Lister House at Chellaston

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