Archived: Kirkley Mill Surgery

Updated 20 July 2017

East Coast Community Healthcare Community Interest Company (ECCH) became the provider for the practice in April 2016, and holds an Alternative Primary Medical Service (APMS) contract with the local CCG. ECCH is a provider of over 30 community services, which includes four GP practices and has been established for five years.

The practice area covers most of the town of Lowestoft and the surrounding villages and offers health care services to approximately 6285 patients. In March 2017, the practice had registered approximately 2,000 patients from the closure of a nearby practice. Kirkley Mill Surgery is located in a purpose built health centre and has consultation space for GPs and nursing team members, including a healthy lifestyles behavioural coach. It is in the Great Yarmouth and Waveney Clinical Commissioning Group (CCG) area and serves patients living in one of the most deprived wards in Lowestoft. The overall deprivation decile is one, which indicates areas with the most deprivation. The practice demography is broadly similar to the CCG and England average. However, there are more male patients aged 25 to 34, 40 to 44 and 50 to 59 than the CCG and England average. There are less female patients aged 5 to 15 and aged 30 to 59. Male and female life expectancy in this area is lower than the England average at 76 years for men and 81 years for women.

The practice employs two regular locum GPs, both of whom are male, and additional locum GP cover to provide the equivalent cover of two full time GPs. If a patient requested to see a female GP, they were offered an appointment with a female nurse initially. There is a full time nurse manager, a full time and part time nurse, a part time health care assistant and a full time healthy lifestyle behavioural coach. The practice also had an emergency care practitioner (a registered paramedic) who worked two days a week. The practice had recently recruited a nurse practitioner; however they had not yet accepted the post. At the time of our inspection, the practice was relying on locum GPs due to difficulties in recruiting permanent GPs in the area. There was a practice manager who had been in post for three months and was supported by a team of administration and reception staff.

The practice is open between 8am and 6.30pm Monday to Friday. GP appointments are generally available between 8am and 5.50pm, although the times of clinical sessions vary day to day.

When the practice is closed Integrated Care 24 provide the out of hours service, patients are asked to call the NHS111 service to access this service, or to dial 999 in the event of a life threatening emergency.

Updated 20 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kirkley Mill Surgery on 1 June 2017. Overall the practice is rated as inadequate. Our key findings across all the areas we inspected were as follows:

• There was a system in place for the recording and reporting of significant events. However, learning from significant events was not always shared with staff.
• There was no effective system in place for receiving, sharing and actioning patient safety alerts.
• Policies and procedures for safeguarding children and vulnerable adults were in place, and staff were aware of these. Not all staff had received safeguarding training appropriate to their role, and not all GPs had the correct permissions in place on the computer system to ensure they were aware of patients with current safeguarding needs.
• Health and safety risks to patients and staff were assessed and monitored, however there was no evidence that fire drills had been undertaken.
• We found the practice was clean and tidy and procedures were in place for infection prevention and control. However, the infection control lead had not completed any specific training to undertake this role. The record of staff hepatitis B immunity was incomplete and the lock on one of the external clinical waste bins was broken.
• We reviewed patients who were prescribed high risk medicines. They had not all been reviewed in a timely manner before their medicines had been reissued.
• There was no effective system in place for dealing with clinical pathology results in a timely manner and the practice did not use an agreed and consistent coding system for patient’s medical records.
• Clinical staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment to patients; however evidence based guidance was not always being followed.
• The arrangements for triaging requests for home visits were undertaken by non-clinical staff, without written guidance or clinical oversight.
• There was limited evidence of quality improvement including clinical audit.
• The practice did not hold regular multi disciplinary meetings and did not ensure that relevant information was shared with other services. The practice planned to hold multi disciplinary meetings, however these had not commenced at the time of the inspection.
• Some areas of the practice performance were insufficiently understood and supported to ensure safe and effective care and treatment for patients.
• A process was in place for receiving, investigating and responding to complaints. Information on how to escalate a complaint was not provided to complainants in response letters; however the practice had included this in their new information leaflet, which was being printed. Improvements were made to the quality of the service provided as a result of complaints and concerns; however actions taken were not shared with all staff to encourage learning.
• A healthy lifestyle behavioural coach worked at the practice and feedback from patients on this service was very positive.
• Most patients reported being treated with compassion, dignity and respect and involved in decisions about their care and treatment. Patients were able to make an appointment with a GP although there was not always continuity of care.
• The results from the national GP patient survey showed the practice was generally performing below CCG and national averages. The practice did not have a Patient Participation Group (PPG).
• We found there was a lack of overall clinical leadership and oversight at the practice.

The areas where the provider must make improvement:

• Ensure care and treatment is provided in a safe way to patients.
• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvement are:

• Offer health reviews to patients with a learning disability.
• Ensure that information about the complaints policy is available for patients and includes information about how to take action if a complainant is dissatisfied with the response.
• Continue with plans to start a Patient Participation Group in order to obtain patient feedback and engagement with the practice and act on this feedback to improve patient satisfaction.

Since our inspection Great Yarmouth and Waveney Clinical Commissioning Group (CCG) and East Coast Community Healthcare Community interest Company (ECCH) have taken significant action in response to our findings. We have been provided with evidence to demonstrate that immediate actions have been undertaken and assurance from the CCG that all identified actions will be completed to minimise the risk to patients.

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 20 July 2017

The practice is rated as inadequate overall, inadequate for providing safe, effective and well led services and requires improvement for providing caring and responsive services. The concerns which led to these ratings apply to everyone using the practice including this group.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified.
• A diabetes specialist nurse undertook monthly clinics for those patients with more complex diabetes.
• The practice used the information collected for the Quality and Outcomes Framework (QOF) to monitor outcomes for patients (QOF is a system intended to improve the quality of general practice and reward good practice). Data from 2015/2016 showed that performance for diabetes related indicators was 90%, which was the same as the local and national average. Exception reporting for diabetes related indicators was 33% which was above the local average of 17% and the England average of 12% (exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects). 2016/2017 unverified data from the practice (which excluded any exceptions) showed the practice performance had reduced to 59% for diabetes related indicators.

• Longer appointments and home visits were available when needed. However we found that requests for home visits were not always reviewed by a clinician.

Updated 20 July 2017

The practice is rated as inadequate overall, inadequate for providing safe, effective and well led services and requires improvement for providing caring and responsive services. The concerns which led to these ratings apply to everyone using the practice including this group.

• Immunisation rates were in line with the Clinical Commissioning group (CCG) and England averages for all standard childhood immunisations. The practice planned to hold drop in clinics for childhood immunisations in order to further increase uptake.
• 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 offered a full range of family planning services and chlamydia screening.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• The practice planned to offer evening appointments to increase the uptake of cervical screening as well as well woman clinics.
• A midwife held a clinic at the practice on a weekly basis.

Updated 20 July 2017

The practice is rated as inadequate overall, inadequate for providing safe, effective and well led services and requires improvement for providing caring and responsive services. The concerns which led to these ratings apply to everyone using the practice including this group.

• The practice offered 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. However requests for home visits were not always reviewed by a clinician.
• GPs and the emergency care practitioner provided alternate weekly home visits to patients living in the one care home covered by the practice.
• Nationally reported data showed that outcomes for patients for conditions commonly found in older people, including rheumatoid arthritis, dementia and heart failure were above the local and national averages. However the exception reporting rate for rheumatoid arthritis and dementia was above the local and national rate. 2016/2017 unverified data from the practice showed that performance had reduced significantly for rheumatoid arthritis, and had been maintained in the other areas.

Updated 20 July 2017

The practice is rated as inadequate overall, inadequate for providing safe, effective and well led services and requires improvement for providing caring and responsive services. The concerns which led to these ratings apply to everyone using the practice including this group.

• Appointments were available between 8am and 5.55pm.
• Pre bookable telephone consultations were not available, however patients could phone on the day and a GP would phone them back. Appointments could be booked online. The practice offered online prescription ordering and access to the patient’s own medical record.
• The percentage of women aged 25-64 whose notes recorded that a cervical screening test had been performed in the preceding five years was 64%, which was below the CCG average of 75% and the England average of 76%. The practice were planning to trial later evening appointments for cervical screening in order to improve uptake.

Updated 20 July 2017

The practice is rated as inadequate overall, inadequate for providing safe, effective and well led services and requires improvement for providing caring and responsive services. The concerns which led to these ratings apply to everyone using the practice including this group.

• The 2015/2016 Quality and Outcomes Framework (QOF) data showed that 50% of patients diagnosed with dementia had their care reviewed in a face to face meeting which was 24% lower than the CCG average and 28% lower than the England average (QOF is a system intended to improve the quality of general practice and reward good practice). Unverified 2016/2017 data provided by the practice showed that performance had improved to 57%.
• 45% of patients experiencing poor mental health had a comprehensive care plan, which was lower than the CCG average of 67% and the England average of 78%. Unverified 2016/2017 data provided by the practice showed that performance had fallen to 34%.
• The practice had information available for patients experiencing poor mental health about how to access various support groups and voluntary organisations. Information was also available on the practice’s website.
• Patients were able to self refer to a service called ‘Solutions’ which was a social prescribing scheme, offered by the practice to provide patients with non-medical support in the community.
• A mental health nurse had recently been employed by the provider ECCH, to offer face to face appointments for signposting to other services, at least once a week.

Updated 20 July 2017

The practice is rated as inadequate overall, inadequate for providing safe, effective and well led services and requires improvement for providing caring and responsive services. The concerns which led to these ratings apply to everyone using the practice including this group.

• The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability. The practice were planning to undertake work with the local learning disability team to corroborate their register.
• The practice had 84 patients on the learning disability register. Six of these patients have had a health review since April 2016.
• The practice supported vulnerable patients through a number of local schemes, including for example ‘Lowestoft Rising’, where the lead nurse provided health expertise at a monthly meeting. The lead nurse supported an access clinic for homeless people and encouraged them to register at the practice. They also supported patients as part of a detox programme, provided by the East Coast Recovery.
• A healthy lifestyles behavioural coach was available at the practice and offered appointments on a range of areas which included healthy eating, exercise and smoking cessation. Feedback from patients on this service was very positive.
• An advisor, trained by the Citizens Advice Bureau, attended the surgery twice a week for patients to drop in and obtain information on self help groups and other support organisations based on the patients’ need. Advisors also attended the practice every day if appointments had been booked in advance, to support and signpost patients other services, including for example, wellbeing, housing and debt support services.
• 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. However not all staff had received safeguarding training appropriate to their role.
• The practice’s computer system alerted practice staff if a patient was also a carer. The practice had identified 76 patients as carers (1.2% of the practice list).