HHR Medical

Updated 15 January 2018

HHR Medical is part of Lambeth Clinical Commissioning Group (CCG) and serves approximately 6500 people. The practice is registered with the CQC for the following regulated activities Diagnostic and Screening Procedures, Treatment of Disease, Disorder or Injury, Maternity and Midwifery Services and Family Planning and Surgical Procedures.

The practice population has a larger working age population and smaller proportion of patients over the age of 65 compared to the national average. The ethnicity of the patient list is diverse with 8.2% identifying as mixed, 5.8% as Asian, 35.6% black and 3.2% other non-white ethnic groups. The practice is located in an area which is ranked as the second most deprived decile on the index of multiple deprivation with higher levels of deprivation amongst both older people and children.

The practice is run by two male partners and employs two GPs one male and one female. The practice employs a full time nurse practitioner and two part time nurses. The practice offers 28 GP sessions.

The practice is open between 8.00 am and 6.30 pm Monday to Friday. Appointments are from 8.30 am to 11.20 am Monday to Friday and resume 3.30pm to 6 pm in the evening except on Thursday when surgery resumes at 4pm. Extended surgery hours are offered between 7.30 am and 8.30 am and 6.30 pm to 7.30 pm on Wednesdays. In addition to pre-bookable appointments that can be booked up to one month in advance, urgent appointments are also available for people who need them which can be booked the same day. Patients can also book appointments 24 hours or 48 hours in advance. If patients require treatment at the weekend the practice can refer them to the local GP access hub which provides care from 8am – 8pm seven days a week through the local Federation.

HHR Medical operates from 1-3 Herne Hill Road, Loughborough Junction, London, SE24 0AU which are purpose built premises which are owned by the partnership. The service is accessible for patients with mobility difficulties and has a lift to enable patients to access consulting and treatment rooms on the upper floors.

Practice patients are directed to contact the local out of hour’s provider when the surgery is closed.

The practice operates under a Personal Medical Services (PMS) contract, and is signed up to a number of local and national enhanced services (enhanced services require an enhanced level of service provision above what is normally required under the core GP contract). These are: extended hours access, learning disabilities health checks, out of area registration, minor surgery and GP delivery scheme.

Updated 15 January 2018

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at HHR Medical on 25 May 2017. The overall rating for the practice was good but requires improvement for the key question: Are services safe? The full comprehensive report on the 25 May 2017 inspection can be found by selecting the ‘all reports’ link for HHR Medical on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 1 December 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 25 May 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as good and is now rated good for key question: are services safe?

Our key findings were as follows:

• There was a consolidated child safeguarding policy which included all relevant information including the name of the practice lead.

• The practice had systems in place to monitor handwritten prescriptions.

• The practice were now reviewing uncollected prescriptions monthly and recording action taken in response to the review.

• Printer prescriptions were stored in locked cabinets.

• The most recently published Quality Outcomes Framework data for 2016/17 showed that some scores relating to the management of patients with diabetes were still below local and national averages. For example the percentage of patients with well controlled blood sugar was 61% compared with 76% in the CCG and 80% nationally).The practice informed us that the nurse was due to start a diploma in diabetes.

• Performance had improved in respect of the percentage of patients with complex mental health conditions who had a care plan in place compared to the previous year (83% compared with 90% in the CCG and 90% nationally). However the percentage of patients with a record of alcohol consumption was still lower than local and national averages (75% compared with 91% locally and nationally). According to unverified performance data the practice had, as at 22 November 2017, completed mental health care plans for 90% of patients with complex mental health conditions for 2017/18.

• In 2016/17 the percentage of patients with dementia who had an agreed care plan in place was also now in line with local and national averages (86% compared to CCG and national average of 84%).

• In 2016/17 the percentage of patients with atrial fibrillation who met specific clinical requirements that were being treated with anticoagulation therapy was now in line with local and national averages (80% compared with 86% of the CCG and national average of 88%).

• Although we were not provided with any recent complaint response which included contact information for organisations that patients could escalate concerns to, the practice provided a leaflet with this information which we were told was available at reception and on the practice’s website.

• The percentage of patients who had bowel cancer screening in 2016/17 was in line with local averages (44% compared with 41% in the CCG).

  However, there was also an area of practice where the provider needs to make improvements.

The provider should:

• Continue with action to improve performance in respect of the management of patients with diabetes.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 4 July 2017

As a result of the practice being rated requires improvement for safe and due to the evidence of below average QOF performance for several indictors relating to the management of long term conditions the practice is rated as requires improvement for the care of people with long-term conditions:

• Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.

• Published data indicated that the practice were performing below local and national averages in the management of patients with atrial fibrillation and diabetes. In the case of diabetes the practice attributed their performance to the loss of a practice nurse who was dedicated to the management of diabetic patients. The practice had recruited a new nurse and an additional GP. One of the existing practice nurses had taken on responsibility for the management of diabetic patients in conjunctions with one of the partners. The practice received support from a specialist diabetic nurse working in the community who would overseas practice diabetic clinics and provide mentorship and support to the practice nurse. The practice said that this had resulted in improved compliance amongst their patients and ensured that patients whose condition was difficult to manage were escalated.

• The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.

• There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.

• All these patients had a named GP and there was a system to recall patients for 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. The practice participated in virtual clinics for Respiratory medicine, Heart Failure, and Diabetes for patients whose conditions were complex and typically required secondary care management. Care and treatment for these patients was optimised under the guidance of consultants from secondary care services.

Updated 4 July 2017

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

• From the documented examples we reviewed we found there were systems 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 (A&E) attendances.

• Immunisation rates were relatively high for all standard childhood immunisations.

• Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals. The practice was participating in the Young Persons Friendly initiative and had trained receptionists to provide advice and information regarding local support services.

• The practice would provide support for premature babies and their families following discharge from hospital.

• Appointments were available outside of school hours and the premises were suitable for children and babies.

• The practice worked with midwives to support this population group and held bi-monthly meetings with the community health visitor where child protection issues were discussed. In addition the practice employed an in house health visitor to support the provision of ante-natal, post-natal and child health surveillance clinics.

• The practice had processes for managing acutely ill children and young people and for acute pregnancy complications.

• The practice could access advice and support from a consultant paediatrician from a local secondary care facility.

Updated 4 July 2017

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

• The practice participated in a local CCG initiative providing holistic health assessments for vulnerable older patients either within the practice or in patient’s homes. The nurse practitioner or practice nurse undertook a comprehensive assessment of patient’s health and social needs followed by engagement with other local health, social and voluntary organisations to ensure that these patients’ needs were supported and could maintain their independence where possible. The practice had completed 30 assessments for housebound patients and 37 assessments within the practice.

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

• The practice offered onsite phlebotomy to older patients.

• The practice offered proactive, personalised care to meet the needs of the other older patients who did not require a holistic health assessment.

• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

• The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.

• The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.

• The practice used a risk tool to identify patients who may need additional support or had complex needs. These patients were discussed in a virtual clinic with a consultant geriatrician to ensure that care and treatment were optimised.

Updated 4 July 2017

The practice is rated as good for the care of working age people (including those recently retired and students).

• The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, extended opening hours on Wednesday and evening and weekend appointments through the local extended access hub.
• In response to patient demand the practice had increased capacity for coil and contraceptive implant fittings and provided a cervical screening during their extended access hours on Wednesdays.
• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group. The practice had facilitated two workshops that provided patients with information on how to book appointments online and increased the availability of online booking above their contractual requirement which benefited working age people.

Updated 4 July 2017

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

• Performance for mental health indicators was lower than local and national averages. For example the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive care plan documented in the record, in the preceding 12 months was 64% compared with a local average of 85% and a national average of 89% nationally. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a record of alcohol consumption in the preceding 12 months was 75% compared with the CCG average of 87% and the national average of 89%.However we reviewed unverified data from 2016/17 which indicated an improvement in these areas.

• The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months was 70% compared with the CCG average of 82% and a national average of 84%. Unverified data from 2016/17 showed that 100% of these patients had their care plan reviewed.

• The practice had an in-house counsellor and hosted a worker from the local talking therapy service.

• The practice specifically considered the physical health needs of patients with poor mental health and dementia both during consultations and when undertaking care reviews under the holistic health assessment scheme.

• Although the practice told us they reviewed uncollected prescriptions every three months there was no formal system in place for dealing with these which could pose a risk to certain patients in this population group.

• The practice held quarterly multi-disciplinary meetings for those with serious mental health needs under a scheme aimed at providing increased mental health support in the community. The practice also participated in a virtual clinic for mental health patients to ensure care and treatment were optimised.

• The care of patients with dementia was also discussed with other agencies.

• Patients at risk of dementia were identified and offered an assessment.

• The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.

• The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.

Updated 4 July 2017

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 homeless people, those who have experienced or are at risk from Female Genital Mutilation and those with a learning disability. Practice staff had received training on how to support these vulnerable groups.

• Of the 18 patients the practice had on their learning disability register 16 had received an annual health check.

• The practice recently participated in a study which resulted in all of their patients deemed to be a risk from Hepatitis B and C to be offered screening.

• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients.

• The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.

• Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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.