropriate immunisations.
• The practice offered longer appointments for patients with a learning disability.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• 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.
• Families who suffered a bereavement, were contacted by their usual GP and a condolence letter was sent to the family which included telephone numbers and addresses for services such as the Wisbech registrar, Age Concern, Citizens Advice Bureau, CRUISE bereavement (a support and counselling organisation), plus a bereavement booklet with signposting and guidance for the family).