Thornbrook Surgery

Updated 22 August 2016

Thornbrook Surgery provides care to approximately 8,522 patients in Chapel-en-le-Frith, a small town in the High Peak area of North Derbyshire. The practice also has a branch site based in the nearby village of Chinley. It provides services to a combination of urban and rural populations. The surgery provides primary care medical services via a Personal Medical Services (PMS) contract commissioned by NHS England and North Derbyshire Clinical Commissioning Group (CCG). The practice operates from a refurbished purpose-built detached building.

The practice is run by a partnership of four GPs (two males and two females), and the partners employ a salaried male GP. Another GP is presently working in the capacity of a long-term locum.

The nursing team comprises of two nurse practitioners, two practice nurses, and two health care assistants. The practice directly employs a community matron and a care co-ordinator, who undertake dual roles within the practice. The clinical team is supported by a practice manager, a business manager and an information technology (IT) manager, with a team of nine administrative and reception staff including an office manager. The practice also employ a cleaner at their branch site.

The partnership is an established training practice and a GP registrar (a qualified doctor who is completing training to become a GP) works within the practice. It is also a teaching practice and accommodates placements for medical and nursing students.

The registered practice population are predominantly of white British background, with only 1.5% of patients recorded as being of non-white ethnicity. The practice is ranked in the second lowest decile for deprivation status, and is generally considered an area of relatively high affluence, with a deprivation score of 11.5 (England average is 21.8). The practice age profile has higher numbers of patients aged 45 and over. For example 22.4% of the practice population are aged 65 and above, which is comparable to the CCG average of 21.7%, but above the national average of 17.1%.

The practice opens from 8am until 6.30pm Monday to Friday. Scheduled GP morning appointments times are usually available from 8.30am (9am on Monday) until approximately 11.20am, and afternoon surgeries run approximately from 3.20pm to 5.40pm. The practice closes on one Wednesday afternoon each month for staff training. Extended hours opening is available on a Monday morning from 7.30am and Monday evening until 8pm.

The practice has opted out of providing out-of-hours services to its own patients. When the practice is closed, patients with urgent needs are directed via the 111 service to a locally based out-of-hours and walk-in urgent care centre in New Mills operated by Derbyshire Health United (DHU). This opens from 6.30pm to 10.30pm each weekday, and from 9.30am until 10.30pm at weekends and bank holidays. Patients also have access to the minor injuries unit in Buxton. The nearest Accident and Emergency (A&E) units are based in Macclesfield and Stockport. 

Updated 22 August 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Thornbrook Surgery on 11 July 2016. Overall the practice is rated as good.

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

• There was a system in place for the reporting and recording of significant events. Learning was applied from events to enhance the delivery of safe care to patients.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. A regular programme of clinical audit reviewed patient care and ensured actions were implemented to improve services as a result.
• The practice planned and co-ordinated patient care with the wider multi-disciplinary team to deliver effective and responsive care to keep vulnerable patients safe.
• The practice was committed to staff training and development and the practice team had the skills, knowledge and experience to deliver high quality care and treatment. The practice had an effective appraisal system in place.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. The practice analysed and acted on feedback received from patients.
• Information about how to complain was available upon request and was easy to understand, although no details were displayed in the waiting area. Improvements were made to the quality of care as a result of any complaints received.
• Patients provided mixed views on their experience in making an appointment to see a GP. However, we saw that patient feedback on access had improved in the latest GP survey, and the practice was taking proactive steps to address this issue.
• Longer appointments were available for those patients with more complex needs. A nurse practitioner triaged calls and ensured that any patient requiring an urgent appointment was seen on the same day.
• Risks to patients were assessed and well managed. However, the practice needed to update their fire risk assessment.
• The practice had good facilities and was well-equipped to treat patients and meet their needs.
• The practice funded a specialist respiratory nurse who attended the practice once a fortnight to monitor and review patients with breathing difficulties.
• The practice had developed their own detailed chaperoning guidelines for staff which were designed around specific examinations. For example, when acting as a chaperone during a breast examination.
• The practice had developed robust contingency planning arrangements.
• There was a clear leadership structure in place and the practice had a governance framework which supported the delivery of good quality care. Regular practice meetings occurred, and staff said that GPs and managers were approachable and always had time to talk with them.
• The practice had a clear vision for the future and ensured that the whole practice team were included in reviewing and planning service delivery. The aspirations of the partners were in line with the CCG strategy of delivering high quality care closer to the patient’s home.

We saw the following areas of outstanding practice:

• We received a number of examples demonstrating where staff had provided care above and beyond expectations. This included visiting patients at home during the weekend; organising a hospital discharge for a complex patient to comply with a patient’s wishes; and providing a course of treatment outside of opening hours to enable a patient to attend work. We observed that patients would have had to be admitted into hospital, retained in the hospital, or attended the hospital to access treatment, without this level of commitment to care by practice staff.
• The practice provided access to a range of mental health support that included a psychotherapist; a counsellor; a consultant psychiatrist for older people; and a cognitive behavioural therapist to support patients with mental health needs. At least one of these professionals was present in the surgery each working day. These services were accessible to all people who resided locally. Outcomes for mental health care were above local and national averages.

The areas where the provider should make improvement are:

• Undertake an up to date fire risk assessment.
• Display information on the complaints procedure in the waiting area.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 22 August 2016

• The practice achieved 96.6% for diabetes related indicators, which was in line with the local average of 96.7% and above the national average of 89.2%. This was achieved with a lower exception reporting rate across the ten individual indicators for diabetes.

• The practice undertook annual reviews for patients on their long-term conditions registers. For example, 76% of patients with chronic obstructive airways disease (COPD) had received a review of their condition in the last 12 months.
• Annual reviews for diabetes consisted of coordinated appointments with the health care assistant, followed by an appointment with the nurse or GP in one visit to discuss patients’ needs.
• The practice was establishing a pre-diabetes register with plans to expand the care provided to this cohort of patients. The majority of diabetes care was provided in-house and this included the initiation of insulin.

• The practice funded a specialist respiratory nurse to attend the practice each fortnight. Care plans had been created for these patients by this nurse and the arrangements in place had impacted on a reduced number of hospital admissions for these patients.
• The practice-employed care co-ordinator worked with other services and agencies to plan and deliver patient care, particularly for those patients being discharged following a hospital admission.
• The practice provided a range of services on site for patients with a long-term condition. This included spirometry (to assess breathing difficulties); memory testing; foot checks for patients with diabetes; and INR monitoring. INR testing measures the length of time taken for the blood to clot to ensure that patients taking particular medicines were kept safe. 

Updated 22 August 2016

• The health visitor attended a meeting with practice clinicians once a month to discuss any child safeguarding concerns, and there was effective liaison between these meetings regarding any issues.
• Child protection alerts were used on the clinical system to ensure clinicians were able to actively monitor any concerns.
• The midwife held an ante-natal clinic on site every week. The practice website had an information section about ante-natal care including local services and their contact details.
• Childhood immunisation rates were high with over 50% of the vaccinations provided achieving 100% uptake. Overall, childhood immunisation rates for the vaccinations given to infants aged five and below ranged from 94.8% to 100% (local average 95.2% to 98.9%).
• Requests for child consultations were prioritised. Telephone advice was offered to parents when required.
• Appointments were available outside of school hours
• A dedicated family planning clinic was provided to fit and remove intrauterine devices (coils) and implants. Clinician provided advice on all aspects of contraception. Chlamydia testing kits were readily available on site.
• The practice had baby changing facilities, and toys were provided for younger children. The practice welcomed mothers who wished to breastfeed on site, and their website provided information on local breastfeeding support groups and general advice.
• The practice engaged with local schools and colleges, for example regarding PPG membership, and the further development of the practice values. Children at a local school had painted a mural displayed in the main waiting area to represent practice values. 

Updated 22 August 2016

• The practice had higher numbers of older people registered with them compared to the national average (for example, 22.4% of patients were over 65, compared against a national average of 17.1%). The practice ensured that their services were tailored to meet the needs of their older patients, and 99% of patients over 75 had received contact from a health professional in the previous 12 months.
• The practice team knew patients and their families very well, and this helped them to provide responsive care and provide additional support if this became necessary.
• The practice had developed a number of in-house services to prevent older patients from travelling to hospitals in Macclesfield, Stockport and Chesterfield. The services included NHS out-patient clinics; a visiting consultant for older people’s mental health; and a hearing assessment clinic.
• The practice had access to a local charitable domiciliary physiotherapy service which provided care for frail and vulnerable patients in their own home.
• The practice worked closely with other professionals to plan and deliver patient care. We observed a multi-disciplinary meeting on the day of our inspection and saw this effectively focused on addressing individual patients’ needs.
• A local charitable service provided transport for the elderly and vulnerable to access surgery appointments. This was important due to the rural nature of some of the area served by the practice.
• Longer appointment times were available and home visits were available for those unable to attend the surgery. Appointments were offered to older patients earlier in the day during winter to prevent patients travelling home when dark.
• Named GPs provided weekly visits to two local care homes. The practice responded to any urgent patient needs on the same day. Staff at the care homes told us that they had a very good relationship with the practice and were highly satisfied with the service provided to patients. The practice held regular meetings with the home to review the service provided.
• Uptake of the flu vaccination for patients aged over 65 was 70% which was in line with local (73.9%) and national (70.5%) averages.

Updated 22 August 2016

• The practice offered on-line booking for appointments and requests for repeat prescriptions. The practice provided electronic prescribing so that patients on repeat medicines could collect them directly from their preferred pharmacy.
• Extended hours’ GP consultations were available at the main site. Early morning and evening appointments were available on one day each week to accommodate the needs of working people.
• The practice provided a simple registration process for students who wished to temporarily return to the practice.
• The practice held twice-weekly ‘drop-in’ blood clinics.
• The practice provided examples of a flexible approach in seeing patients to accommodate their requirements. For example, a nurse received a CCG award having attended work early on a regular basis to provide treatment for a patient to enable them to get to work and also visited them at home during the weekend.
• The practice promoted health screening programmes to keep patients safe. For example, screening uptake for cervical, bowel and breast cancer was in line with local and national averages.
• The practice offered health checks for new patients and NHS health checks for patients aged 40-74.
• The practice referred patients to health trainer sessions for support and advice including weight management, smoking cessation, and alcohol consumption.
• The practice provided free Wi-Fi facilities for patients attending the practice. This was organised further to feedback received by Healthwatch.

Updated 22 August 2016

• The practice achieved 100% for mental health related indicators in QOF, which was 1.9% above the CCG and 7.2% above the national averages. This was achieved with significantly lower levels of exception reporting.
• 97.4% of patients with poor mental health had a documented care plan during 2014-15. This was 4.1% higher than the CCG average and 9.1% higher than the national average.
• Access to a range of professionals for mental health support was provided on site each day. This included a counsellor, a consultant psychiatrist for older people, and a cognitive behavioural therapist. CBT is a technique used to empower patients to resolve problems by changing their thinking and behaviours.
• A GP had been involved in developing the mental health strategy for the region as part of a role with the CCG. The practice had initially funded a psychotherapist to provide support for patients on site. This was successful and was expanded to all local patients and funded by the CCG, with the service still being delivered from the practice.
• Appointments were usually booked with the same GP to ensure continuity of care for patients experiencing mental health difficulties.
• 98.1% of people diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months. This was 14% above local and national averages, but with exception reporting rates at 12% higher.
• Staff had undertaken dementia awareness training, and the practice had applied for ‘Dementia Friends’ status to enhance their knowledge of support available to patients and their carers.
• A community psychiatric nurse (CPN) worked with the practice, and usually attended weekly multi-disciplinary meetings to review and discuss any patients with ongoing mental health needs. 

Updated 22 August 2016

• The practice had undertaken an annual health review in the last 12 months for 70% of patients with a learning disability.
• Longer appointments and home visits were offered to vulnerable patients, including patients with a learning disability, when required.
• The practice ensured flexibility in their approach to individuals for specific needs, and provided examples to support this. For example, a patient with a learning disability could sit with their carer in the car whilst waiting for their appointment as they felt calmer in doing this. Staff made the clinician aware and would arrange to go and collect the person from the car park when their appointment was due.
• The practice provided high quality end of life care. Patients with palliative care needs were reviewed at a monthly multi-disciplinary team meeting, and had supporting care plans in place. Community nursing staff informed us that the GPs were caring and highly responsive to these patients, and ensured that any needs were acted upon promptly.
• Staff had received adult safeguarding training and were aware how to report any concerns relating to vulnerable patients.