Stonecot Surgery

Updated 7 March 2017

Stonecot Surgery provides primary medical services in Merton to approximately 9000 patients and is one of 24 practices in Merton Clinical Commissioning Group (CCG).

The practice population is in the second least deprived decile in England. The proportion of children registered at the practice who live in income deprived households is 12%, which is below the CCG average of 17%; and for older people the practice value is 12%, which is below the CCG average of 16%. The practice age range of the practice’s patients largely follow the same pattern as the local average. Of patients registered with the practice, 19% are of non-caucasian ethnicity. The practice provides services to veterans who reside in a nearby residential development.

The practice operates from a 2-storey converted residential premises. A small amount of car parking is available at the practice, and there is space to park in the surrounding streets. The reception desk, main waiting area, and five consultation rooms are situated on the ground floor. The practice manager’s office, administrative office, staff kitchen, small waiting area and two consultation rooms are situated on the first floor.

The practice team at the surgery is made up of two part time male GPs and two part time female GPs who are partners, a nurse practitioner and a physician’s associate. The practice is a training practice and at the time of the inspection had three GP trainees. In total the practice offers 30 GP sessions, 23 trainee GP sessions and eight nurse practitioner/physician associate sessions per week. The practice also employs three part time female nurses. The clinical team are supported by two practice managers (one currently on maternity leave), a reception manager and nine part time receptionists, a medical receptionist and three administrative assistants.

The practice operates under a Personal Medical Services (PMS) contract, and is signed up to a number of local and national enhanced services (enhanced services require an enhanced level of service provision above what is normally required under the core GP contract).

The practice is open between 8am and 8pm Monday to Thursday and 8am to 7:30pm on Friday. Appointments are from 8am to 8pm on Monday, Tuesday and Thursday, and from 8am to 6:30pm on Wednesday and Friday. In addition to pre-bookable appointments that can be booked up to three weeks in advance, urgent appointments were also available for people that needed them.

The practice is registered as a partnership with the Care Quality Commission to provide the regulated activities of diagnostic and screening services; maternity and midwifery services; treatment of disease, disorder or injury; surgical procedures; and family planning.

Updated 7 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Stonecot Surgery on 10 January 2017. Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Opportunities for learning from internal and external incidents were maximised.
• Risks to patients were assessed and well managed; however, they had not ensured that all staff had received fire safety training and had not completed any full evacuation fire drills.
• 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 they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had an established Patient Participation Group, which it consulted with regularly in order to gather patients’ views of proposed changes within the practice.
• The practice had strong and visible clinical and managerial leadership and governance arrangements.
• The practice had a programme of continuous clinical audit, which was informed by both incidents within the practice and external factors. We saw evidence that the outcomes of audits was used to drive improvement within the practice.
• The provider was aware of and complied with the requirements of the duty of candour.

We saw two areas of outstanding practice:

The practice was committed to securing the future of general practice. This was demonstrated by their commitment to the training of doctors and nurses; the practice provided placement opportunities to medical students, GP registrars, nursing students, physician’s associates and pharmacists undertaking the non-medical prescriber course.

The management team were dedicated to ensuring that all patients at the practice received the care and treatment they required, and this ethos was embedded in the way that tasks were carried-out at the practice. For example, the partners had a low tolerance for excepting patients from the Quality Outcomes Framework (QOF) and the practice was committed to engaging with patients to ensure that their existing health conditions were well managed and that they participated in preventative screening. The success of this approach was demonstrated by the practice’s high QOF achievement, low rate of exception reporting, and their high uptake of bowel, breast and cervical cancer screening. The practice’s rate of outpatient attendance and unplanned hospital admission were significantly below the expected rate for their patient population.

The areas where the provider should make improvement are:

• Ensure that all staff have received fire safety training and carry-out full evacuation fire drills.
• Put processes in place to ensure that all regular locum staff are up to date with mandatory training.
• Consider ways to allow patients without access to a computer to participate in the PPG.
• Put in place a failsafe system to ensure that results are received for all samples submitted for the cervical screening programme.
• Advertise the availability of translation services to patients in the waiting area.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Updated 7 March 2017

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.
• Overall, performance for diabetes related indicators was comparable to the CCG and national average. The practice achieved 85% of the total QOF points available, compared with an average of 84% locally and 90% nationally. Their exception reporting rate overall for diabetes indicators was 5% compared to a CCG average of 10% and national average of 12%.
• The practice provided in-house services for patients with long-term conditions which reduced the need for patients to travel. For example, they provided a comprehensive diabetes service including insulin initiation, in-house INR testing for patients taking Warfarin, asthma and chronic obstructive pulmonary disease clinics, and advanced wound dressing.
• 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; the practice achieved a high rate for long-term condition annual reviews. For patients who were housebound, annual reviews were carried-out in the patient’s home; the practice had provided 78 home visits for long-term condition reviews in the past year.
• 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.

Updated 7 March 2017

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.
• Cervical screening had been carried-out for 83% of women registered at the practice aged 25-64, which was comparable to the CCG and national average of 81%; the exception reporting rate was 2% compared to a CCG and national average of 7%.
• 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.

Updated 7 March 2017

The practice is rated as outstanding 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 actively monitored and supported patients identified as at risk of an unplanned admission to hospital and reviewed all patients who were admitted. The practice’s rate of outpatient attendance and unplanned hospital admission were significantly below the expected rate for their patient population (80 per 1000 patients compared to a predicted rate based on the patient demographic of 130 per 1000 patients), and the practice explained that this was due to their pro-active approach to managing these patients, for example, by providing a high proportion of home visits to these patients. The practice had also put in place a policy of having all urine test results checked by the duty doctor before the practice closed; this enabled any patients with urinary tract infections (which can require hospitalisation in older people when left untreated) to be treated promptly without a delay overnight or over the weekend.
• The practice had trained five of their administrative staff as “care navigators”, whose role was to act as patient advocates to support elderly patients by providing advice about services available to them, remind those with cognitive impairment about upcoming appointments, and to contact patients who had failed to attend appointments to check on the welfare of the patient and re-book their appointment where necessary.

Updated 7 March 2017

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 open until 8pm Monday to Thursday and until 7:30pm on Fridays, which allowed patients who worked during the day to access the practice for routine tasks such as picking up prescriptions and making appointments.
• 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 provided a full range of contraception services including the fitting of coils and contraceptive implants.

Updated 7 March 2017

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

• The practice had 100 patients diagnosed with dementia and 90% of these patients had had their care reviewed in a face to face meeting in the last 12 months, which was better than the CCG average of 85% and national average of 84% (their exception reporting rate was 2% compared to a CCG average of 4% and national average of 7%).
• The practice had 98 patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses, and had recorded a comprehensive care plan for 88% of these patients, compared to a CCG average of 90% and national average of 89% (however, their exception reporting rate was 1% compared to a CCG average of 8% and national average of 13%).
• 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 7 March 2017

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, and those with a learning disability.
• The practice recognised they had a number of patients belonging to groups with particular needs. For example, there was a development of homes for ex-service personnel within the practice boundary, and therefore it had a large number of patients who had served in the armed forces. These patients were coded on their patient records system to ensure that they received the priority treatment they were entitled to. The practice also had a high number of patients who did not speak English as a first language, and it had ensured that information was available and processes were in place to provide care to these patients.
• 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.