Dr Duffield and Partners Also known as The Park Surgery

Updated 21 January 2016

Dr Noakes and Partners also known as The Park Surgery provides general medical services to approximately 10,600 patients in the mainly urban areas of Great Yarmouth and the suburban areas of Gorleston and Bradwell. Treatment and consultation rooms are situated on the ground and first floor. There is a lift and a stair lift available for patients to access the first floor waiting area and treatment rooms. Parking is available with level access and automatic doors.

The practice has a team of seven GPs meeting patients’ needs. All seven GPs are partners, meaning they hold managerial and financial responsibility for the practice. GPs run personal lists but patients are given the option to see a GP of their choice. There is a team of two practice nurses, and two health care assistants who run a variety of appointments for long term conditions, minor illness and family health.

There is a practice manager and a team of non-clinical administrative, secretarial and reception staff who share a range of roles, some of whom are employed on flexible working arrangements. Community midwives run sessions three times a week at the practice and a health trainer provides two sessions per week. The community matron, a specialised diabetic nurse and the district nursing team also attend the practice. In addition there is a team of cleaners employed to oversee the practice cleaning. The practice is a long standing teaching and training practice.

The practice provides a range of clinics and services, which are detailed in this report, and operates generally between the hours of 8.00am and 6.30pm, Monday to Friday. Appointments are from 8.30am every morning to 11am and from 2.30pm to 5pm. if the appointments are full the surgeries are often extended to ensure all patients could see their own GP on the same day. Pre-bookable extended hours surgeries are offered Tuesday and Thursday mornings between 7am and 8am for working patients who are unable to attend during normal opening hours. In addition to pre-bookable appointments that could be booked from three to six months in advance, urgent appointments are available for people who need them.

Outside of these hours, the out of hours provider is a professional medical agency commissioned by the Great Yarmouth & Waveney Clinical Commissioning Group (Healtheast). Primary medical services are accessed through the NHS 111 service.

Updated 21 January 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Noakes and Partners also known as The Park Surgery on 10 November 2015. Overall the practice is rated as outstanding.

Specifically, we found the practice to be outstanding for providing caring, responsive and well-led services. We found the practice to be good for offering safe and effective services.

In addition we found the practice to be outstanding for providing services for older people, people with long term conditions, families, children and young people, working age people, people whose circumstances might make them vulnerable and people experiencing poor mental health.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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 several areas of outstanding practice including:

• In response to the high rates of teenage pregnancy and termination of pregnancy (TOP) rates in the area, one GP had trained to fit intrauterine coil devices and contraceptive implants. As a result the practice had seen a 60% decrease in the number of patients undergoing TOPs since 2011.

• Patients who did not attend for bowel and breast screening were identified by the practice and written to with supporting information to ensure they were able to make a clear and informed choice. In addition patients who did not attend for cervical screening were personally telephoned by the practice manager in the early evening to ensure they had received the information to make an informed and valid choice.

• The practice had a health trainer to support weight management, alcohol reduction and smoking cessation and could demonstrate this had a positive impact for patients using this service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 21 January 2016

The practice is rated as good for safe and effective services and outstanding for caring, responsive and well led services for the care of patients 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. Longer appointments and home visits were available when required. All these patients have a named GP and a structured annual review to check that their health and medicine 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 was available when needed.

A phlebotomy service was provided from the practice each morning and had recently been extended to early afternoons to support patient access.

The practice achieved high QOF scores and had a principle of rarely excepting patients from QOF. In addition the practice had developed a suite of searches that were run at least three monthly to target conditions and patients not identified by QOF indicators and registers. Clinical audits were used to improve the outcomes for patients with long term conditions.

The practice nurses worked with patients to manage long term conditions and recalled patients with conditions such as asthma and diabetes. The nurses maintained their training in this area to ensure they complied with best practice and the most recent guidelines. The nurses did not run long term condition clinics, and appointments could be made at any time to suit the patients’ needs and lifestyle rather than waiting for pre-set clinics. One GP utilised a risk profiling computer search software weekly to identify patients who had a high risk of hospital admission, overdue screening or were put at risk because of their medications. The evidence from these searches was used to inform clinical management of these patients and ensure their safety.

Updated 21 January 2016

The practice is rated as good for safe and effective services and outstanding for caring, responsive and well led services 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. The GP lead for safeguarding and the practice manager worked closely with the health visitor and other agencies. The practice had very high levels of deprivation and a significant number of children on the child protection register. As a result the practice worked hard to ensure they were kept up to date with their patients and tried to maintain high immunisation rates. The practice manger routinely liaised with the health visitor each month to check the list of ‘at risk’ patients and to let her know which children required immunisations or were a new addition to the child protection register.

Childhood immunisation rates for the vaccinations given were higher than local CCG averages. Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this. Appointments were available outside of school hours and the premises were suitable for children and babies. The practice had identified a gap in the sexual health service in the area and services had been developed to improve access to advice and support, particularly for young people.

All new-borns and their mothers were sent an invitation for a six week check with their GP. There were a number of positive comments about the care and treatment of children and young babies in respect of access to urgent appointments and the caring attitude of reception and clinical staff. Great Yarmouth continues to have a major problem with very high teenage pregnancy and Termination of Pregnancy (TOP) rates. In response to this, four years ago, one GP trained to fit intrauterine coils and contraceptive implants and as a result the practice had seen a dramatic reduction of 60% in patients undergoing TOPs since 2011.

Updated 21 January 2016

The practice is rated as good for safe and effective services and outstanding for caring, responsive and well led services for the care of older people. Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. The practice offered proactive, personalised care to meet the needs of the older people in its population. It was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs. The practice provided weekly GP visits to local care homes. The practice worked to try to reduce poly-pharmacy in patients and had met with the manager at one home and was able to reduce medication significantly as a result. A meeting was scheduled with a second care home to do the same.

GPs administered a lot of flu vaccinations to patients opportunistically and flu vaccination rates were in line with national averages. A local support service had attended the practice for a fortnight to promote the Message in a Bottle initiative, this was a scheme for anyone living at home that ensured vital information was available to identify them and to give advice of their medication and recent illness for the emergency services.

The practice contacted those patients who did not attend for their vaccination and the practice nurses visited care homes and house bound patients to administer vaccinations. This also gave an opportunity for chronic disease monitoring for those patients.

The practice took part in the Avoiding Unplanned Admissions direct enhanced service contract (DES). One GP partner helped to implement this service for the local clinical commissioning group.

Updated 21 January 2016

The practice is rated as good for safe and effective services and outstanding for caring, responsive and well led services for the care of working age patients (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 continued to work to maintain good access. In addition they offered clinical telephone access, from 11 am and would phone patients back if necessary. Pre bookable extended hours surgeries were available twice a week aimed at patients unable to attend during normal working hours.

The practice offered a number of online services, including booking and cancelling appointments and requesting repeat medicines. They also provided a full range of health promotion and screening clinics that reflected the needs of this age group. The practice encouraged patients to book appointments and repeat medications on-line. We were told prescriptions were usually available by midday one working day after requesting. The practice had also introduced the electronic prescribing system achieving nearly an 80% uptake rate since introduction. GPs did their own prescription requests regularly during the day, so usually the prescription was with the chemist within a few hours of being requested.

The practice offered routine health checks with nurses for those patients between the ages of 40 – 74 years, which could be booked at any time and as of September 2015 all appropriate patients in this age group had been offered a check within the previous five years by the practice. Cervical smears could also be booked at any time with the practice nurses. Patients who did not attend for bowel and breast screening were identified by the practice and written to with supporting information to ensure they were able to make a clear and informed choice. In addition patients who did not attend for cervical screening were personally telephoned by the practice manager in the early evening to ensure they received the information to make an informed and valid choice. The practice uptake for cervical smear attendance was 81.6%, which was comparable to the national average of 81.88%. The practice nurses had oversight for the management of a number of clinical areas, including immunisations, cervical cytology and some long term conditions. Appointments for these areas could be made at any time as opposed to specific clinics to ensure patients were able to make appropriate appointments at a time that suited them.

Updated 21 January 2016

The practice is rated as good for safe and effective services and outstanding for caring, responsive and well led services for the care of people experiencing poor mental health (including people with dementia). The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. It carried out advance care planning for patients with dementia. All GPs were up to date with mental capacity training and the practice actively screened patients for dementia where appropriate. We saw that since 1 April 2015 the practice had screened 274 patients.

There was a high incidence of mental illness in Great Yarmouth and alcohol and drug dependence were a common issue. The practice actively worked to decrease the use of tranquilizer medicine, ran regular searches on patients prescribed medicines used for the treatment of bi-polar disorder, or serious mental health conditions and liaised with the Mental Health Trust to ensure these patients were being monitored. We were told the practice had lost their mental health worker due to a lack of resources within the local Mental Health Trust. Replacements had been requested by the practice and we were advised that two new liaison workers had recently been allocated to the practice. The practice told us they would continue to monitor the effectiveness of this situation.

The practice carried out annual health checks on patients with serious mental health conditions and we saw that 95% of these patients had received an annual health and medicine review in the previous twelve months.

Updated 21 January 2016

The practice is rated as good for safe and effective services and outstanding for caring, responsive and well led services 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. Annual health reviews were completed for these patients and care and treatment could be provided in the patient’s own home where this was beneficial and assisted in engaging patients to have appropriate care.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. It had told vulnerable patients about how to access various support groups and voluntary organisations. There were robust systems in place to safeguard children and adults whose circumstances might make them vulnerable. The child protection lead had initiated quarterly practice meetings which were attended by all GPs along with the local midwife and health visitor; during these the practice reviewed families on the child protection register. Vulnerable adults were discussed at clinical governance meetings. GPs took the responsibility to ensure the correct coding of all clinical data including families and children on the child protection register. The practice computer system had been set up to ensure patients records were flagged to alert staff that a patient was on a vulnerable patient register. 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.

 The practice maintained a register of patients with learning disabilities and aimed to carry out health checks on them annually. Those patients who did not attend were contacted and of the 95 patients on the register 90 had received a learning disability health check in the previous 12 months.