Archived: The Ardleigh Surgery

Updated 6 September 2017

The Ardleigh Surgery provides primary care services to approximately 7043 patients with a main practice in Ardleigh and a branch practice in Dedham. They hold a ‘General Medical Service’ (GMS) contract for the services they provide which includes a dispensing service from the main surgery for 4975 patients; this equates to 71% of their population and is available during practice opening hours daily.

• They are a training practice that supports qualified doctors, known as registrars, completing the final stages of their GP training.

• The deprivation score is low for the practice area in comparison with other local and national GP practices.

• The practice has three GP registered partners, two male and one female GPs. The GP partners are supported by two salaried GPs, one female and one male and a trainee registrar. The GPs are supported by one prescribing advanced nurse practitioner, one prescribing practice nurse, an assistant practitioner and a phlebotomist. The dispensary team comprises of three members of staff. The management and administration team comprises of a practice manager and nine other staff members with a range of roles; secretary, administrators and receptionists.

• The staff members hold a combination of roles and work patterns of full and part time hours. During 8am to 8.30am and at lunchtime from 1pm until 2pm, an answerphone message connects patients to the duty doctor for emergencies. The practice opening hours are 8.30am until 1pm and from 2pm until 6.30pm every weekday. The branch practice opens from 8.30am until 1pm each weekday morning. The branch practice is open each afternoon for nurse clinics, for podiatry, audiology, and outreach clinics from the hospital that use the premises. The clinical sessions run during the opening hours and include clinics for asthma, chronic obstructive pulmonary disease (COPD), diabetes, contraception, including coils and implants, smoking cessation, phlebotomy (blood taking), minor surgery, childhood immunisation and holiday vaccinations, and minor injuries, including suturing.

• The practice has opted out of providing GP out of hour’s services. Patients calling the practice outside normal practice working hours are advised by the answerphone message to contact the 111 non-emergency services. Patients requiring urgent treatment are advised to contact the out of hour’s service which is provided by Care UK.

Updated 6 September 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Ardleigh Surgery on 1 November 2016 where the practice was rated as good overall. However the practice was found to be requires improvement for providing safe services. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for The Ardleigh Surgery on our website at www.cqc.org.uk.

This announced desk based review was carried on 10 August 2017 to confirm that the practice had made the improvements required that were identified in our previous inspection on 1 November 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is rated as good for providing safe services.

Our key findings were as follows:

• The practice was recording and learning from near misses when dispensing. These had been discussed at a practice meeting.

• The practice had a new process to ensure prescriptions and medicines waiting to be collected were securely stored.

• There was an effective checking process in place to meet the ‘cold chain procedure’ requirements for the storage of medicines.

• The practice had appropriately authorised ‘Patient Specific Directions’ (PSDs) which were signed prior to the administration of vaccinations by the assistant Practitioner.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 10 February 2017

The practice is rated as good for the care of people with long-term conditions.

• Nursing staff and GPs had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. Personalised care plans had been created, agreed with patients, and shared to ensure continuity of care.

Diabetic quality data from 2015 to 2016 showed:

• The percentage of patients with diabetes, on the register, in whom the last IFCCHbA1c is 64 mmol/mol or less in the preceding 12 months, was 78% (compared with 75% locally and 78% nationally).
• The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less was 84% (local practices 78% and nationally 78%).

Other services provided by the practice for this population group were:

• Longer appointments and home visits were available when needed.
• People with long-term conditions were provided a named practice GP and given a structured annual review to check health and medicine needs were maintained and met. The named GP worked with relevant health and social care professionals to deliver a multidisciplinary package of care.
• The practice used a 24 hour ambulatory blood pressure monitors to collect an accurate recording of blood pressure to assist clinicians with diagnosis and treatment.
• The practice nurses had received specialist training in diabetes, asthma, and chronic obstructive pulmonary disease, to support the GPs manage long term condition patients. Home visits to monitor patients were made by practice nurses to ensure those unable to attend the practice received their reviews.
• Practice prescribers used clinical templates designed to ensure patient’s received the blood tests, and diagnostic checks required before repeat prescriptions were given to patients.
• There was a practice based blood taking service to support patients in this population group that would struggle to access the local hospitals blood taking clinics.
• Regular medicine monitoring searches were undertaken for patients taking high risk medicine and medicines that required extra monitoring. Full ranges of services were offered for those patients with chronic diseases. This included heart failure, chronic obstructive pulmonary disease (COPD) and diabetes management, to reduce the need for hospital visits. This included minor injury, minor surgery and a wound care service.
• Telephone consultations were also used to monitor chronic diseases parameters for example; blood glucose levels for diabetic patients and, peak flow for COPD patients.

Updated 10 February 2017

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

• There was a system in place to follow-up children living in disadvantaged circumstances or at risk; for example, those that had experienced a high number of A&E attendances. Children that ‘do not attend’ (DNA) appointments were checked promptly.
• The practice told us they saw all babies, children and young people on the day.
• On-line appointments were available for both advanced and on the day appointments.
• Immunisation rates were high for all standard childhood immunisations and flu in comparison with practices locally and nationally.
• Parents of children we spoke with told us they were treated in an age-appropriate manner; that staff members encouraged children to ask questions, and the language used during consultations to explain treatment was easy to understand.
• Patients aged 25-64, attending cervical screening within the target period of 3.5 or 5.5 years coverage was 85% (compared locally 83% and nationally 81%).
• Appointments were available outside school and college hours.
• Midwives held clinics at the practice on a fortnightly basis. The practice nurses said there was positive joint working with their community professional colleagues.
• The GPs provided baby checks and pre-school checks and educational leaflets were provided to support parents when required.
• There was a range of contraception including the fitting and removal of intrauterine contraceptive devices and other contraceptive implant devices.
• The safeguarding lead GP at the practice led on all safeguarding issues identified at the practice.
• The provision of a minor injuries service meant the practice was able to stitch or glue wounds and remove foreign bodies to avoid trips to A&E or the minor injuries unit at the hospital.
• The practice phlebotomist was experienced at taking blood from children and young people to avoid the need for them to attend the hospital.

Updated 10 February 2017

The practice is rated as good for the care of older people.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments when needed or requested.
• All older people had a named GP.
• GPs provided routine weekly ward rounds at residential and nursing homes covered by the practice to ensure they received continuity of care.
• A member of the nursing team had completed specialist dementia training which enabled opportunistic dementia screening for the most vulnerable.
• They provided a phlebotomy service which included home visits for frail/housebound patients for medicine monitoring.
• Palliative care meetings were used to understand and discuss patients identified as frail and at risk of deteriorating health.
• The practice provided abdominal aortic aneurysm (AAA) screening of all males over the age of 65 years, podiatry, and audiology to offer care closer to home.
• They had a high uptake for shingles and flu vaccinations and actively campaigned across a variety of media, for example; prescription repeat forms, posters in the waiting room, on their website and opportunistically during routine appointments.
• Senior health checks were offered, on an ad hoc basis to maximise their uptake.
• The ground floor purpose built practice was wheelchair accessible and a hearing loop and interpreter services were available for patients with impaired hearing.
• A care advisor visited the practice regularly to help patients deal with benefits and equipment needs.
• GPs made urgent ad hoc medicine deliveries and the dispensary provided patients with single dose boxes as support for those patients needing it.

Updated 10 February 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 at the practice and they had adjusted the services offered to ensure they were accessible, flexible and provided continuity of care.
• Although the practice did not offer extended hours they did offer on-line services to support working patients for example; appointments booking, repeat prescription management, and telephone consultations to fit in with working lives. Appointments were available from 8am until 6.30pm with the prescribing nurse practitioner.
• Telephone monitoring of chronic disease patients was also available to meet their health needs
• Those that had requested the service received text messages regarding appointment reminders and the results of any diagnostic tests they had received. Patients telephone details were updated with patients each time they had a verbal or face-to-face contact to check their details were correct.
• There was a full range of health promotion and patient screening that reflected the needs of this population group, for example “NHS Health Checks” for 40 - 74 year olds.
• Private employment medicals and insurance reports were available, to support patients that required them for work.

Updated 10 February 2017

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

Mental health quality data from 2015 to 2016 showed, the practice performance was lower than the national and local practice averages for patients with schizophrenia who have a comprehensive, agreed care plan documented in their record. However performance of patients diagnosed with dementia that had their care reviewed in a face to face meeting was comparable with national and local practice averages for example:

• 67% of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive, agreed care plan documented in the record, in the preceding 12 months (compared with 83% locally and 89% nationally).
• 85% of patients diagnosed with dementia that had their care reviewed in a face to face meeting in the last 12 months at the practice, (compared with 83% locally and 84% nationally).

Other services provided by the practice for this population group were:

• The practice worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. Clinicians visited a local care home where 90% of the 58 residents had dementia.
• The practice had told patients experiencing poor mental health how to access various support groups and voluntary organisations such as ‘Health in Mind’ and ‘IAPT’ services.
• The practice followed up patients who had attended accident and emergency that may have been experiencing poor mental health.
• Staff members had received training and understood how to support patients with mental health or dementia needs.
• Patients with mental health issues had an appropriate alert placed on their records; this allowed staff members to recognise any extra support these patients may need.
• The practice told us they offered patients in this population group on the day appointments to ensure patients in mental health crisis could access a clinician and receive the support they needed. Patients on the mental health register were followed up by a telephone call if they did not attend their appointment.
• Practice staff members told us they would find a suitable quiet area for patients to wait if they were feeling anxious, depressed, or too unwell to wait in the busy waiting room.
• Prescribing and monitoring for patients at risk of poor concordance or overdose was set to the person’s specific needs, we were told this could be daily, weekly, or fortnightly.

Updated 10 February 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

• The practice had identified patients living in vulnerable circumstances; this included those with a learning disability, homeless people, or travellers.
• The practice clinical members of staff worked with other health care professionals in the case management of vulnerable patients. They worked closely with local care homes to provide, treatment planning, and home visits when needed.
• There were 21 patients identified by the practice as living with a learning disability that had been offered an annual assessment and health check. Home visits were provided when appropriate for annual learning disabilities health checks and a lead nurse had been appointed to support those living with learning disabilities or a mental illness.
• Longer appointments were provided for patients with a learning disability and staff members were learning disability aware which meant they knew how to treat people accordingly.
• The practice provided information to vulnerable patients about how to access various support groups and voluntary organisations.
• Staff knew how to recognise the signs of abuse in vulnerable adults and children. They were aware of their responsibilities concerning the sharing of information and the documentation of safeguarding concerns. The practice safe guarding policy set out the details around how to contact the relevant local agencies during normal working hours and out of hours for staff members.
• All staff members had undergone safeguarding training and could recognise the signs of abuse in vulnerable adults and children. Staff members were aware of their responsibilities regarding information sharing and discussed this with leads if they were unsure.
• The GP safeguarding lead at the practice attended forums when possible.