Burnt Ash Surgery

Updated 9 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of the practice on 10 February 2016. Breaches of the requirements of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 were found. The practice was rated as Requires Improvement for Safety.

After the comprehensive inspection, the practice wrote to us to say what they would do to address the breaches of regulation. 

We undertook a desk-based focussed inspection on 16 November 2016 to check that they had followed their plan and to confirm that they now met the legal requirements. This report covers our findings in relation to those requirements and also where other improvements have been made following the initial inspection. You can read the report from our last comprehensive inspection by selecting the ‘all reports’ link for Burnt Ash Surgery on our website at www.cqc.org.uk.

Overall the practice is rated as Good. Specifically, following the focussed inspection we found the practice to now be good for providing safe services.

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

• Risks to patients were assessed and well-managed, including those related to recruitment, staff training and support.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 25 May 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.

• Performance indicators for the care of diabetic patients was broadly in line with national averages. For example, 88% of patients recorded by the practice as diabetic had been reviewed in last year. (The national average is 88%).

• The senior nurse practitioner at the practice was trained to start treatment with insulin for patients with diabetes, meaning that patients did not have to travel to hospital if they needed insulin to manage their diabetes.

• 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.

Updated 25 May 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.

• 69% of patients with asthma had a formal review of their asthma (compared to the CCG average of 73% and the national average of 70%.)

• 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.

• 76% of women aged 25 – 64 received a cervical screening test. This was lower than the national average of 82%. The practice was taking active steps to improve their uptake of cervical screening, and expected this to be reflected in the next performance figures.

• 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 two well-baby clinics a week, one run by a Health Visitor and one run by a Health Visitor and a GP.

Updated 25 May 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.

• 93% of the practice’s patients diagnosed with dementia had received a face to face review of their care in the last year, compared with a national average of 84%.The Older Person Liaison Officer provided a personalised responsive service for older people. This included: home visits, support and transport to attend appointments at the surgery and at hospital, liaison with other local services, and prescription collection.

• The practice participation group (PPG) ran a ‘time for tea’ project once a month where older people were invited to drop in to the PPG chair’s house after their appointment, for conversation and refreshments.

Updated 25 May 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 offered a full range of health promotion and screening that reflects the needs for this age group.

• Online services (such as online appointment booking) were available, but were not advertised on the practice website or widely within the practice.

Updated 25 May 2016

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

• 91% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the record in the preceding 12 months. (The national average was 89%).

• The practice regularly worked with multi-disciplinary teams in the case management of people 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.

• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 25 May 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.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.

• 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 generally 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.