Mill Stream Surgery

Updated 13 December 2016

We undertook an inspection of this practice on 10 October 2016. The practice provided services from Mill Stream, Benson, Wallingford, Oxfordshire, OX10 6RL

Mill Stream Surgery has a purpose built location with good accessibility to all its consultation rooms. The practice serves 4,740 patients from the surrounding area.

The practice demographics show that the population has a lower proportion of patients under 50 compared to the national average, but has more older patients. The practice had a low proportion of patients from ethnic minority backgrounds. There is minimal social deprivation according to national data.

• There are three whole time equivalent (WTE) GPs.
• There are 1.3 nurses and 0.6 healthcare assistants.
• Mill Stream Surgery is open between 8.30am and 6.00pm Monday to Friday. The GPs are available for emergencies between 8am and 8.30am and between 6pm and 6.30pm via an alternative phone number.
• There are extended hours appointments available on Saturdays from 8.30am to 10.45am.
• Out of hours GP services were available when the practice was closed by phoning 111 and this was advertised on the practice website.
• The practice had a General Medical Services (GMS) contract. GMS contracts are negotiated directly between NHS commissioners and the practice.
• This is a teaching and training practice with placements for a GP in training and a medical student

The practice had not been inspected previously by CQC.

Updated 13 December 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Mill Stream Surgery on 10 October 2016. Overall the practice is rated as outstanding. Our key findings were as follows:

• The culture and leadership within the practice provided an open learning environment where all staff contributed to making ongoing improvements to patient care.
• The system in place for reporting and recording significant events enabled positive change and learning to be circulated to staff. Changes were implemented to improve safety and quality. Reviews of complaints, incidents and other learning events were thorough.
• Risks to patients were assessed and well managed. Risks were identified both internally and from external incidents and guidance. This led to clinical and non-clinical protocols resulting to reduce risks to patients.
• Staff assessed patients’ ongoing needs and when they delivered care to patients it was in line with current evidence based guidance. The practice was highly proactive in responding to changes in national guidance.
• The practice was performing well in national data in terms of clinical outcomes.
• Audit was used to further improve care outcomes for patients, even where performance was already high compared to national and local averages.
• The practice planned its services based on the needs and demographic of its patient population. The planning of services was dynamic, allowing changes to services even where feedback from patients was higher than average.
• Screening rates for diseases such as cancer were higher than averages.
• Vaccination rates for children were higher than averages.
• There were well developed processes to ensure the continuity of care, particularly for patients with the most complex health needs.
• Staff were trained in order to provide them with the skills, knowledge and experience to deliver effective care and treatment. The partners ensured a learning environment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patient feedback regarding the approach of staff and care they received was consistently higher than local and national averages.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The provider was aware of and complied with the requirements of the duty of candour.
• There was an ethos of continuous learning and improvement.

We identified the following areas of outstanding practice:

• The practice was a high performer in providing screening programmes for specific conditions. The chlamydia screening uptake was 12.7% in the last year, the highest performance among the local group of practices. Of those eligible 62% had undertaken bowel cancer screening compared to the national average of 59% and 82% of had attended breast cancer screening compared to the national average of 73%. The practice’s uptake for the cervical screening programme was 92%, which was significantly higher than the national average of 82%. All patients who did not respond to invitations for reviews were written to and if this did not lead to a response a variety of other means were used such as text reminders or calls to patients’ landlines, for example.
• The practice innovated its own assessment protocols. The local clinical commissioning group adopted some of these including a protocol for headaches developed by the practice. The partners had responded to concerns regarding the diagnosis and complications regarding sepsis nationally in recent months designing a sepsis protocol to assist GPs and nurses.
• To monitor the long term outcomes for patients who previously had cancer diagnoses a comprehensive list of all patients who had historical diagnoses was created. This enabled reference to any patient’s previous diagnosis and resulting treatment and this could be considered in relation to any current illnesses.
• A broad programme of continuous clinical and internal audit was ongoing within the practice even where care outcomes already showed high quality care. Although performance was high for respiratory disorders according national and internal data, the practice repeated yearly audits which showed improved outcomes in line with national guidance. Nurses undertook their own audit.
• The practice continued to review and improve areas of its service even where patient feedback suggested high performance. For example, the practice undertook a review of its appointment system in early October 2016 as part of its away day to identify where any further improvements could be made. This led to short, long and medium term actions to improve the appointment system. For example, the means by which patients were contacted for follow up appointments, and longer term, whether extended hours appointments needed reviewing. This was despite 100% of patients finding it easy to contact the surgery by phone in July 2016 compared to the CCG average of 84% and 91% patients describing their experience of making an appointment as good compared to the CCG average of 80%.
• Efficiencies which led to savings within the practice were re-invested in services. For example, prescribing incentive funds were used to fund a cognitive behavioural therapy (CBT) service in-house.
• The patient panel (a patient reference group) very involved in the core decision making of the practice. For example, panel members undertook their own independent interviews of prospective GPs during recruitment and then took part in the determination of appointment following the partners’ interviews.

Areas the provide should make improvements are:

• Consider purchasing a hearing loop
• Review the carers’ register to identify any carers not listed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 13 December 2016

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

• The practice is rated outstanding for providing effective and well-led services. This is because planning of services continuously considered the needs of all patients. This led to high performance in clinical outcomes, ease of access to appointments and changes to services where this improved outcomes for patients. The findings which led to these ratings relate to all population groups.
• The most recent published national data showed 100% of the total number of points related to care outcomes was achieved compared to the clinical commissioning group (CCG) average of 97% and national average of 95%.
• The practice has a rate of 6% exception reporting compared to the national average of 9% and regional average of 10%.
• A broad programme of continuous clinical and internal audit was ongoing within the practice even where care outcomes already showed high quality care.
• Nursing staff had lead roles in chronic disease management and had appropriate training.
• Patients at risk of hospital admission were identified as a priority.
• All these patients were offered 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 13 December 2016

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

• The practice is rated outstanding for providing effective and well-led services. This is because planning of services continuously considered the needs of all patients. This led to high performance in clinical outcomes, ease of access to appointments and changes to services where this improved outcomes for patients. The findings which led to these ratings relate to all population groups.
• 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.
• A sepsis protocol had been developed to assist in identifying patients who may present with symptoms that require urgent assessment and treatment.
• The practice’s uptake for the cervical screening programme was 92%, which was significantly higher than the national average of 82%.
• Immunisation rates were similar to average for all standard childhood immunisations.
• Staff explained how they treated children and young people in an age-appropriate way including recognition of their rights to access treatment.
• We saw positive examples of joint working with midwives and health visitors.
• Joint working with external organisations took place in the management of children at risk of abuse.
• The practice provided staff with training on female genital mutilation and how to report and respond to any instances or risks of this occurring.

Updated 13 December 2016

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

• The practice is rated outstanding for providing effective and well-led services. This is because planning of services continuously considered the needs of all patients. This led to high performance in clinical outcomes, ease of access to appointments and changes to services where this improved outcomes for patients. The findings which led to these ratings relate to all population groups.
• The practice offered proactive, personalised care to meet the needs of the high proportion of older people in its population.
• To monitor the long term outcomes for patients who previously had cancer diagnoses a comprehensive list of all patients who had historical diagnoses was created. This enabled reference to any patient’s previous diagnosis and resulting treatment and this could be considered in relation to any current illnesses.
• The partners worked closely with patients living at a supported living community very close to the practice (for people who have additional social or healthcare needs, who had access to support within their complex). They worked with social services integrated locality team to better manage those with complex health needs, in both the supported living community and patients requiring additional support at home at home.
• Screening for cancer among over 65 year olds was higher than national average.
• The premises were accessible for patients with limited mobility.
• A hearing loop was not available for patients with hearing difficulties.
• Patients over 75 had a named GP to maintain continuity of care.
• Care planning was provided for patients with dementia.
• There was support provided for carers where necessary through referrals to external services and charities.
• GPs regularly visited nursing and care homes to enable them to provide the necessary care and treatment to these patients.

Updated 13 December 2016

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

• The practice is rated outstanding for providing effective and well-led services. This is because planning of services continuously considered the needs of all patients. This led to high performance in clinical outcomes, ease of access to appointments and changes to services where this improved outcomes for patients. The findings which led to these ratings relate to all population groups.
• Feedback regarding access to appointments was among the best in the local clinical commissioning group.
• The appointment system was monitored to identify improvements weekly.
• The needs of the working age population, those recently retired and students had been considered and the practice had adjusted the services it offered enable 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.
• Travel vaccinations were available.
• There were extended hours appointments available on Saturdays from 08.30am to 10.45am.

Updated 13 December 2016

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

• The practice is rated outstanding for providing effective and well-led services. This is because planning of services continuously considered the needs of all patients. This led to high performance in clinical outcomes, ease of access to appointments and changes to services where this improved outcomes for patients. The findings which led to these ratings relate to all population groups.
• Performance for mental health related indicators was 99% compared to the national average 92% and regional average of 95%.
• The proportion of patients on mental health register with an up to date care plan and physical health assessment was 85%.
• The practice funded its own cognitive behavioural therapy (CBT). CBT is a talking therapy that can help patients manage their problems by changing the way they think and behave; most commonly used to treat anxiety and depression.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• We saw dementia care planning included comprehensive information regarding relevant medical history, patient preferences, changes to medicine, regular reviews and significant others in patients’ lives.
• The practice carried out advanced care planning for patients with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

Updated 13 December 2016

The practice is rated as outstanding for the care of people whose circumstances may make them vulnerable.

• The practice is rated outstanding for providing effective and well-led services. This is because planning of services continuously considered the needs of all patients. This led to high performance in clinical outcomes, ease of access to appointments and changes to services where this improved outcomes for patients. The findings which led to these ratings relate to all population groups.
• The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
• The partners worked closely with patients living at a supported living community very close to the practice (for people who have additional social or healthcare needs, who had access to support within their complex). They worked with social services integrated locality team to better manage those with complex health needs, in both the supported living community and patients requiring additional support at home at home.
• The practice offered longer appointments for vulnerable patients.
• A temporary registration process was available to patients who may be in the area for a short period of time and who needed to see a GP.
• 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.
• Joint working with external organisations took place in the management of patients at risk of abuse or harm.