Three Chequers Medical Practice

Updated 4 June 2018

Three Chequers Medical Practice is a GP practice located in Salisbury, in Wiltshire. It is one of 47 practices within the Wiltshire Clinical Commissioning Group (CCG) area and has approximately 25,300 patients.

The practice was formed in 2017, by the merger of Endless Street Doctors Surgery, Three Swans Surgery and St Ann Street Surgery (all based in Salisbury city centre).The practice now operates across five sites, three of which have a dispensary. The practice was able to offer dispensing services for those patients on their practice list who live more than one mile (1.6km) from their nearest pharmacy.

This is our first inspection of Three Chequers Medical Practice. Previously, Endless Street Doctors Surgery was inspected in May, 2016, and rated good overall, but as requires improvement for effective care. We did a follow up inspection of the effective domain in February, 2017, and found the practice had resolved the issues we had previously found and rated them as good for providing effective care. We previously inspected Three Swans Surgery July, 2016, and rated them as good overall and in all the individual domains we look at. We previously inspected St Ann’s Street Surgery in November, 2016 and rated them as outstanding overall. We rated them as Good for providing safe services and as outstanding for the effective, caring, responsive and well-led domains.

The practice’s main surgery in Endless Street is based in three converted Georgian town houses close to the centre of Salisbury. The buildings are Grade 2 listed, which has limited the improvements to the building structure that the practice wished to make. It has seven consulting rooms, three treatment rooms and a dispensary. Some of the consulting and treatment rooms are on the first floor. There is no lift but arrangements are in place to see patients in a downstairs consulting or treatment room when necessary.

The practice is registered to provide the following activities:

• Diagnostic and screening procedures;
• Family planning;
• Maternity and midwifery services;
• Surgical procedures;
• Treatment of disease, disorder or injury.

The practice provides a number of services and clinics for its patients including childhood immunisations, family planning, minor surgery and a range of health lifestyle management and advice including asthma management, diabetes, heart disease and high blood pressure management.

The practice provided medical care for 22 Intermediate Care beds in Salisbury as part of an Intermediate Care team (Intermediate care is a specific type of short term residential care involving medical and social care services).

Data available shows a measure of deprivation in the local area recorded a score of 9, on a scale of 1-10, where a higher score indicates a less deprived area. (Note that the circumstances and lifestyles of the people living in an area affect its deprivation score. Not everyone living in a deprived area is deprived and not all deprived people live in deprived areas). The area the practice serves has relatively low numbers of patients from different cultural backgrounds. 97% of the practice population describes itself as White British. Average male and female life expectancy for patients at the practice is 81 years and 85 years respectively, which is the same as the Wiltshire average and broadly in line with the national average of 79 and 83 years respectively.

There are 13 GP partners and 11 salaried GPs. Some are part-time making a full-time equivalent of 15.75 GPs. There is a clinical pharmacist and a nursing team of two advanced nurse practitioners, six nurses including the nurse lead (who is a nurse prescriber) and seven healthcare assistants.  There are 12 dispensers and an administrative and reception team of 43 staff led by the practice manager. In addition the practice had a business manager.

The practice is a training and teaching practice for medical students and trainee GPs. (A teaching practice accepts medical students while a training practice accepts qualified doctors training to become GPs who are known as Registrars.) At the time of our inspection there  were two registrars being supported by the practice.   The practice is also accredited to participate in medical research.

Most of the practice buildings, including the main surgery at Endless Street, are open from 8am to 6.30pm, Monday to Friday. The branch surgery at Winterslow has more restricted opening times which are available on the practice website. Appointments are from 8.30am to 6.30pm. Extended hours appointments with a GP are available from 7.30am to 8am on Tuesday, 6.30pm to 7.30pm on Monday and from 10am to 12 noon on alternate Saturdays.

The practice has opted out of providing a full Out Of Hours service to its own patients. Patients are directed to access an Out Of Hours GP service by calling NHS 111.

The practice has a General Medical Services contract with NHS England (a locally agreed contract negotiated between NHS England and the practice).

The practice provides services from the following sites:

• Endless Street Surgery, 72 Endless Street, Salisbury, SP1 3UH
• St Ann Street Surgery, 82 St Ann Street, Salisbury, SP1 2PT
• Three Swans Surgery, Rollestone Street, Salisbury, SP1 1DX
• Winterslow Surgery, Middleton Road, Winterslow, Salisbury, SP5 1PQ
• Porton Surgery, 32 Winterslow Road, Porton, Salisbury, SP4 0LR

As part of our inspection we visited all sites, except Winterslow Surgery.

The practice has a website containing further information. It can be found here:

On the day of our inspection the practice registration with the CQC was not correct. There was one GP partner who was not shown in the practice registration with the CQC and three partners had left but continued to be registered as partners with us. Our records showed the practice was in the process of dealing with these issues.

Updated 4 June 2018

This practice is rated as Good overall.

The key questions are rated as:

• Are services safe? – Good
• Are services effective? – Outstanding
• Are services caring? – Good
• Are services responsive? – Good
• Are services well-led? - Outstanding

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

• Older People – Good
• People with long-term conditions – Good
• Families, children and young people – Good
• Working age people (including those recently retired and students – Good
• People whose circumstances may make them vulnerable – Good
• People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Three Chequers Medical Practice on 17 April 2018. This is our first inspection of Three Chequers Medical Practice, which we carried out as the practice is a newly registered service. The practice was formed in 2017, by the merger of Endless Street Doctors Surgery, Three Swans Surgery and St Ann Street Surgery (all based in Salisbury city centre). The practice now operates across five sites, three of which have a dispensary.

At this inspection we found:

• The recent merger of three practices to create Three Chequers Medical Practice had caused some disruption to services. However, the practice was aware of the issues and we saw numerous examples of a clear and structured approach to resolving them. The strategy and supporting objectives were stretching, challenging and innovative, while remaining achievable.
• The practice had a clear and strong management structure. GP partners at the practice had a long history of initiating and developing new ways of working prior to the merger and we saw evidence this was continuing. For example, they had recently introduced a computerised workflow system to manage medical correspondence.
• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. However, we found that routine checks recommended to reduce the risk of Legionella infection had not been carried out since February 2017.
• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff involved and treated patients with compassion, kindness, dignity and respect. There was evidence staff went ‘that extra mile’ to support patients when necessary.
• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
• There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw a number of areas of outstanding practice:

• The practice ran a specialist service to deliver annual health checks to people with a learning disability. The service included a GP, a consultant in learning disabilities and a learning disability specialist nurse. Patients with the most complex care needs were reviewed by the GP and Consultant in joint consultations.
• The practice ran a service that aimed to improve the care provided to older people and reduce unplanned admissions to hospital for people aged 75 or over. There was evidence that while the rate of unplanned admissions for this group of patients had gone up nationally, the practice rate had remained the same.
• The practice led a Community Heart Failure project in partnership with other local practices. It was a pilot project designed to establish the need for a community service and to set up such a service if the evidence showed it to be a practical and cost effective service model. In the three months up to December 2017, 322 new patients had been referred to the service, all had been seen within 14 days, with an average waiting time of 6 days, and 34 patients had been cared for at home who might otherwise have needed hospitalisation.
• The practice had developed a service for patients with mental health and substance misuse problems, and who frequently used health services, such as the accident and emergency department. The service was led by a GP with an interest in mental health and a psychiatric nurse. Patients where offered a more intensive service and we saw evidence it was helping patients achieve more stability and positive outcomes.

The areas where the provider should make improvements are:

• Review their systems to allow the practice to confirm that all learning points from complaints and significant events had been shared with all appropriate staff.
• Review their systems to allow the practice to confirm that all patients who make a complaint are given information about the escalation process if they are not satisfied with the practice response.
• Review their systems to ensure the appropriate checks are carried out for the prevention of legionella.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Updated 4 June 2018

Updated 4 June 2018

Updated 4 June 2018

Updated 4 June 2018

Updated 4 June 2018

Updated 4 June 2018