Tollgate Medical Centre

Updated 28 September 2016

Tollgate Medical Centre is situated within the NHS Newham Clinical Commissioning Group (CCG). The practice provides services to approximately 16,800 patients under a Personal Medical Services (PMS) contract. The practice provides a full range of enhanced services including a diabetes clinic, child and travel vaccines, and family planning including coil fitting. It is registered with the Care Quality Commission to carry on the regulated activities of Maternity and midwifery services, Family planning services, Treatment of disease, disorder or injury, Surgical procedures (joint injections only), and Diagnostic and screening procedures.

The premises are purpose built and arranged over two storeys; all consulting rooms are on the ground floor.

The staff team at the practice includes eight GP partners, (four female working a total of 28 sessions, and four male working a total of 21 sessions per week), two salaried GPs (both male working a total of ten sessions per week), three GP registrars (one male working eight sessions and two female working a total of 16 sessions per week), a female advanced nurse practitioner and independent prescriber working 37.5 hours per week, four female practice nurses (three working 37.5 hours and one working 36 hours per week), three female health care assistants (working 36, 28 and 16 hours per week), a practice pharmacist working 37.5 hours per week, a practice manager working 37 hours per week, a team of full time reception and administrative staff, and one part time member of reception staff. The practice provides teaching for medical students and training for qualified GP registrars, Senior House Officers (a junior position for graduate doctors who are under training within a medical specialty), pre-registration nursing students, a trainee advanced nurse practitioner, and a trainee practice nurse.

The practices core opening hours are between 8:00am to 6.30pm every weekday. The practice offers extended hours from 7.00am to 8.00am every weekday and from 6.30pm until 7.00pm on Mondays. GP appointments are from 7:00am to 6.30pm every weekday except Monday when they are until 6.50pm. Patients telephoning are transferred to the local out-of-hours service provider when the practice is closed. Appointments include pre-bookable appointments, home visits, telephone consultations and urgent appointments for patients who need them.

The practice is located in one of the most diverse and deprived areas in England. Locally held data shows the top five languages spoken by patients whose first language is not English are Lithuanian, Bengali, Polish, Russian and Romanian. The average male and female life expectancy for the practice is 78 years for males (compared to 77 years within the Clinical Commissioning Group and 79 years nationally), and 83 years for females (compared to 82 years within the Clinical Commissioning Group and 83 years nationally).

Updated 28 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Tollgate Medical Centre on 4 July 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.

• Risks to patients were generally assessed and well managed with the exception of those relating to infection control and prescriptions security.
• 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.
• Feedback from patients about their care was consistently positive. 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 strong and visible clinical and managerial leadership and governance arrangements 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.
• 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.

We saw two areas of outstanding practice:

• The practice showed leadership and took responsibility at an organisational level to improve local child protection arrangements. For example, clinical and non-clinical staff made detailed records of barriers in reporting and communicating individual child protection concerns to allied health and social care professionals. Staff collated and sustained escalation of its concerns until they reached persons responsible for the system. The practices ongoing commitment triggered an analysis of the system to improve child protection arrangements in the local area.
• The practice was responsive to its patients and had proactively engaged its PPG as partners in operational and strategic planning as well as work to engage the local community. For example, the PPG had made suggestions to improve medicines prescribing and the practice facilitated the PPGs direct contact with the local CCG to discuss policy. The PPG made suggestions for improvements to stoma care and diabetes care which led to the practice initiating a borough wide support group and local diabetes educational group within the practice. (A stoma is an opening on the front of the abdomen which is made using surgery. It diverts faeces or urine into a pouch on the outside of your body). The practice had worked jointly with the PPG to provide health promotion through local events such as healthy eating, a PPG 3rd birthday fun party and a festival at Easter time. The practice had plans to move to bigger premises and the PPG was involved with the plan.

The areas where the provider should make improvement are:

• Review and embed systems for prescriptions security and infection prevention and control.
• Ensure plans to improve communication with patients who are deaf or hard of hearing are implemented.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 28 September 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.
• Longer appointments were available when needed and the practice nurse and health care assistant team undertook regular home visits for housebound patients.
• The practice identified 2517 patients with long term conditions (15% of its list size). These patients had a named GP and a structured annual review to check their health and medicines needs were being met.
• 96% of patients with long term conditions had their smoking status recorded in the last 12 months and 99% of those who smoke (450 patients) received smoking cessation advice.
• 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.

• On site services included phlebotomy, ECG, 24 hour blood pressure monitoring, contraception and joint injections. (Phlebotomy is blood sample collection and an ECG or “electrocardiogram” is a test which measures the electrical activity of your heart's rhythm and activity).
• Performance for diabetes related indicators was 93% compared to the CCG average of 87% and national average of 89%. The practice identified 234 patients with prediabetes and 59% had an annual monitoring review.

• The percentage of patients with hypertension having regular blood pressure tests was 88% compared to the CCG and national averages of 84%.
• The PPG made suggestions for improvements to stoma care and diabetes care which led to the practice initiating a borough wide support group and local diabetes educational group within the practice. 

Updated 28 September 2016

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

• The practice demonstrated a high degree of commitment and leadership to improve local child protection arrangements and had triggered an analysis of wider arrangements to make systemic improvements in this area.
• The practice worked in close partnership with the PPG to provide health promotion community and family events such as healthy eating during a PPG pride 3rd Birthday with face painting, and seasonal festivals for example at Easter time.
• Three GPs at the practice offered IUCD (“coil”) procedures. All GPs and two specially trained members of the nursing team offered contraception services including to teenagers. Records indicated that they were treated in an age-appropriate way and recognised as individuals.
• 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.
• The practice had a wide range of services available on site.
• Childhood immunisation rates for the vaccines given to under two year olds ranged from 82% to 98% (CCG ranged from 82% to 94%) and five year olds from 85% to 98% (CCG ranged from 82% to 94%).
• 79% of patients diagnosed with asthma, on the register had an asthma review in the last 12 months compared to 78% within the CCG and 75% nationally.

• The practice’s uptake for the cervical screening programme was 94% compared to the CCG average of 81% and the national average of 82%.
• The practice held eight weekly multidisciplinary team meetings with community nursing and health visitor colleagues to discuss and plan care for children and protected children.
• Appointments were available outside of school hours and the practice ran a child development clinic and hosted a midwife clinic, both weekly.
• We saw positive examples of joint working with health visitors and the premises were suitable for children and babies.
• A midwife attended the practice twice weekly. The practice also provided a consulting room on a weekly basis for the Ultrasound department of Newham University Hospital for patients on their own list and patients from other practices.
• The practice had recruited three apprentices from the local community to train and develop in general practice administration and support the wider team.

Updated 28 September 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 percentage of patients with rheumatoid arthritis, on the register, who had had a face-to-face annual review in the preceding 12 months was 100% which was comparable to 91% within the CCG and 91% nationally.
• The practice identified 396 patients at high risk of hospital admission such as frail older people (2% of its list size), 345 of these patients (87%) had a care plan review in the past 12 months.
• The practice held eight weekly multidisciplinary team meetings to discuss the care of older people with community nursing, palliative care and health visitor colleagues

Updated 28 September 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.
• Patients could refer themselves for talking therapies and physiotherapy.
• The practice was the highest performer for health checks for 40 – 75 year old patient’s years in Newham.
• The practice had a wide range of services available on site.

Updated 28 September 2016

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

• The practice had identified 38 patients diagnosed with dementia on its register. Eighty three percent of these patients had their care reviewed in a face to face meeting in the last 12 months, which was comparable to CCG average of 87% and the national average of 84%.
• Several GPs had undertaken rotations at Newham Centre for Mental Health as part of their GP training and staff had undertaken online dementia awareness training.
• Performance for mental health related indicators was 100% compared to the CCG average at 87% and the national average of 93%.
• The practice had identified 167 patients on its register with a mental health condition and 13% had been exception reported. 89% of these patients had a care plan, 94% had their alcohol intake recorded in the last 12 months and 100% of those eligible had a smear test in the past five years.
• The practice hosted three full days of counselling services that were accessible to its patients and patients could self-refer to access talking therapies.
• The practice held alternate monthly multidisciplinary meetings with the community mental health team to discuss the most complex cases, including to achieve outpatients transfer to GP care for some patients recovery closer to home.

Updated 28 September 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 and those with a learning disability and a spreadsheet to ensure vulnerable patients discharged from hospital were followed up within three days.
• The practice had a nominated lead GP for patients with learning disabilities. Sixty six of the 77 patients with learning disabilities (86%) had had received an annual health check.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients and had links with a local hospice and referred isolated patients to the local befriending service.
• The practice informed vulnerable patients about how to access various support groups and voluntary organisations. such as “Community Links” and the Citizens Advice Bureau.
• Staff knew how to recognise signs of abuse and were proactive in safeguarding 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 liaised with and provided shared care prescribing with a local substance misuse service.