Archived: Lime Tree Surgery

Updated 18 July 2017

Lime Tree Surgery is located in a converted building in a residential area of East London and is a part of Waltham Forest Clinical Commissioning Group (CCG).

There are 7,500 patients registered with the practice, 50% of which are aged between 25 and 49, 12% of patients are aged over 60 and 14% of patients are aged between 0 and 9 years old. The practice has a deprivation score of 31, which is similar to the CCG average of 30 and higher (more deprived) than the national average of 22. The practice has two residential homes that it provides primary care services to.

The practice has one male GP partner and two female salaried GPs who carry out a total of 20 sessions per week. The practice is a teaching and training practice and has four trainees who carry out a total of 17 sessions per week. There is a practice nurse who does seven sessions per week and a physician’s associate who carries out eight sessions per week. The practice has a practice manager, an assistant practice manager and eight reception/administration staff members.

The practice operates under a Personal Medical Services (PMS) contract (a locally agreed alternative to the standard GMS contract used when services are agreed locally with a practice, which may include additional services beyond the standard contract).

The practice is open Monday to Friday between 8:30am and 6:30pm except Thursdays when it closes at 1:30pm. Phone lines are answered from 8:30am and appointment times are as follows:

• Monday 8:30am to 12:30pm and 2pm to 8pm
• Tuesday 8:30am to 12:30pm and 2pm to 8pm
• Wednesday 8:30am to 12:50pm and 2pm to 7:30pm
• Thursday 9:20am to 12:30pm
• Friday 8:30am to 5:50pm

The locally agreed out of hours provider covers calls made to the practice when the practice is closed.

The Lime Tree Surgery operates regulated activities from one location and is registered with the Care Quality Commission to provide diagnostic and screening procedures, treatment of disease, disorder or injury and maternity and midwifery services.

Updated 18 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lime Tree Surgery on 9 May 2017. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Data showed that practice achievement for cervical cytology, immunisations for five year olds and bowel screening was below the CCG and national averages.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• All staff had completed mandatory training in line with their role; this included safeguarding children, fire training and chaperoning.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day, however results from the GP Patient Survey did not support this and were low in relation to making and obtaining an appointment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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 was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
• The patient participation group was active and they purchased a defibrillator for the practice from monies they raised from fundraising.

The areas where the provider should make improvement are:

• Continue to work to improve patient satisfaction with access to services including getting through to the practice by telephone and obtaining an appointment.
• Continue to work to increase the uptake of cervical cytology, childhood immunisations and bowel screening.

Review the process for recalling patients with mental health illnesses to increase the uptake of annual reviews.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Updated 18 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.
• 78% of patients with diabetes had a record of a foot examination and risk classification documented in their records compared to the CCG average of 80% and the national average of 88%. The practice had an exception reporting rate of 4%, which was lower than the CCG average of 6% and the national average of 8%.
• 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 held health promotion events for these patients.

Updated 18 July 2017

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

• From the sample of two 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 low for immunisations for five year olds.
• The practice provided 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, 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.
• The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications.
• There was a GP with a specialist interest in womens health who carried out six week baby checks.
• The practice had a dedicated room for breastfeeding.

Updated 18 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.
• These patients were offered an annual review and had a named GP.
• 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.
• 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 18 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.
• Telephone consultations were available each day.
• The practice was signed up to the local HUB which provided appointments on weekday evenings and weekends when the practice was closed.
• 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 18 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.
• 76% of with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive agreed care plan documented in the record compared to the CCG average of 91% and the national average of 89%.The practice had an exception reporting rate of 3%, which was lower than the CCG average of 7% and the national average of 13%.
• The practice had a policy to not exception report these patients unless there were extenuating circumstances.
• The practice specifically considered the physical health needs of patients with poor mental health and dementia and gave these patients longer appointments to give enough time to discuss their complex needs.
• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
• The practice regularly worked with multi-disciplinary 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.

Updated 18 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, refugees 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.
• These patients were offered an annual review.
• 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.