Gade Surgery

Updated 5 April 2018

Gade Surgery provides a range of primary medical services from its premises at 99b Uxbridge Road, Rickmansworth, Hertfordshire, WD3 7DJ and Witton House, Lower Road, Chorleywood, Hertfordshire, WD3 5LB. We only visited the Rickmansworth surgery as part of this focused inspection. The practice has a registered manager in place. (A registered manager is an individual registered with CQC to manage the regulated activities provided).

The practice serves a population of approximately 11,920 and is a teaching and training practice. National data indicates the area served is less deprived compared to England as a whole. The practice population is mostly white British. The practice serves an above average population of those aged from 40 to 59 years and 65 to 69 years. There is a lower than average population of those aged from 15 to 39 years.

The clinical team includes four male and two female GP partners, two female salaried GPs, three practice nurses, two healthcare assistants and a phlebotomist. (A phlebotomist is a specialised clinical support worker who collects blood from patients for examination). The team is supported by a practice manager, a deputy practice manager, an office manager and 17 other secretarial, administration and reception staff. The practice provides services under a General Medical Services (GMS) contract (a nationally agreed contract with NHS England).

At Gade Surgery the phone lines open from 8am and the practice is fully open (phones and doors) from 8.30am to 6.30pm Monday to Friday. Between 1pm and 2pm daily the phone lines close but the doors remain open. Appointments are available from 8.40am to 11.30am and 1.30pm to 6.30pm daily, with slight variations depending on the doctor and the nature of the appointment. The practice is also part of the Watford Care Alliance and offers appointments on Saturdays and Sundays every two weeks to patients on the practice list and those registered at other practices in the scheme.

An out of hours service for when the practice is closed is provided by Herts Urgent Care.

Updated 5 April 2018

We carried out an announced comprehensive inspection at Gade Surgery on 1 December 2016. Overall the practice was rated as good. However, we identified a breach of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided safe services. Consequently the practice was rated as requires improvement for providing safe services. The full comprehensive report on the December 2016 inspection can be found by selecting the ‘all reports’ link for Gade Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 7 March 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach of regulation that we identified in our previous inspection on 1 December 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

On this focused inspection we found that the practice had made improvements since our previous inspection and were now meeting the regulation that had previously been breached.

The practice is now rated as good for providing safe services.

Our key finding was as follows:

• Sufficient arrangements were in place for the management of Patient Group Directions (PGDs) and they were appropriately reviewed, signed and countersigned. (Patient Group Directions are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment).

Additionally where we previously told the practice they should make improvements our key findings were as follows:

• The practice kept prescription pads securely and monitored their use.
• Appropriate recruitment checks had been undertaken and documented prior to the employment of new staff members.
• Actions to reduce the risks identified by the fire and Legionella risk assessments were completed and recorded. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings). Water temperature checks were completed and recorded. Fire extinguishers were checked to ensure they were working properly.
• The practice risk assessed how it transported patient identifiable data between its two sites and staff understood the precautions they needed to take to reduce the identified risks.
• We saw that a process was in place and adhered to for monitoring the completion of staff training. Staff received training that included: adult and child safeguarding, fire safety, chaperoning and basic life support. Most of the training was provided by the use of an e-learning facility. All newly employed staff had received a training needs assessment and a process was in place to ensure all staff received one by the completion of this year’s staff appraisal process on 31 March 2018.
• During our inspection on 1 December 2016 we found the practice’s policy for obtaining and recording patient consent for procedures was not always followed and the consent process was not monitored. During this focused inspection we reviewed the records of seven patients who had recently received joint injections, travel vaccinations or baby immunisations and found that in all the cases we looked at the appropriate consent was obtained and documented. We saw that the practice monitored the process for seeking consent to minor procedures appropriately. We looked at three quarterly audits completed between April and December 2017 which showed the 26 patients who had received a minor procedure in that time all had their consent obtained and recorded in accordance with the practice’s policy.
• Following our inspection in December 2016 the practice had completed a piece of work to ensure its carers register (those patients on the practice list identified as carers) was correct and accurately reflected those patients who were active in a carer role. This had reduced the number of carers identified from 122 to 103. Through a proactive approach from staff this was increased and at the time of this focused inspection on 7 March 2018 the practice had identified 124 patients on the practice list as carers. This was approximately 1% of the practice’s patient list. Of those, 93 (75%) had been invited for and 22 had accepted and received a health review since 1 April 2017. Dedicated carers’ notice boards in the reception areas provided information and advice including signposting carers to support services. A member of reception staff was the practice’s carers’ lead (or champion) responsible for providing useful and relevant information to those patients and attending the relevant locality meetings.
• Practice specific policies were implemented and were available to all staff. We looked at examples of these including the practice’s recruitment, consent, chaperoning and child safeguarding policies. We found these were regularly reviewed and updated and contained the appropriate information which reflected the practice’s current processes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 3 February 2017

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.
• The practice worked closely with the specialist community diabetes team and consultant to enable referrals to education programmes, to provide advice and support to practice nurses.
• Performance for diabetes related indicators was in line or above the local and national averages. For example, the percentage of patients with diabetes, on the register, in whom the last blood glucose reading showed good control in the preceding 12 months was 82% compared to the Hertfordshire Valley CCG average of 77% and national average of 78%.
• Longer appointments and home visits were available when needed.
• The practice offered equipment loans for patients in this group, for example blood pressure monitors, nebulisers and glucose monitors.
• 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.
• Care plans were completed for patients deemed at high risk of hospital admissions. 

Updated 3 February 2017

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. Immunisation rates were relatively high for all standard childhood immunisations.
• 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.
• We saw positive examples of joint working with midwives, health visitors and school nurses.
• The practice’s uptake for the cervical screening programme was 79% which was comparable to the CCG average of 82% and the national average of 81%.
• The practice offered contraception (IUCD and implants) and family planning services.
• There was a nominated partner who liaised with a local secondary school to improve adolescent mental health. The GP also attended the regional pastoral care meetings and had been in discussion with the school to explore holding teaching sessions in school.

Updated 3 February 2017

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. For example;

• The practice operated with personalised lists meaning each patient had a named GP and family units were encouraged to register with the same GP to enable coordinating care for older patients by assessing all aspects of the family.
• All the patients we spoke to on the day told us that they saw the same GP for most appointments.

• Vulnerable elderly patients were encouraged to register for electronic prescriptions with a single designated pharmacy, who offered a home delivery service, in order reduce risk of lost paper prescriptions
• The practice liaised closely with local pharmacists to ensure prescriptions were efficiently managed for patients. Where necessary, practice staff would request home delivered prescriptions to ensure elderly patients did not go without medication.
• Following the withdrawal of the community domiciliary phlebotomy service the practice identified an unmet need for housebound or elderly patients. The practice made a decision to recruit a nurse to provide care to this group. Domiciliary tasks not covered by the community nursing teams were scheduled for the nurse on a weekly basis, for example, blood tests, diabetic reviews and immunisations.
• The practice worked with the local Rapid Response Team (a multi-disciplinary team comprised of Nursing, Social Care, Physiotherapy and Occupational Therapy professionals) to prevent hospital admissions and provide urgent care closer to home for vulnerable elderly patients.
• Complex vulnerable elderly patients requiring intensive coordination of care in the community were referred to the Living Well Team.
• There was a dedicated GP allocated to visiting and providing care to patients in local nursing or care homes. Weekly ward rounds were carried out and the GP worked closely with the staff to ensure coordinated care for all the patients.
• The practice hosted weekly session for Age UK at the surgery in order to improve awareness and access to their services.

Updated 3 February 2017

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.
• There was a flexible appointment system with extended hours bookable appointments offered to patients on selected evenings and weekends.
• Aortic aneurysm screening and physiotherapy was offered to patients in this group on site.
• Sequential appointments were offered for patients attending with other family members.

Updated 3 February 2017

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

• The percentage of patients with dementia whose care had been reviewed in a face-to-face review in the preceding 12 months was 81% where the CCG average was 85% and the national average was 84%.
• The percentage of patients with diagnosed psychoses who had a comprehensive agreed care plan was 84% where the CCG average was 92% and the national average was 88%. Although the results were below the CCG and national averages 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 and had a dedicated GP as dementia lead.
• 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 lead for mental health and dementia had attended a mental health forum and had delivered the presentation to practice staff. All staff were to undertake dementia awareness training in 2017.
• Therapy services to support mental health patients were available at the practice.
• Regular liaison with practice assigned CBT (cognitive behavioural therapy) therapist enabled good communication and helped manage more complex patients.
• There was a confidential area and room available for discussion of more private issues if required.

Updated 3 February 2017

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. Annual reviews with 20 minute appointments were offered for patients on learning disability register. A questionnaire was sent to the carers in advance in order to streamline the appointments and act as a checklist.
• Vulnerable patients identified on registration were flagged early to a registered 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.
• Vulnerable patients who did not attend appointments were followed up by community teams.
• Clinical system allows sharing of critical information with out of hours and other community services
• Weekly or monthly prescriptions were arranged for patients at risk of over-using medications.
• All staff had undertaken training for all staff for children and adults at risk and how to recognise signs of domestic violence.