Archived: Tollgate Lodge

Updated 31 March 2017

Tollgate Lodge provides NHS primary medical services to around 8100 patients in the Stoke Newington area of Hackney in North East London. The service is provided through an alternative provider medical services (APMS) contract.

The practice is one of a number of primary care services (including general practices, urgent care centres and out of hours services) provided across England by Care UK Clinical Services Limited.

The practice is currently located within portacabins which are in need of replacement. The practice is due to merge with another practice and move to a new location in the same area in the near future.

The current practice clinical team comprises the lead GP, a senior salaried GP and five regular self-employed (or regular locum) GPs. The practice staff team also includes two nurse practitioners, two practice nurses and a health care assistant. The provider employs a local practice manager and assistant manager, administrative staff and receptionists. The practice team are also supported by the provider's central and regional teams who are based at different locations.

Patients have the choice of seeing a male or female GP. The GPs typically provide 28 clinical sessions at the practice per week. The practice opening hours are:

• Monday from 8am to 6.30pm
• Tuesday from 8am to 6.30pm
• Wednesday from 8am to 7.30pm
• Thursday from 8am to 6.30pm
• Friday from 8am to 6.30pm
• Saturday from 8am to 2pm
• Sunday from 10am to 6pm

The GPs make home visits to see patients who are housebound or are too ill to visit the practice. Same day appointments are available for patients with complex or more urgent needs. The practice offers online appointment booking and an electronic prescription service.

When the practice is closed, patients are advised to use the local out-of-hours primary care service. The practice provides information about its opening times and how to access urgent and out-of-hours services in the practice leaflet, on its website and on a recorded telephone message.

The practice serves a diverse, multicultural and multilingual population including patients with high social and health care needs. The practice had a relatively young practice population compared to the English average.

The practice is registered with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures and treatment of disease, disorder and injury.

Updated 31 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Tollgate Lodge on 17 January 2017. Overall the practice is rated as good.

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

• Staff were open and transparent and fully committed to reporting incidents and near misses. The level and quality of incident reporting ensured a reliable picture of safety.
• Learning was based on a thorough analysis and investigation of any errors and incidents. Opportunities for learning from internal and external incidents were maximised.
• The practice had effective systems in place to minimise risks to patient safety. The practice actively pre-empted risks to patients known to be more vulnerable.
• Staff were aware of current evidence based guidance. Staff had the skills and knowledge to deliver effective care and treatment.
• Patient feedback indicated that patients were treated with compassion 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.
• The service was accessible. Patient feedback was positive about the ease of getting an appointment. Urgent appointments were available the same day.
• The practice had adequate facilities and was equipped to treat patients and meet their needs. The lack of space acted as a constraint on the expansion of services.
• 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.

We saw two areas of outstanding practice:

• The practice had comprehensive, systems and processes in place to ensure that patients received safe care and treatment. The practice and corporate team had fostered a genuinely open and transparent culture of reporting and maximised learning from incidents. There were comprehensive systems to keep people safe, taking account of current best practice. The whole team was engaged in reviewing and improving safety and safeguarding systems.

• The practice had developed a proactive approach to anticipating and managing risks to people who use services. The practice maintained lists of its more vulnerable patients. These patients were allocated a personal GP who proactively reviewed their list and was alerted each time one of their patients contacted the practice. This system enabled the practice to monitor the wellbeing of patients at risk and identify any developing issues at an early stage.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 31 March 2017

The practice is rated as good for the care of people with long term conditions.

• The practice maintained registers of patients with long term conditions. There was a system to recall patients for a structured annual review to check their health and medicines needs were being met. The GPs and practice nurse had lead roles in long term disease management.
• The practice performed well on the Quality and Outcomes Framework (QOF) for long term disease management, having consistently achieved 98%-99% of all achievable QOF points over the last nine years.
• The practice ran specialist clinics for common long term conditions. For example, it ran a weekly clinic led by the local diabetes specialist nurse and diabetic dietitian. In 2015/16, the percentage of diabetic patients whose blood sugar levels were adequately controlled was 77% which was in line with the national average of 78%.
• The local heart failure nurse ran clinics at the practice for patients with this condition. The practice was able to demonstrate effective links with other multidisciplinary and specialist teams, for example in managing patients with chronic obstructive pulmonary disease (COPD).
• The practice followed up patients with long term conditions following discharge from hospital and ensured that care plans were updated to reflect any additional needs.
• Patients with long term conditions had access to longer appointments (20 minutes) when required.

Updated 31 March 2017

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

• The practice provided antenatal and postnatal care and the eight week baby check.
• Immunisation rates were high for standard childhood immunisations.
• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals.
• The practice invited all younger patients for a health check when they reached the age of 16.
• Appointments were available outside of school hours and the premises were suitable for children and babies. Breastfeeding and baby changing facilities were available.
• The practice held an annual 'mother and baby' forum for new parents to signpost relevant services and provide advice and education, for example on breastfeeding.
• The practice prioritised acutely ill children and women experiencing acute pregnancy complications for urgent attention.
• 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 or following a hospital discharge.
• The GP child safeguarding lead had protected time to follow-up cases and liaise with relevant agencies including the local multiagency safeguarding hub (MASH).
• The GP child safeguarding lead held monthly meetings with the midwife and health visitor and liaised as needed with school nurses to support families and children.
• The practice staff received annual training and worked in partnership with community based organisations to identify and act on concerns about domestic violence. This work was based on the 'IRIS' model (Identification and referral to promote safety) and funded by the clinical commissioning group across all practices in Hackney.

Updated 31 March 2017

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

• The practice offered proactive, personalised care to meet the needs of the older patients in its population. One of the GPs took a lead role for the care of older patients within the practice.
• The practice was responsive to the needs of older patients, and offered home visits, longer appointments and urgent appointments as appropriate.
• The GPs worked with health and social care professionals and workers to deliver a tailored multidisciplinary package of care. Patients had access to a local care coordinator who could signpost to community based activities and services for example to combat social isolation.
• The practice maintained a register of patients receiving palliative care. Patients on the register (and when appropriate their carers) were involved in planning their care, including their end of life care.
• The practice participated in a Hackney-wide scheme to reduce unplanned admissions through multidisciplinary care planning and a shared care approach. This was primarily aimed at patients aged over 75 with complex conditions at risk of hospital admission or sudden deterioration.
• The practice followed up older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.
• Older patients were provided with advice and preventive care to help them to maintain their health and independence. For example, the practice offered flu, shingles and pneumococcal vaccination to eligible older patients.
• Staff were able to recognise the signs of abuse in vulnerable older patients and knew how to escalate any concerns.
• The practice offered an extended range of services, for example adult phlebotomy, reducing the need for patients to travel.

Updated 31 March 2017

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

• The practice provided accessible services to meet the needs of working age patients. The practice was open seven days a week and also offered telephone consultations, online appointment booking and an electronic prescription service.
• The practice used a messaging service to communicate with patients for example it sent appointment reminders, patient survey questionnaires and checked patients' smoking status by text message. Patients were also readily able to cancel appointments by return of text.
• The practice offered health promotion and screening services for this age group, for example NHS health checks for patients aged 44-75 years, weight management advice, alcohol counselling and information about local exercise classes and exercise referral.
• In 2015/16, 80% of eligible women registered with the practice had a cervical smear test within the last five years, in line with the national average of 81%.
• The practice provided an oral contraceptive service and signposted patients requiring other forms of contraception to local family planning services.

Updated 31 March 2017

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

• Patients at risk of dementia were offered screening and referral to the local memory services.
• In 2015/16, 82% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was comparable to the national average of 84%.
• Patients had access to an Alzheimer's Society dementia advisor who was assigned to the practice to support patients and their families following diagnosis. This was part of a Hackney-wide scheme funded by the clinical commissioning group.
• The practice regularly worked with multi-disciplinary and specialist teams in the case management of patients experiencing poor mental health. The practice was positive about involving mental health advocates to support patients.
• In 2015/16, 93% of patients with a diagnosed psychosis had a comprehensive care plan in their records. This was above the national average.
• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
• The practice had information available for patients experiencing poor mental health about how to access various services, support groups and voluntary organisations including 24 hour crisis services.
• The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

Updated 31 March 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 for example patients with a learning disability. Alerts were included on the electronic patient record system to ensure that staff were aware of patients who required additional assistance.
• The practice offered longer appointments for patients with a learning disability and annual health checks.
• 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 services, support groups and voluntary organisations for example drug and alcohol services. The local wellbeing coordinator ran a weekly clinic at the practice and was able to refer or signpost patients to community services and social activities.
• Staff interviewed knew how to recognise signs of abuse in children, young people and vulnerable adults. 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.
• The practice identified carers and provided them with written information about available support. The practice had dedicated appointments for carers outside of working hours.
• The practice aimed to meet the 'Accessible information standard'. This ensures that patients (or their carers) with a disability or sensory loss receive information from the practice that they can access and understand, for example in large print, Braille or via email.