Lister House at Chellaston

Updated 27 February 2017

Lister House at Chellaston was formally known as Meadowfields Practice. Since January 2016, It has been managed in a caretaker role by Dr Moss and Partners, who are the providers for Lister House surgery. Dr Moss and Partners also provided caretaker services to Coleman Street surgery and incorporated both locations in its governance, financing and staffing structures, which has enabled GPs, nurses and some non-clinical staff to work across all four provider sites. On the day of our inspection, the provider was waiting for a formal decision to be made on whether the caretaking arrangement was to become permenant. This was confirmed shortly after our inspection.

Clinicians and most staff work across all four sites managed by the providers, Dr Moss and Partners. The current combined patient list size is 34,620. The patient population is diverse, ranging from the inner city to more affluent suburban areas. All 4 premises are purpose built and accessible for patients with disabilities.

Additional services provided by Dr Moss and Partners at Lister house surgery and branches are available to patients at this practice.

For all four sites, patient access is governed by a clinically led triage protocol, that ensures patients are seen by clinicians appropriate to their condition, and that any patient that needs to talk to or see a clinician will do so on the same day.

Lister House at Chellaston is located in purpose built premises in Chellaston, Southern Derbyshire. Facilities are on two floors including consulting and treatment rooms. The practice has car parking including parking for patients with a disability.

The level of deprivation within the practice population is below the national average with the practice falling into the 4th most deprived decile. The level of deprivation affecting children and older people is significantly higher than the CCG and national average. The practice has higher than average numbers of children and working age patients. Numbers of older people are below average. 

The clinical team is comprised of seven GP partners (two female, five male), and nine salaried GPs, (eight female and one male) three Advanced Nurse Practitioners (ANP), 10 practice nurses and three healthcare assistants. The clinical team is supported by a practice business manager, assistant practice manager, community attached staff, two care coordinators, reception and administrative staff. The team is also supported by a head of quality and practice improvements and a special projects administrator, whose roles are dedicated to improving efficiency, safety and the collection of evidence.

The provider also employs a mental health nurse and a community support worker, and an ANP to coordinate care for care homes aligned to the practice.

The practice is a teaching practice for medical students and nursing students.

The surgery is open from 8am to 6.30pm on Monday to Friday. Consulting times vary but are usually from 8am to 6.30pm during the day with urgent appointments each day from 9am to 12pm and 3.30pm to 6.30pm.

The practice has opted out of providing out-of-hours services to its own patients. This service is provided by Derbyshire Health United (DHU) and is accessed via 111.

Updated 27 February 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Moss and Partners, Lister House at Chellaston on 18 October 2016. Overall the practice is rated as good.

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

• Dr Moss and Partners had taken over the practice in a ‘caretaker’ capacity since January 2016 and put in place improved governance structures and facilities for patients that were available at  other locations already managed by Dr Moss and Partners. A  new clinical team was put in place at the practice. Since our inspection Dr Moss and Partners have been offered a 10 year contract to provide services at Lister House at Chellaston. The practice is one of four sites managed by Dr Moss and Partners. 
• We identified that Dr Moss and Partners had made significant improvements to this practice during the ‘caretaker’ stage and was responsive to the needs of the population, in particular for older people and for people experiencing poor mental health.
• The partners utilised creative methods to communicate changes, updates and practice news with staff and to encourage feedback. For example; they held Friday feedback sessions for staff to give feedback, and they produced a staff bulletin quarterly. Staff told us that this made them feel more involved and part of the team.
• The partners funded specialist services in order to help address the GP capacity issues they inherited at the practice; For example, a full time mental health nurse, and a full time advanced nurse practitioner (ANP) to coordinate activity in care homes. Both these roles freed up time for GPs to attend to other activities, but had not yet been fully analysed in terms of cost savings or patient benefit at this practice.
• There was an open and transparent approach to safety within the practice. Effective systems were in place to report, record and learn from significant events. Learning was shared with staff at regular meetings and through a staff bulletin.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.

• The provider had developed and implemented a triage system for non-clinical staff to use in order to prioritise requests for urgent appointments, and ensure the patient could access the right clinician in the right timescale. The prioritisation tool was based on clinical algorithms and regularly reviewed and updated by clinicians. (clinical algorithms are a tool that uses an ordered sequence of steps, each step depending on the outcome of the previous one, to reach a decision) The triage system enabled patients to be prioritised according to their clinical need or directed to the most appropriate resource. The providers had just introduced this system from their other practice and it was anticipated that it would have a positive impact on patient satisfaction and clinician’s time. The protocol had been commended by the CCG who were liaising with the provider to see whether it could be shared more widely.

• There was a strong focus on continuous learning, improvement and education at all levels. Staff were proactively supported to acquire new skills and share best practice. This included: engaging with Health Education England and the clinical commissioning group in developing the training and qualifications for advanced nurse practitioners and advanced care practitioners in Southern Derbyshire; being part of a training hub and taking part in CCG pilot projects which included employing a pharmacist and design of specific pathways for long term conditions such as diabetes.
• Outcomes for patients were generally in line with local and national averages.
• Training was provided for staff which equipped 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.
• Patients told us they were able to get an appointment with a GP when they needed one, with urgent appointments available on the same day.
• Feedback from patients and staff identified that services at the practice had improved since being managed by Dr Moss and Partners. A patient survey conducted by the practice after six months showed that 84% of respondents would be happy for Dr Moss and partners to continue to provide services at Chellaston and Coleman street surgeries.
• 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 and learning from complaints was shared with staff
• The practice premises were purpose built, had good facilities and was well equipped to treat patients and meet their needs. Services were designed to meet the needs of patients and additional services were being planned.
• 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 are partners with another local practice and Alexin Healthcare Limited in a training hub, that provides placements for medical students and student nurses in General Practice.
• The provider engaged with their CCG and other stakeholders in pilot projects, For example; a practice nurse was working with the CCG to re-design a community based diabetes service; they provided mentorship for an Independent Prescribing Pharmacist to work at the practice.

We saw areas of outstanding practice;

• A senior Nurse Practitioner (ANP) had been recruited to provide dedicated support to nursing home residents. The ANP worked closely with care home staff and practice GPs to review care for residents on an ongoing basis. In the four months since commencing the role, the practice told us that requests for GP visits had reduced and there had been a significant cost saving with regards to improved prescribing of nutritional supplement drinks. (There were plans to formally audit this after one year). A brief review of the work over a six week period showed that the ANP had completed; 11 ‘Do not attempt active resuscitation’ (DNAR) agreements; 20 care plans; 22 face to face visit requests; 21 medicines reviews; 16 dementia reviews and two reviews for chronic illness.
• The provider hosted and facilitated community based services from Lister House surgery which enabled care to be provided closer to home for patients. For example, since 2010, the provider had hosted a GP led community musculoskeletal assessment and treatment service which is accessible to patients registered with 26 local practices. Two of the GPs took a lead role with support from another local GP. The impact of this service provision included a 50% to 60% reduction in orthopaedic referrals to secondary care services.

The areas where the provider should make improvement are:

• The partners should review the need for contingency plans to cover absences so that administration staff are able to complete administration processes effectively.
• The partners should consider incorporating sufficient detail in their safeguarding meeting minutes to enable staff to access relevant information when they have not attended the meeting.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 27 February 2017

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

• Long term conditions management was provided by a team of qualified nurses who took lead roles in specific chronic illness. The nurses had all received training to diploma or degree level in chronic disease management.
• The lead nurses for diabetes liaised with the practice GPs, the Integrated Diabetic Service, a Diabetic Specialist Nurse, a local diabetes consultant and the dietary service for advice and support
• The practice operated a comprehensive recall system to ensure patients’ conditions were appropriately monitored. This was managed by a dedicated administrator.

• Appropriately monitored COPD patients benefited from having anticipatory drugs provided to reduce incidences of exacerbation. 

• 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 27 February 2017

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

• Systems were 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.
• A comprehensive immunisation and follow up immunisation program was in place which was managed by a dedicated administrator. The programme included a monthly checking process and up to two letters were sent by recorded delivery to parents where children had not attended for vaccination. The nurse lead for immunisations followed this up by contacting parents by telephone to discuss reasons for not attending and made a follow up appointment. If it was not possible to make telephone contact then the lead contacted the health visitor and an alert was placed on the child’s record.
• Joint working was in place with midwives, health visitors and school nurses who were invited to regular meetings.
• Patient status alerts were used to identify vulnerable people.
• There were baby change facilities and a private room was made available for breast feeding.
• A support event for new mothers and parents to be is planned.
• The practice hosted a weekly health visiting clinic that was extended to children who were registered with other local practices as well as this one.
• The practice provided information on their website which signposted parents to a number of support services.
• The practice provided a comprehensive travel vaccination service, and was a designated yellow fever vaccination centre.
• Appointments were available on the day for children and were given a high priority in the triage protocol.

Updated 27 February 2017

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. For example;

• All patients over 75 had a named GP.
• They worked closely with district nurses and community matrons to plan care. These teams were accommodated at the Lister House site, easily accessible and told us they had a good working relationship with the practice.
• A senior Nurse Practitioner (ANP) had been recruited to provide dedicated support to nursing home residents. The ANP worked closely with care home staff and practice GPs to review care for residents on an ongoing basis. In the four months since commencing the role, the practice told us that requests for GP visits had reduced and there had been a significant cost saving with regards to improved prescribing of nutritional supplement drinks. (there were plans to formally audit this after one year) A brief review of the work over a six week period showed that the ANP had completed; 11 ‘Do not attempt resuscitation’ ( DNAR) agreements; 20 care plans; 22 face to face visit requests; 21 medicines reviews; 16 dementia reviews and two reviews for chronic illness.
• The provider hosted and facilitated community based services from Lister House surgery which enabled care to be provided closer to home for patients. For example, since 2010, the provider had hosted a GP led community musculoskeletal assessment and treatment service which is accessible to patients registered with 26 local practices. Two of the GPs took a lead role with support from another local GP. The impact of this service provision included a 50% to 60% reduction in orthopaedic referrals to secondary care services.
• There was regular review of the palliative care register in accordance with local guidelines, and care plans were shared to enable appropriate care to be accessed quickly where required.
• The practice liaised closely with the community nursing team and a care co-ordinator to review patients at risk of unplanned admission. This enabled patients to receive coordinated care and be directed to services to assist them in all aspects of their lives to facilitate better health.
• The provider had a contract with Southern Derbyshire Clinical Commissioning Group (CCG) to provide ‘step down beds’ in a local care facility for short term intermediate care.This facilitated early discharge which enabled patients to return to the community. 
• The in-house phlebotomy service encouraged compliance for blood tests for people who found it difficult to travel to hospital.
• The practice supported events for carers and provided information for carers on their website.
• Urgent appointments were always available.

Updated 27 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 and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. This included;

• The practice was open from 8.00am to 6.30pm Monday, Tuesday Thursday and Friday and from 7.00am until 6.30pm on Wednesday.  Appointments were from 8am to 12pm and 12.30pm to 6.30pm daily. Extended hours appointments were offered on Wednesday mornings from 7am to 8am. Access was also provided to on-line services via the practice’s website.
• The practice communicated with patients by email and text and planned to introduce an enhanced electronic 2 way communication package in the near future.
• Patients were able to access a comprehensive musculoskeletal triage and treatment service which was provided at one of the local sites aligned with the practice. This was also made available to practices within the locality (City) by two GPs. This was supported by on site physiotherapy services.
• The provider hosted consultant led first outpatient spinal clinics operated by Royal Derby Hospital at one of the sites. This enabled care to be more accessible for patients and allowed a closer working relationship between practice GPs and the consultants.
• The practice was proactive in offering a full range of health promotion and screening that reflected the needs for this age group. The was a proactive recall system in place to follow up patients who did not attend their screening appointment. The dedicated nurse administrator also followed up test results for samples taken.

Updated 27 February 2017

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

• The provider employed its own Mental Health Nurse and Community Support Worker who provided counselling and signposting advice for patients from this practice.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia and carried out advance care planning for patients with dementia. Risk assessments and care plans were in place for appropriate patients.
• The practice told us they had a dementia diagnosis rate of 70% compared to a CCG average of 59%.
• The provider recently hosted a pilot study for dementia support and ran an event specifically to support dementia patients during May. This was attended by 20 patients and carers which led to a number of referrals to local groups including lunch groups and music groups.
• The most recently published data from 2014/15 showed that 77% 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 CCG and national averages which were 85% and 84% respectively. This data referred to the performance of the previous provider. Dr Moss and Partners took over the practice in January 2016.

• The practice supplied data which showed that they had completed face to face assessments for 37% of patients who had a diagnosis of dementia for the current year but had recently taken on an additional 23 patients from a local care home and had planned to complete those outstanding within the next five months.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The provider 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 27 February 2017

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

• 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. The practice had a GP partner who was the safeguarding lead, and liaised closely with the safeguarding lead for Lister House surgery, regularly attended meetings and provided their details on the practice’s website. All staff had received safeguarding training at a level appropriate to their role.
• Flags were placed on patient records to alert clinicians to patient issues.
• Longer appointments were available where appropriate.
• The reception team were alerted to patients who had been identified as having particular challenges accessing services. The alert on the computer screen told the receptionist of the individual requirements to help patients with an appointment.
• The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
• The practice held a register for patients with a learning disability and had engaged with Derbyshire NHS Foundation Trust and Derby Teaching Hospitals to support patients. Care plans were used that were user friendly and easy to read. Appointment invitations were audited to better understand reasons for DNAs. The practice offered longer appointments for patients with a learning disability.
• The provider recently ran a substance abuse support event.
• The practice provided information in a non-written form to support those with learning disabilities as well as those who were unable to read.
• Patients had access to Citizens Advice Bureau clinics which were hosted at a nearby site.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.