Cherry Hinton & Brookfields Medical Practice

Updated 20 June 2016

Letter from the Chief Inspector of General Practice

We carried out a desk based review for Cherry Hinton & Brookfields Medical Practice

on 13 June 2016. This was to follow up on actions we asked the provider to take after our announced comprehensive inspection on 10 March 2016. During the inspection in March 2016, we identified that the provider had to make improvements to the systems in place to ensure medical equipment was in date. The provider wrote to tell us about the actions they had implemented in order to comply with Regulation 12: safe care and treatment.

We found the practice had made improvements and put systems in place to ensure medical equipment was in date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 14 April 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 for diabetes related QOF indicators was above the local clinical commissioning group (CCG) and national averages, with the practice achieving 91% across diabetes indicators; this was 1% above CCG average and 2% above national average. The practice team liaised with the diabetes specialist nurse.

• 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 14 April 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.

• Performance for asthma QOF indicators was better or in–line when compared to the CCG and national averages, with the practice achieving 100% across each indicator for 2014/2015.

• 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.

• The practice’s uptake for the cervical screening programme was 80.28% which was comparable to the national average of 81.83%. There was a policy to offer telephone reminders for patients who did not attend for their cervical screening test.

• 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 14 April 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 practice identified a high percentage of over 65 year old patients who frequently contacted the practice or were at risk of admission to hospital. There was a dedicated daily duty GP who triaged all patient contact with out of hours care. The GP would contact these patients and either make an appointment, offer advice or arrange an early home visit. This meant that patients in need of further treatment or referral to secondary care would receive early intervention and access to treatment. The practice had identified that 19% of this patient group contacted were in need of clinical advice, whilst 43% were identified as being over 80 years old and required either a home visit or further referral.

Updated 14 April 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 continued to adjust 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.

Updated 14 April 2016

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

• 70% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average.

• 84% of patients who may be experiencing poor mental health had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average.

• 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.

• 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 14 April 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 had identified 40 patients on the learning disability register, 39 patients were suitable for annual review. The practice confirmed that due to a temporary staff shortage none of these patients had received their annual review this year, but confirmed these were scheduled for the following two weeks. We saw that the 2014/2015 QOF

• 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 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.