Archived: Crawford Street Surgery

Updated 7 November 2017

Crawford Street Surgery provides NHS primary medical services to approximately 5,000 patients living in the surrounding area of Marylebone, London. The practice has a General Medical Services (GMS) contract (GMS is one of the three contracting routes that have been available to enable commissioning of primary medical services). The practice is part of the Central Locality of NHS Central London (Westminster) Clinical Commissioning Group (CCG), and the Marylebone Village peer group which comprises of three practices.

The practice had been provided with management and clinical support from a management holding company from 2013 to April 2016. The new partnership variation with the current GP partners came into effect from April 2016. Due to issues with the staffing arrangement, the new partners recruited a new team of clinical and non-clinical staff.

The practice team consists of two female GP partners (one clinical and one non-clinical) and two salaried GPs (male) providing 12 clinical sessions collectively. The GPs are supported by an advanced nurse practitioner (four hours); two health care assistants (seven hours); a practice manager; and three receptionists / administrators. A new salaried GP, offering two clinical sessions per week, is due to start in October 2017.

The practice is located on the ground and lower ground floors of a residential property, with three consulting rooms on the ground floor and two consulting rooms on the lower ground floor. There are administrative areas on both floors. The premises are accessible by wheelchair and there is an internal lift to access the lower ground floor.

The practice is open from 8am to 6.30pm every weekday, with the exception of Thursday when it closes at 1pm (From October 2017 the practice will be open on Thursday till 6.30pm). Pre-booked appointments are available during these times. Extended hours appointments are available from 7am to 8am and 6.30pm to 8pm on Wednesday. Same day appointments are available for patients with complex or more urgent needs. When the practice is closed, patients are advised to use the local out-of-hours provider or are booked an appointment at the local primary care service ‘hub’.

The practice population is characterised by average levels of income deprivation. Employment rates and life expectancy are higher than the national average. The practice has a higher percentage of male patients aged 25 to 49 and female patients aged 20 to 39 compared to the English average. The population is ethnically diverse.

The practice service is registered with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures; treatment of disease, disorder and injury; surgical procedures; and maternity and midwifery services.

Updated 7 November 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Crawford Street Surgery on 11 February 2016. The practice was rated as good for providing effective, caring, responsive and well-led services, and requires improvement for providing safe services. Overall the practice was rated as good. The full comprehensive report on the February 2016 inspection can be found by selecting the ‘all reports’ link for Crawford Street Surgery on our website at www.cqc.org.uk.

This inspection was an announced comprehensive follow up inspection on 26 September 2017 to check for improvements since our previous inspection. The practice is now rated as requires improvement for providing effective and caring services, and good for providing safe, responsive and well-led services. Overall the practice is now rated as requires improvement.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed, with the exception of those relating to checking uncollected repeat prescriptions and the monitoring of patients taking azathioprine.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Data from the Quality and Outcomes Framework showed patient outcomes were below average compared to the national average.
• There was evidence of quality improvement activity including clinical audit.
• Results from the national GP patient survey 2017 showed patients rated the practice below average for satisfaction scores on consultations with the GPs and for several other aspects of care.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• 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.
• 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.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

However, there were also areas of practice where the provider should make improvements.

Importantly, the provider must:

• Ensure that all patients’ needs are identified and care and treatment meets their needs.

The provider should:

• Review the systems for monitoring patients on high risk medicines, and checking uncollected blank prescriptions.
• Consider ways to improve performance against national screening programmes.
• Review ways to improve patient satisfaction with consultations, and the availability and punctuality of appointments.
• Continue to identify and support patients who are carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 7 November 2017

The practice is rated as requires improvement for the care of people with long-term conditions. The practice was rated as requires improvement for providing effective and caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group; however there were examples of good practice.

• Clinical staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.
• The practice used the information collected for the Quality and Outcomes Framework (QOF) to monitor outcomes for patients (QOF is a system intended to improve the quality of general practice and reward good practice). The most recent published results were 72% of the total number of points available (CCG average 88%, national average 95%). Unpublished and unverified data from the QOF 2016/17 showed results were 85% of the total number of points available. However, performance for some clinical indicators such as diabetes and asthma remained low.
• The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.
• There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health. For example, rescue medication packs for patients with chronic obstructive pulmonary disease.
• Patients had a named GP and there was a system to recall patients for 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.

Updated 7 November 2017

The practice is rated as requires improvement for the care of families, children and young people. The practice was rated as requires improvement for providing effective and caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group; however there were examples of good practice.

• From the sample of documented examples we reviewed we found there were systems 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 accident and emergency (A&E) attendances.

• Data from 2015/16 showed immunisation uptake rates for the standard childhood immunisations were comparable to CCG averages and below national averages. For example, rates for the vaccines given to under two year olds averaged 74% compared to the national standard of 90%. Uptake for five year olds ranged from 59% to 82% (CCG 62% to 80%; national 88% to 94%).
• Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.
• The practice had emergency processes for acutely ill children and young people.

Updated 7 November 2017

The practice is rated as requires improvement for the care of older people. The practice was rated as requires improvement for providing effective and caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group; however there were examples of good practice.

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
• The practice offered proactive, personalised care to meet the needs of the older patients in its population.
• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The practice also worked with community healthcare teams to support the patient at home.
• The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.
• The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.
• Where older patients had complex needs, the practice shared summary care records with local care services.
• Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible. For example, patients could be referred to a care navigator service where their health and social needs were assessed and further support arranged.

Updated 7 November 2017

The practice is rated as requires improvement for the care of working age people (including those recently retired and students). The practice was rated as requires improvement for providing effective and caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group; however there were examples of good practice.

• The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours on Wednesday from 7am to 8am and 6.30pm to 8pm.
• The practice could remotely book appointments for patients to access the local primary care ‘hub’ in the evenings and at weekends.
• The practice offered online services to book appointments and order repeat prescriptions, as well as a full range of health promotion and screening that reflects the needs for this age group.
• The practice planned to introduce virtual consultations as a result of patient feedback.

Updated 7 November 2017

The practice is rated as requires improvement for the care of people experiencing poor mental health (including people with dementia). The practice was rated as requires improvement for providing effective and caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group; however there were examples of good practice.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
• Patients at risk of dementia were identified and offered an assessment.
• The practice carried out advance care planning for patients living with dementia. Although in 2015/16, 75% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the previous 12 months, which was below the CCG average of 87% and the national average 84%.
• Performance for mental health related indicators was lower than the CCG and national averages. For example in 2015/16, 52% of patients with a diagnosed psychosis had a comprehensive care plan in their records compared to the CCG average of 87% and national average of 89%.
• The practice had assessments and systems to follow up patients who may be at risk of experiencing poor mental health. For example, women attending post-natal checks were screened for post-natal depression and monitored.
• Patients could be referred to the primary care plus service and be seen by a community psychiatric nurse who offered a weekly clinic at the practice.
• The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.
• Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.

Updated 7 November 2017

The practice is rated as requires improvement for the care of people whose circumstances may make them vulnerable. The practice was rated as requires improvement for providing effective and caring services. The concerns which led to these ratings apply to everyone using the practice, including this population group; however there were examples of good practice.

• The practice held a register of patients living in vulnerable circumstances including patients who were housebound, elderly and vulnerable, and those who were at high risk due to their conditions. This list was shared with all staff and reviewed monthly at the practice meeting.
• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
• 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 had information available for vulnerable patients about how to access various support groups and voluntary organisations.
• Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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.