The Windmill Practice

Updated 3 August 2016

The Windmill Practice provides primary medical services to approximately 7800 patients through a personal medical services (PMS) contract. The practice is located in very close proximity to Nottingham City Centre in purpose built premises which are shared with other local community health services. The practice is sole provider of GP services for a forensic psychiatric service and the Nottingham City Complex Alcohol Service. There is a homeless hostel located next to the practice.

The level of deprivation within the practice population is above the national average. The practice is in the first most deprived decile meaning that it has a higher proportion of people living there who are classed as deprived than most areas. Data shows number of 20 to 44 year olds registered at the practice is higher than the national average. The practice experiences a high turnover of patients due to the transient population groups in the area.

The practice team comprises seven GP partners, one salaried GP, three practice nurse prescribers, two healthcare assistants, a practice manager and the administrative/reception team. There are seven female GPs and one male GP .It is a training practice for GP registrars in training.

The practice is open between 7.30am and 6.30pm Monday to Friday. Appointment times start at 8am and the latest appointment offered at 5.50pm daily. Extended hours appointments are offered on the second Saturday of every month from 8.30am to 12.30 pm as pre-bookable appointments only with GP and nurse appointments available.

When the surgery is closed, patients are advised to dial NHS 111 and they will be put through to the out of hours service which is provided by Nottingham Emergency Medical Services.

Updated 3 August 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Windmill Practice on 11 May 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 and near misses, and we saw evidence that learning was applied.

• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, education courses for patients with long term conditions such as diabetes and working with the local diabetes specialist nurse to improve the wellbeing of patients.

• There was easy access to appointments for patients whose circumstances made them vulnerable, for example homeless patients, asylum seekers and patients from the traveller community. They were assured of an appointment on the day when they presented to the practice without a booked appointment.

• Feedback from patients about their care was consistently positive. Data from the GP survey was consistently high.

• The practice planned and co-ordinated patient care with the wider multi-disciplinary team to plan and deliver effective and responsive care to keep vulnerable patients safe.
• 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.
• The practice actively reviewed complaints to see if there were any recurrent themes, and identified issues where learning could be applied to improve patient experiences in the future.
• The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

• The practice had strong and visible clinical and managerial leadership and governance arrangements, and staff told us that they were well-supported and felt valued by the partners and the practice manager.

We saw areas of outstanding practice including:

• The practice was committed to working with people whose circumstances might make them vulnerable. For example, the practice had a long history of working with homeless patients across Nottingham and provided substance misuse clinics to their own registered patients and those registered as temporary residents. In addition to removing barriers for these patients to access services at the practice, they undertook outreach clinics in local hostels on a weekly basis.

• A number of GPs used their expertise to provide education to colleagues locally and nationally in areas such as substance misuse, domestic violence, child safeguarding and health management of asylum seekers.

• The practice demonstrated continuous improvement and innovation in leading on a number of pilot schemes within their Clinical Commissioning Group (CCG) which are now available as commissioned services, such as prostate cancer screening service for men of African Caribbean ethnic background, a community epilepsy specialist nurse and an urgent referral service to Welfare Rights.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 3 August 2016

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

• The practice was proactive in chronic disease management by having a recall system in place to invite patients with long term conditions for at least one health check annually. This involved coordinated appointments with the health care assistant, followed by an appointment with the nurse or GP in one visit to discuss patients’ needs.

• The practice achieved 89.6% on QOF in 2014/15. This was in line with the CCG average of 91.5% and the national average of 94.8%. The practice told us they their QOF performance had improved to 96.6% for 2015/16 (unpublished results), and attributed their success to the recall system. There was evidence of detailed reflection on their performance at the end of each year. Meetings were held with all clinical staff to analyse performance on each disease area and suggestions for improvements made.

• There were a large number of leaflets providing education and self-care advice and patients were directed to online resources. The practice actively encouraged patient education sessions for patients with conditions such as diabetes and chronic obstructive pulmonary disease, referring them to courses and the primary care education college. Feedback from patients indicated this had improved their health and understanding of their conditions.

• The practice promoted self-referral to services such as podiatry, physiotherapy and psychological therapies.

• Nursing staff worked collaboratively with a community specialist diabetes nurse on their more complex patients with a diabetes diagnosis to improve outcomes for the patients.

• QOF achievement on indicators for diabetes was consistently in line with CCG averages. For example, the percentage of patients with diabetes, on the register who had their cholesterol measured within the preceding 12 months was 81.4%, compared to a CCG average of 76.31% and national average of 80.53%. The practice supplied data indicating the number of patients with diabetes under poor control had reduced and their overall performance in diabetes had improved significantly in 2015/16, although the data has not yet been published.

• QOF achievement on indicators for atrial fibrillation and chronic obstructive pulmonary disease were broadly in line with national averages.

• Longer appointments and home visits were available and offered when needed.

Updated 3 August 2016

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

• The practice worked closely with midwives, health visitors and community nurses attached to the practice. 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 held meetings every six weeks with the health visitor, and also reviewed any children on a child protection plan at their clinical meetings.

• Immunisation rates were broadly in line with the CCG averages for standard childhood immunisations. Vaccination rates for children under two years old ranged from 89.2% to 96.1% compared against a CCG average ranging from 91.1% to 96.3%. Vaccination rates for five year olds ranged from 84.5% to 94.8%, compared to the CCG average of 86.9% to 95.4%.

• Appointments were available outside of school hours with urgent appointments available on the day for children and babies.

• The practice offered a pregnancy pack to newly pregnant patients. A joint weekly baby clinic was offered with a GP, nurse and health visitor present. This allowed mothers and babies attending for the eight week check to have their post-natal check, baby check and first immunisation done in one visit.

• The practice offered a full range of family planning services including fitting of intra-uterine devices (coil) and contraceptive implant fitting.

• The premises were suitable for children and babies. Baby changing facilities were available and the practice accommodated mothers who wished to breastfeed. There were minor illness booklets offered to new parents.

Updated 3 August 2016

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

• The practice had a significantly lower elderly population with 10% aged over 65, compared to a national average of 17.1%. 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 by the GPs and nurses for those with enhanced needs.

• Feedback from a care and nursing home indicated that the named GP carried out weekly review visits and responded to urgent requests when needed to ensure continuity of care. They told us residents had care plans in place and the GP involved patients and their relatives in decisions about their care.

• They worked effectively with multi-disciplinary teams to identify patients at risk of admission to hospital to ensure their needs were met. For example, the practice coordinated care with the district nurse and community matron. There was evidence of close partnership working with other community teams co-located in the health centre such as the Falls and Bone team.

• The practice team had undertaken adult safeguarding awareness training and were looking to improve their knowledge of Deprivation of Liberties (DoLS) through joint training with their main care home.

• The practice offered annual health checks to patients aged 75 and over and performed the checks on request. They identified 336 patients aged over 75, and 299 patients were seen for a review of their blood pressure and/or long term conditions. All patients over 75 years old had a named GP for continuity of care.

• The practice reported the flu vaccination uptake for 2015/16 was 70%, in line with the CCG average of approximately 72% and higher than the average for practices in the same care delivery group of 65%.

Updated 3 August 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. This included access to telephone appointments, text reminders and the availability of early morning appointments from 7.30am to 8am on weekday mornings.

• The practice offered extended hours appointments every second Saturday of the month from 8.30am to 12.30pm with three GPs and a practice nurse available. An additional clinic was held from 7.30am to 8am every Tuesday with a practice nurse to cater for working patients.

• Appointments with the health care assistant were available from 7.40am for working patients in need of phlebotomy services. There were 27 appointments offered each week and the practice reported these were fully utilised.

• The practice was proactive in offering online services such as online prescription requests, appointments, and accessing medical records.

• There was a full range of health promotion and screening information in the practice and online that reflects the needs for this age group. Self-referral was encouraged for accessing psychological services, podiatry and physiotherapy.

• The practice hosted a Physio First service which allowed patients to see a physiotherapist within a week and did not require them to see a GP first. Physiotherapy clinics were offered twice a week on Wednesday mornings and Friday afternoons. Patients were encouraged to self-refer to this service. Practice supplied evidence indicated this was a popular service with appointments uptake ranging from 16 to 48 a month, and approximately 500 patients having used it between March 2015 and June 2016.

• There were joint injections offered by the practice.

• The practice’s uptake for cervical screening for eligible patients was 82.9%, which was higher than the CCG average of 81.5% and the national average of 81.8%.  

Updated 3 August 2016

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia, learning disabilities, alcohol and substance misuse).

• The practice offered annual health reviews with care plans in place for patients with dementia, working closely with key workers, relatives and other health professionals. Data showed that 80.4% of patients diagnosed with dementia that had their care reviewed in a face to face meeting during 2014/15. This was in line with the national average of 84.01%.

• Staff told us that of the 54 patients on the dementia register in 2015/16, and 42 had their care plans reviewed. This represented 79.2% of their register. The practice told us they carried out regular data quality checks to identify patients appropriate for annual reviews, which increased the number of patients offered health checks.

• The practice achieved 93.2% for mental health related indicators in QOF, which was 4.5% above CCG average and 0.4% above national average. The exception reporting rate was 19.2% (The exception reporting rate is the number of patients which are excluded by the practice when calculating achievement within QOF) compared to a CCG average of 10.5%. The practice was able to demonstrate patients had been excluded appropriately.

• The practice provided GP care to a local forensic psychiatric unit, offering a full range of GP services.

• There was proactive review and follow up of any patients with a mental health condition presenting at accident and emergency.

• Staff told us that there were 142 patients on the mental health register in 2015/16, and 89.8% had care plans reviewed that year.

• Staff had a good understanding of how to support patients with a wide range of patients with no judgements. The nursing staff told us they reviewed their appointments a day before to ensure that reasonable adjustments were made to suit the patient, for example if a room with wheelchair access was required.

Updated 3 August 2016

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

The practice held a register of patients living in vulnerable circumstances, providing a non-judgemental, flexible and welcoming approach to ensure there were minimal barriers to accessing healthcare. The patients included homeless people, asylum seekers, travellers, Lesbian, Gay, Bisexual and Transgender people, people experiencing domestic violence, and people coming to the end of their life.

• The practice provided temporary and permanent registrations to all patients, encouraging the latter so that they are able to obtain their medical records and ensure continuity of care.

• The practice had identified that compliance with appointments was difficult for vulnerable people, so they encouraged these patients to present to reception whenever they felt the need for medical care and an appointment was offered to them on the day. GPs offered a holistic assessment at first contact with the patients, assessing their mental, physical and social needs to plan their care.

• There was evidence of liaison with hostels, support agencies, homeless nursing team, local housing department, and drug and alcohol services. The practice held quarterly multi-disciplinary health meetings for the homeless.

• The practice saw a significant number of asylum seekers, offering them 30-60 minute appointments for their first health check when they register with the practice. They actively used interpreters and Language Line for patients who could not communicate in English, and advised self-referral to language lessons. Referrals were made to local support agencies such as Refugee Forum and Refugee Action.

• There was proactive management of patients from the travelling community who were offered telephone advice by GPs if they were unable to travel to the practice. Patients were offered flexible registrations through the out of area registration scheme, and those with complex health needs were given care plans to present to any health professional seeing them outside of Nottingham.

• The practice offered a non-judgemental approach to patients from the LGBT community. They offered referrals to gender and HIV clinics, and a full range of sexual health advice and testing where appropriate.

• All staff had received domestic violence awareness training and two GPs at the practice were champions who used their role as trainers of domestic violence awareness to the wider GP community. There was evidence the practice actively advertised to patients that they were a domestic violence aware practice to encourage disclosure and offer support through referrals to a domestic violence counsellor who offered clinics within the practice as well as referrals to Women’s Aid.

• Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing and how to contact relevant agencies in normal working hours and out of hours.

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations. For example, the practice encouraged identification of carers to offer them support and provided food vouchers for a local food bank scheme.

• The practice provided good care and support for end of life patients, keeping them under close review in conjunction with the wider multi-disciplinary team. These included patients with end stage alcoholic liver failure.

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations. For example, the practice liaised with Carers Federation to identify carers and offer them support.

• The practice received training and advice from a learning disabilities facilitator, enabling them to offer annual health checks to patients identified as having learning disabilities. Staff told us they worked closely with key workers and offered longer appointments for patients.

• Staff told us they were aware of how to access interpreting and text talk services for their patients with hearing impairment. The self-signing in screen allowed patients to choose from different languages and receptionists presented patients with a list of languages to choose from if they could not speak in English, so that an interpreter could be arranged for them through Language Line. The practice recorded 75 different languages spoken by their patients. This represented 25.5% of their patients.

• Two of the GPs at the practice had additional training to become domestic violence champions, and a domestic violence counsellor attended the practice to offer support to patients and raise awareness.

• The practice offered an in house alcohol abuse clinic, promoting and referring to Last Orders alcohol service. They provided community detox and offered injections to patients supported at a local community alcohol detox unit.

• There were three GPs providing four shared care opiate dependence clinics every week with a drug worker and support worker, for patients with conditions relating to substance misuse. The practice ensured there was access to advice and support from the GPs on days when the clinics were not available.

• The practice proactively arranged health checks and reviews such as cervical smears, contraception and smoking advice to be undertaken when patients attend for methadone prescriptions to avoid making additional appointments which they may not attend. Practice supplied data indicated that of the 38 female patients seen in the substance misuse clinic in the last year who were eligible for a cervical smear test, 33 had undertaken the test, showing an uptake rate of 86.8% in that population group.

• A nationally recognised hepatitis C clinic was also offered in parallel to the substance misuse clinics offering testing, treatment and support to patients, with the assistance of practice staff.