Mount Farm Surgery

Updated 12 December 2016

Mount Farm Surgery is a large modern purpose built practice situated in the Moreton Hall area of Bury St Edmunds, and is approximately 2.4 miles to West Suffolk Hospital.

Bury St Edmunds station has rail links to London Liverpool Street and London Kings Cross.

There is free parking in Lawson Place adjacent to the surgery. There is also a local Tesco Express and pharmacy in the area. The latter is currently incorporated into the practice building structure. At the time of the inspection there were building works in progress to move the pharmacy to a larger space within the surgery.

The practice currently has four clinical partners plus a business partner, three salaried GPs, two nurse prescribers, 3 practice nurses and two health care assistants. The practice is supported by an administrative team including reception staff, medical secretaries. an assistant practice manager, administrative team leader and clinical services analyst. The practice is a training practice and three GPs have the additional skills, experience and qualifications to support qualified registrars through their vocational training to become a GP. 

The practice holds a Personal Medical Services contract (a locally agreed contract between NHS England and a GP Practice) to provide services to its patient population of 13,500.

The practice also offers a range of enhanced services commissioned by their local Clinical Commissioning Group including the diagnosis and support for people with dementia, supporting patients with learning disabilities and extended hours appointments.

The surgery opening times are: Monday – Friday 8.00am – 6.30 pm.Extended Hours are offered from 8am – 11.30am on Saturdays: these are pre-bookable appointments only. Clinic times vary and run from 8am – 1pm and 2pm – 6pm.

An urgent care clinic was held daily for patients who required to be seen on the same day. Calls for this service were triaged by the GPs and appointments made where necessary.

Routine appointments can be booked up to six weeks in advance.

Telephone consultations are also available daily.

Appointments could be booked on-line, by telephone or face to face. 30% of patients had registered for on-line appointment access.

House calls were available to all patients and all requests were triaged by the GPs with telephone consultations if appropriate.

There was a practice mission statement which was framed and displayed in multiple rooms. All staff were aware of the practice mission and values.

Updated 12 December 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mount Farm Surgery on 13 September 2016. 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 an effective system in place for reporting and recording significant events. Regular meetings were held to discuss, analyse and learn from significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment including safeguarding training, equality and diversity, basic life support, health and safety and infection control.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients said they found it easy to make an appointment with a GP or practice nurse and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs including disabled access, disabled toilets, and baby changing facilities, disabled parking and a hearing loop.
• 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 and complied with the requirements of the duty of candour.
• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

• Feedback from patients about their care was consistently positive.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 12 December 2016

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

• The practice maintained comprehensive disease registers which enabled them to identify patients with diagnosed long term conditions i.e. ischaemic heart disease, asthma and diabetes.
• A dedicated team carried out regular recalls of patients with long term conditions and one-stop chronic disease reviews were carried out for patients with multiple conditions. Invitation letters and text messages were sent to patients to arrange review appointments. Specific training had been undertaken by the practice nurses for respiratory conditions such as chronic obstructive pulmonary disease, and asthma and also diabetes.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
• Longer appointments and home visits were available when needed.
• All 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.
• The practice performance for diabetes against national screening programmes to monitor outcomes for patients was 99% which was above the CCG average and the national average. (Diabetes mellitus is when the body is unable to regulate the amount of sugar in the blood due to problems producing insulin).
• The practice performance for hypertension was 100% which was above the CCG average and the national average. (High blood pressure may increase the chance of having a heart attack or stroke).

Updated 12 December 2016

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

• 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. For example, midwives held a weekly clinic at the practice.
• The practice is rated as good for the care of families, children and young people.
• Children were offered appropriate immunisations and 6 week baby checks.
• The practice offered contraceptive and sexual health services.
• Patients with long term conditions i.e. asthma and diabetes were reviewed with a selection of appointments available including after school and during school holidays.
• The practice had achieved the second best overall percentage of patients undergoing cervical screening in the West Suffolk area.

Updated 12 December 2016

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 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.
• Staff had received training in dementia and a dementia assessment had been carried out of the premises by a dementia friendly employee.
• Nurses carried out home visits for housebound patients for annual reviews and to administer flu vaccinations.

Updated 12 December 2016

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

• Saturday morning clinics were available for patients unable to access services during the week, along with early morning and late evening appointments.
• The practice offered home blood pressure monitoring.
• Patients were able to access the Bury St Edmunds GP plus scheme for appointments after 6.30pm and at weekends.
• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs of this age group.

Updated 12 December 2016

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

• 93% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was above the national average of 84% and CCG average of 82%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice carried out advance care planning for patients with dementia.
• The practice 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 had undergone Mental Capacity Act training.

Updated 12 December 2016

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.
• The practice offered longer appointments for patients highlighted as being vulnerable.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• 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. Staffs 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.
• Coding of vulnerable patients on the practice medical system ensured that vulnerable patients were identified and their needs were recognised. For example, patients with learning disabilities, mental health problems, veterans, sex workers, travellers and homeless patients.

• The practice worked closely with the local learning disability specialist nurse.
• The practice had regular multi-disciplinary team meetings between clinician, health visitors and social services.
• The practice regularly hosted meetings of the Suffolk Family Carers group.
• The practice coded vulnerable patients to ensure that they were recognised and treated in the most supportive way i.e. travellers, veterans, homeless people, people who do not read, patients with mental health issues and those in extreme poverty.