Archived: Church View Surgery

Updated 27 December 2017

Church View Surgery is located in Denaby Main, Doncaster, DN12 4AB. The community library also occupy the building along with health visitors and the school nursing team. It has accessible facilities and there is a car park at the back of the building.

The practice provides services for 4,128 patients under the terms of the NHS Personal Medical Services contract. The practice catchment area is classed as within the group of the most deprived areas in England. The age profile of the practice population is similar to other GP practices in the area. Of those patients registered at the practice, 63.3% have a long-standing health condition while the national average wa is 58%.

The practice has a female GP, a salaried female GP and one female regular locum GP. They are supported by an advanced nurse practitioner, an emergency care practitioner, two practice nurses, a healthcare assistant and phlebotomist, a practice manager and assistant practice manager and a team of administration and reception staff. The practice is open at Denaby Main from 8.00am to 6.30pm Monday to Friday. Extended hours are available on Tuesday evenings until 7.30pm.

When the practice is closed calls are answered by the out-of-hours service which is accessed via the surgery telephone number or by calling the NHS 111 service. 

Under the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, Dr Karen Wagstaff is registered to provide treatment of disease, disorder or injury, surgical procedures, diagnostic and screen procedures and maternity and midwifery services. At the time of this report there is currently an application in progress to add family planning to the regulated activities. 

Updated 27 December 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Church View Surgery on 13 June 2017. The overall rating for the practice was good with requires improvement for being effective. The full comprehensive report from the June 2017 inspection can be found by selecting the ‘all reports’ link for Church View Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 23 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified in our previous inspection on 13 June 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is rated as good.

Our key findings were as follows:​

• The minor surgery protocol had been reviewed and updated to reflect NHS England Service Specification for Minor Surgery Direct Enhanced Services guidance. T
• An audit had been undertaken to review all minor surgery procedures and we saw four skin samples were sent for histology and the results followed up by practice staff.
• The locum staff pack had been updated to include the practice chaperone procedure. Chaperones were routinely offered to patients.
• Staff had access to online fire safety training modules and in addition completed weekly fire safety checks with the fire marshalls.

​Following our June 2017 inspection we recommended the provider should review of relevant policies and procedures during incident investigation processes. During this inspection we reviewed a recent significant event and the relevant procedure had been reviewed and updated and shared with all practice staff.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 28 July 2017

The practice is rated as good 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.
• Performance for diabetes related indicators was 100% which was 3% above the CCG and 10% above the national average.
• 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.

Updated 28 July 2017

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

• From the sample of 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 comparable 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 provided support and signposting to other services for families who experienced bereavement.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.

Updated 28 July 2017

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

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
• The practice offered proactive, personalised care to meet the needs of the older patients in its population.
• 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.
• Where older patients had complex needs, the practice shared summary care records with local care services. For example, with community matrons.

Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible 

Updated 28 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 Tuesday evenings.
• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

Updated 28 July 2017

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

• The practice carried out advance care planning for patients living with dementia.
• The practice achieved 98% of the available outcomes for caring for patients living with dementia.
• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
• The practice achieved 78% of the available outcomes caring for patients experiencing poor mental health.
• The practice regularly worked with multidisciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
• 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 and were trained dementia friends.
• All patients living with dementia registered at the practice  were encouraged to complete the form which was  designed to make sure that, if someone was reported  missing, the police could access important information  about that person as soon as possible. The form  contained information about their medical status, mobility, access to transport, places of interest and daily  routines. Once completed, copies were made and then  available for use if the person should ever be reported  missing. The idea is that speedy access to information  will help officers track missing people down quickly.

Updated 28 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, travellers and those with a learning disability.
• 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.