Leesbrook Surgery

Updated 3 January 2018

Leesbrook Surgery is located in a residential area in Lees, a district of Oldham. The practice provides services from a purpose built two storey building. Consulting rooms are on both floors and there is a passenger lift available. There is a large car park and disabled parking is available.

At the time of our inspection there were 9555 patients registered with the practice. The practice is a member of NHS Oldham Clinical Commissioning Group (CCG). The practice delivers commissioned services under the General Medical Services (GMS) contract.

The practice age and gender profile is similar to the national averages, with a slightly above average number of patients over aged 45. The proportion of patients registered who have a long standing health condition is below the CCG and national average. The practice is in the seventh most deprived decile and life expectancy rates are above average for males and females.

There are four GP partners, two male and two female. One of the partners was in the process of registering with the Care Quality Commission (CQC). In addition there is a male salaried GP. There are also two practice nurses, a nurse practitioner, a community matron (directly employed by the practice) and a healthcare assistant. There is a practice manager and administrative and reception staff.

Normal opening hours are 7.30am until 6.30pm Monday to Friday and 9.30am until 12.30pm on Saturdays. GP consulting times are:

Monday 8.30am until 11am and 2pm until 5pm.

Tuesday 7.30am until 11am and 2pm until 5pm.

Wednesday 7.30am until 11am and 2pm until 5pm.

Thursday 7.30am until 11am and 2pm until 5pm.

Friday 7.30am until 11am and 2pm until 5pm.

Saturday 9.30am until 12 noon.

Emergency appointments are available outside these times.

There is an out of hours service available provided by Go To Doc Limited.

Updated 3 January 2018

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall.

We first carried out an announced comprehensive inspection at Leesbrook Surgery on 15 March 2016. The overall rating for that inspection was inadequate and the practice was placed into special measures.

A further announced comprehensive inspection was carried out on 12 January 2017. During that inspection it was found that improvements had been made. The practice was given an overall rating of good and was taken out of special measures.

The full comprehensive reports on the March 2016 and January 2017 inspections can be found by selecting the ‘all reports’ link for Leesbrook Surgery on our website at www.cqc.org.uk.

This announced full comprehensive inspection was carried out on 10 November 2017 in accordance with our inspection methodology. The practice is rated as good.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

At this inspection we found:

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

• The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

• The provider should ask potential employees about gaps in their employment history.

• The provider should carry out a fire evacuation, and also revert to carrying out weekly fire alarm checks.

• The provider should make further improvements to their administration and documentation. For example, learning from complaints should be documented, meeting minutes should contain enough information for staff and audit programme where audits are repeated to monitor improvement would be helpful.

• The provider should evaluate their policies to avoid duplication and complication.

• The provider should continue the process of having all partners correctly registered.

• The provider should check data protection arrangements, especially relating to computer smart cards and password.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 23 March 2017

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

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

• Performance for diabetes related indicators was 89%. This was in line with the CCG average of 87% and the national average of 90%.

• Longer appointments and home visits were available when needed.

• All these patients had a named GP and 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 23 March 2017

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

• There were systems in place 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 A&E attendances. Immunisation rates were in line with the CCG and national average for all standard childhood immunisations.

• Children and young people were treated in an age-appropriate way and were recognised as individuals.

• The practice’s uptake for the cervical screening programme was 86%, which was above the CCG average of 81% and the national average of 81%.

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

• We saw positive examples of joint working with midwives, health visitors and school nurses.

Updated 23 March 2017

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

• The practice employed a community matron who mainly worked with elderly patients.

• The community matron worked closely with care homes who could contact them directly with any issues. They regularly visited patients in care homes to put in place and review care plans.

• Over 75 health checks included a memory assessment and the community matron worked closely with the dementia and memory service to provide appropriate support for patients.

• An advisor from Age UK attended the practice at least every two weeks to provide additional support to patients under their Promoting Independent People (PIP) Project.

• The practice offered proactive, 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.

Updated 23 March 2017

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

• The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

• 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.

• Appointments were routinely available on Saturday mornings.

Updated 23 March 2017

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

• Performance for mental health related indicators was 96%. This was above the CCG average of 91% and the national average of 93%.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

• The community matron worked with the dementia service to identify patients who may require additional support.

• The mental health charity MIND attended the practice on a weekly basis to support patients who could self-refer or be referred by their GP.

• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

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

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

Updated 23 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 with a learning disability. However only six of the 22 on the list had had an annual review.
• The practice offered longer appointments for patients with a learning disability.
• 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.