Background to this inspection
Updated
11 November 2016
Moorends Surgery, or Thorne Moore Medical Practice as it is known locally, is located on the outskirts of Doncaster. The partners have another practice at Chestnut House Surgery in Thorne, Doncaster, DN8 4BQ. Both practices have one patient list and provide services for 8,748 patients under the terms of the NHS General Medical Services contract. The practice catchment area is classed as within the group of the third more deprived areas in England. The age profile of the practice population is similar to other GP practices in the area.
The practice has five GP partners, two female and three male and they are supported by two advanced nurse practitioners, two practice nurses, two healthcare assistants an associate practice manager and a team of reception and administrative staff.
The practice is open between 8am to 6pm Monday to Friday. Appointments are available with GPs between 8.30am to 12 noon and 3.30pm to 5.30pm daily with the exception of Wednesday afternoon from 4pm to 5.30pm. Appointments with other staff are available throughout the day. Extended hours appointments are offered every Saturday with GPs, practice nurse and healthcare assistant from 9am to 11am at the Chestnut House surgery. In addition to pre-bookable appointments that could be booked up to six weeks in advance, urgent appointments were also available for people that needed them. A phlebotomy service with the healthcare assistant is available daily.
When the practice is closed calls are answered by the out-of-hours service which is accessed via the surgery telephone number or by calling the NHS 111 service.
The practice is located in a purpose built building with all patient facilities on the ground floor. There are a number of parking spaces to the front and rear of the practice and designated disabled parking spaces.
As part of the Care Quality Commission (Registration) Regulations 2009: Regulation 15 Notice of changes we noted GP partners registered with the Care Quality Commission as the partnership did not reflect the GP partners currently at the practice. We were told this would be addressed following the inspection and the appropriate applications and notifications submitted.
Updated
11 November 2016
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Moorends Surgery on 26 September 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 assessed and well managed.
- 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.
- There was a clear leadership structure 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 areas where the provider should make improvement are:
- Implement a process to track prescriptions through the practice in accord with NHS Protect Security of Prescription Guidance 2013.
- Record the practice process for safeguarding adults and children within a procedural document.
- Complete a detailed infection prevention and control audit and take action in accord with the findings.
-
Continue to progress telephone system upgrade plans and review patient satisfaction with telephone access to the practice.
Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice
People with long term conditions
Updated
11 November 2016
The practice is rated as good for the care of people with long-term conditions.
- Nursing staff had lead roles in long term condition management and patients at risk of hospital admission were identified as a priority.
- Performance for diabetes related indicators was 3% below and 4% above the national average.
- 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.
Families, children and young people
Updated
11 November 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 accident and emergency 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.
-
The practice’s uptake for the cervical screening programme was 82%, which was comparable to the CCG average the national average of 82%.
- 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
11 November 2016
The practice is rated as good for the care of older people.
- All these patients had a named GP.
- 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.
Working age people (including those recently retired and students)
Updated
11 November 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.
People experiencing poor mental health (including people with dementia)
Updated
11 November 2016
The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).
- 80% of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the last 12 months, which is just below the national average of 84%.
- 91% of patients experiencing long term poor mental health had an agreed care plan documented in place which was above the national average of 88%.
- The practice regularly worked with multidisciplinary 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.
People whose circumstances may make them vulnerable
Updated
11 November 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 those with a learning disability.
- The practice offered longer appointments for patients who needed them.
- 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 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.