Norbury Health Centre 2 Also known as Norbury Medical Practice

Updated 10 May 2017

Norbury Health Centre provides services to approximately 10,600 patients in south west London under a Personal Medical Services contract (an agreement between NHS England and general practices for delivering personal medical services). It sits within the Croydon Clinical Commissioning Group (CCG) which has 58 member practices serving a registered patient population of approximately 395,000. Norbury health centre provides a number of enhanced services including minor surgery; remote care monitoring; unplanned admissions and rotavirus & shingles immunisation. It is also a training practice for GP trainees.

The staff team at the practice consists of two male and two female GPs, one specialist nurse and two practice nurses, a practice manager, an assistant practice manager and 13 administrative staff. The permanent GPs at the practice provided 23 sessions per week, and an additional eight to ten sessions were provided by locum GPs. The service is provided from this location only. There is wheelchair access to the building; lift access the first and second floors, an accessible toilet, a hearing loop and reserved parking for patients with disabilities.

The practice is open between 8am and 6.30pm each weekday. Appointments are available between 9am – 11am and 4pm – 6pm each weekday, and bookable appointments are offered up to 7pm each weekday evening. Patients who wish to see a GP outside of these times are referred to an out of hour’s service. The practice provides an online appointment booking system and an electronic repeat prescription service.

The practice is registered with the Care Quality Commission as a partnership to carry on the regulated activities of maternity and midwifery services, treatment of disease, disorder or injury, family planning, surgical procedures, and diagnostic and screening procedures.

The practice has a lower percentage than the national average of people with a long standing health conditions (50% compared to a national average of 54%). It has a higher percentage of unemployed people compared to the national average (13.6% compared to 5.4%). The practice sits in an area which rates within the fifth most deprived decile in the country, with a value of 23 compared to the CCG average of 23.6 and England average of 21.8 (the lower the number the less deprived the area). Life expectancy in this area is the same as the England average for men (79 years) and one year above the England average for women (84 years compared to 83).

The practice is located in a diverse borough with around half of the population from black and ethnic minority groups and where more than 100 languages are spoken as a first language. For example a high percentage of patients speak Urdu, Guajarati, Polish, Punjabi, Hindi, Portuguese, Bengali and French. The age group profile for the patient population is comparable to the England average for almost all age groups. It is slightly above the England average for men and women aged between 20 – 34; and slightly above for male patients aged 35 – 39.

Updated 10 May 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Norbury Health Centre 2 on 18 July 2016. The overall rating for the practice was Good, however the practice was rated as Requires Improvement for the key question: are services Well Led? The full comprehensive report on the Month Year inspection can be found by selecting the ‘all reports’ link for Norbury Health Centre 2 on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 11 April 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 18 July 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice remains rated as Good. Specifically, following the focussed inspection we found the practice to be good for providing well led services.

At our previous inspection on 18 July 2016, we rated the practice as requires improvement for providing well led services as the provider had not acted upon the below averages results from the National Patient Survey (published in January 2016) with regard to access to care and treatment; and had not ensured all patients with a learning disability had received an annual review.

We also highlighted other areas where the provider should take action:

• Take appropriate steps to identify patients who are also carers to allow the practice to provide support and suitable signposting.
• Record when fire evacuation drills are carried out and amalgamate the four separate fire safety policies into one, up to date, cohesive document.
• Carry out a pre-acceptance audit with regard to clinical waste management.
• Review the repeat prescription policy and ensure it is being followed.
• Regularly review and update when necessary the business continuity plan.
• Complete the audit cycle for by re-auditing each of the audits carried out.
• Review their handling of complaints to ensure that all complaints are recorded and that information on the complaints process is made available to patients.

Our key findings at this inspection were as follows:

We found that the provider had taken a number of measures to improve, and had also taken action on the areas we had identified for improvement.

Results from the National Patient Survey published in July 2016 indicated that the practice performance had improved in relation to access to care and treatment, although results were still below national average. We saw that results were discussed at clinical meetings and patients were being encouraged to cancel appointments they did not need so as to free them up for others. Reception staff had received training in signposting patients to alternative, appropriate services. We were told that the practice was trying to address complaints about access by changing the telephone system, and they provided us with details of two new systems they were considering.

Thirty (out of 49) patients (61%) with a learning disability had received an annual review up to the end of February 2017. This compared to 20% at the time of the last inspection. The provider sent us a copy of a clinical meeting where we could see that the needs of these patients had been discussed.

We also found that the provider had taken the following action with regard to the good practice areas:

• The practice had taken steps to help identify patients who were also carers, including displaying a poster asking such patients to contact reception and also a poster relating to a local carers group. They had also obtained leaflets relating to a carers drop in centre.

• The provider had taken measures to improve fire safety. We saw a copy of the fire log book which indicated the fire alarms were being tested weekly, and regular fire drills were now being carried out. There was also an updated fire safety policy.

• Practice staff had carried out an in-house pre-acceptance audit with regard to clinical waste management.

• The practice had reviewed its repeat prescribing policy and was also recording on a database uncollected or lost prescriptions.

• The business continuity plan had been reviewed and updated and a copy was sent to us, along with a business continuity risk assessment.

• The Practice sent us a copy of a completed, two-cycle, antibiotic prescribing audit. This indicated that there had been a 69% (44 compared to 14 patients) reduction in the number of patients who have been prescribed cephalosporins, quinolones and co-amoxiclav in May 2016 compared to March 2015. The practice also sent in two completed audits relating to two week referrals and obesity. Whilst these had been completed with a second cycle, the audits did not demonstrate how the outcomes had led to an improvement in the quality of patient care.

• The practice had improved the complaints procedure information available to patients. A new poster had been displayed in the waiting area; the process was signposted on the practice website and we saw evidence that the practice was risk rating each complaint and also recording the outcome.

  However, there remained areas of practice where the provider should continue to make improvements.

  In addition the provider should:

• Continue to review the results from the national GP patient survey and implement measures to improve patient satisfaction with access to care and treatment, particularly with regard to telephone access.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 20 October 2016

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.

• Nationally reported data showed that outcomes for patients with diabetes were broadly in line with CCG and England averages. For example, the percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) was 140/80 mmHg or less (01/04/2014 to 31/03/2015) was 77% compared to the CCG and England average of 78%. The percentage of patients with diabetes, on the register, who had had an influenza immunisation in the preceding 1 August to 31 March (01/04/2014 to 31/03/2015) was 89% compared to the CCG average of 90% and the England average of 94%.

• 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.

• The practice offered a number of enhanced services to help address the needs of patients with long term conditions including ulcer management and secondary wound care management.

Updated 20 October 2016

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.

• Staff were aware of their safeguarding responsibilities and we saw appropriate referrals were made.

• Immunisation rates for the standard childhood immunisations were mixed. For example all immunisations rates for children aged 12 months and 24 months fell below the CCG averages, whilst six out of ten immunisation rates for children aged five years were above the CCG averages.

• Some staff had received training in teenage health issues such as Fraser competence and consent.

• The practice had a recall system for cervical smears. A named administrator oversaw the recall system. Patients with abnormal smears were actively followed up. The practice’s uptake for the cervical screening programme was comparable to the CCG and England averages (80.2% compared to 81.8%).

• Cancer data showed the practice rate of screening females aged 50-70 for breast cancer in the last 36 months was 65% compared to the CCG average of 60% (England average 72%); however those screened within 6 months of invitation was 47% compared to the CCG average of 68% and England average of 73%. The number of patients aged 60 – 69 screened for bowel cancer in the last 30 months was 44% compared to the CCG average of 48% and England average of 55%.

• Priority appointments were offered for children. Protected appointment slots for children were released in the afternoon for after school consultation.

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

• The practice had a programme for antenatal care. There was a weekly antenatal clinic and priority appointments were available for pregnant patients if they need urgent attention. There was a named administrator to monitor the follow up arrangement of antenatal patients and to ensure postnatal and baby checks were booked. Teenage mothers were signposted to midwives with special responsibilities for young mothers.

• Patient information leaflets were available, relating to, for example young person’s counselling and sexual health issues.

Updated 20 October 2016

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

• The practice offered proactive 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.

• The seasonal flu vaccination uptake figures (2014-2015) showed 66% of patients over the age of 65 received a vaccination, which was 10% below target, but was a 10% improvement on the previous year.

• Personalised care was offered to elderly patients with a named GP.

• A proactive approach was taken to promote health and prevent harm. For example, elderly patients’ nutritional health was evaluated; referrals, where appropriate, were made to the falls clinic, occupation therapists and physiotherapists and the practice worked with the Rapid Response team to keep patients at home and avoid hospitalisation.

• Housebound patients were delivered medicines at home. The practice worked with the local community pharmacist to ensure safe dispensation of medicines and patient compliance.

• The practice provided a service to a local nursing home and also to four sheltered housing schemes. One of the latter had required over 300 visits during the course of the preceding year. We spoke with the nursing home who said they were happy with the service provided.

Updated 20 October 2016

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. For example, text messaging was used to remind patients of their appointments; a number of online resources such as a self-care forum were available; electronic prescriptions were being promoted to help working age people getting medication close to their work place and well persons checks were offered.
• The practice offered extended opening hours for working age people.
• Counselling and stress management was offered through IAPT (Improved Access to Psychological Therapies).

Updated 20 October 2016

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

• There were 83 patients on the practice’s mental health register. The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive, agreed care plan documented in the record, in the preceding 12 months (01/04/2014 to 31/03/2015) was 90% compared to the national average of 88%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health.
• There were 67 patients on the practice’s dementia register. Of these 72% had had their care reviewed in a face to face meeting in the last 12 months, which was below the national average of 84%.
• 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.
• The practice took part in the part in the Shared Care Prescribing for continuity of care and care closer to home.

Updated 20 October 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 those with a learning disability. There were 55 patients on the learning disability register; however, the practice had only carried out health checks on 11 of these patients.
• 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 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. We saw staff had referred a homeless person for a safeguarding assessment as they were concerned for the person’s vulnerability.

• We saw that systems were in place to assist vulnerable people with their medicines. For example, repeat prescriptions were sent directly to the local pharmacy who then delivered the medicines. Where appropriate, patients were given weekly supplies of their medicines in dosset boxes so that they had a clear indication of what to take and when.
• The seasonal flu vaccination uptake figures (2014-2015) showed 43% of patients in at-risk groups under the age of 65 received a vaccination, which was 30% below target, but was a 10% improvement on the previous year.