Archived: Feldon Practice (Hawne Lane Branch)

Updated 21 April 2017

Hawne Lane Surgery is a branch surgery of Feldon Lane Practice. The two surgery locations that form the practice are based in the Halesowen area of the West Midlands. There are approximately 9200 patients of various ages registered and cared for across the practice and as the practice has one patient list, patients can be seen by staff at both surgery sites. Systems and processes are shared across both sites.

A desk top review inspection has been completed for both locations. As the locations have separate CQC registrations we have produced two reports. However where systems and data reflect both practices the reports will contain the same information.

Services to patients are provided under a General Medical Services (GMS) contract with NHS England. The practice has expanded its contracted obligations to provide enhanced services to patients. An enhanced service is above the contractual requirement of the practice and is commissioned to improve the range of services available to patients.

The clinical team consists of three GP partners including a senior partner and three salaried GPs. The practice nurse team included four practice nurses and a health care assistant. The GP partners and the practice manager form the practice management team and they are supported by a team staff that cover reception, administration and secretarial duties.

Hawne Lane practice is open between 8am and 6:30pm on weekdays except for Thursdays when the practice closes at 2:30pm. Feldon Lane practice is open between 8am and 6:30pm on weekdays except for Wednesdays when the practice closes at 2:30pm. There is a GP on call during the afternoons when appointments are closed.

During the mornings the practice offers an open access service, where patients are guaranteed an appointment through the walk in and wait service; this service is operational from 8am with last attendance time at 10:30am. There are also arrangements to ensure patients received urgent medical assistance when the practice is closed during the out-of-hours period. 

Updated 21 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hawne Lane Surgery, branch surgery of Feldon Lane Practice on 4 May 2016. Overall the practice is rated as good.

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

• The practice had defined and embedded systems in place to keep people safeguarded from abuse. There was a system in place for reporting and recording significant events and staff we spoke with were aware of their responsibilities to raise and report concerns, incidents and near misses.

• Staff assessed needs and delivered care in line with current evidence based guidance. Clinical audits were carried out to demonstrate quality improvement and to improve patient care and treatment and results were circulated and discussed in the practice. Staff had the skills, knowledge and experience to deliver effective care and treatment.

• Governance and risk management arrangements were not always robust. We did not see evidence to demonstrate that risk was assessed and managed in the absence of disclosure and barring checks for members of the reception team who occasionally chaperoned.

• We observed the premises to be clean and tidy. However, we did not see evidence of records in place to reflect the cleaning of specific medical equipment, such as the equipment used for ear irrigation.

• Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs. We saw evidence that monthly multidisciplinary team meetings took place and a range of chronic disease and vulnerable patient registers were continually reviewed and discussed as part of these meetings.

• We noticed that members of staff were courteous and helpful to patients both attending at the reception desk and on the telephone.

• During our inspection staff spoke positively about the team and about working at the practice, however discussions with staff also highlighted that not all staff members were familiar with what the practices vision was.

The areas where the provider must make improvements are:

• Ensure records are kept to demonstrate that risk is assessed in the absence of disclosure and barring checks for members of the reception team who chaperone.

• Ensure records are kept to reflect the cleaning of medical equipment.

The areas where the provider should make improvement are:

• Address areas for improvement highlighted through patient feedback such as national survey results.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 30 June 2016

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• Performance for overall diabetes related indicators was 98%, compared to the CCG average of 88% and national average of 89%.

• We saw minutes of meetings to support that joint working took place and that patients with long term conditions and complex needs were discussed as part of the practices multi-disciplinary team meetings (MDT) meetings.
• The practice offered a range of clinical services which included care for long term conditions such as diabetes, a range of health promotion and chronic disease support.

Updated 30 June 2016

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• Childhood immunisation rates for under two year olds ranged from 86% to 100% compared to the CCG averages which ranged from 40% to 100%.

• Immunisation rates for five year olds ranged from 97% to 100% compared to the CCG average of 93% to 98%.

• The practice offered urgent access appointments were available for children, as well as those with serious medical conditions.
• The practices patient participation group (PPG) held a range of art competitions to engage with families and children who were registered at the practice.

Updated 30 June 2016

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• Clinical staff conducted ward rounds to the local residential homes and carried out home visits for older patients and patients who would benefit from these.

• The practice had effective systems in place to identify and assess patients who were at high risk of admission to hospital. This included a daily check and review of discharge summaries following hospital admission to establish the reason for admission. These patients were regularly reviewed to ensure care plans were documented in their records and assisted in reducing the need for them to go into hospital.
• The practice offered an open access service, where patients were guaranteed an appointment during the morning through the walk in and wait service.

Updated 30 June 2016

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• The practice’s uptake for the cervical screening programme was 81%, compared to the national average of 81%.

• Practice data highlighted that 1339 patients had been identified as needing smoking cessation advice and support, 1233 patients (92%) had been given advice and 257 patients (21%) had successfully stopped smoking.
• Appointments could be made in the practice, over the phone and online. There was a text messaging appointment reminder service available and the practice also used an electronic prescription service. The practice offered an open access service, where patients were guaranteed an appointment during the morning through the walk in and wait service.

Updated 30 June 2016

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• Performance for mental health related indicators was 100%, with an exception rate of 0%. There were 57 patients on the practices mental health register and 52 (92%) of these patients had care plans in place and 51 eligible patients (94%) had received a medication review in a 12 month period.

• The practice also provided information and supported patients by referring them to counselling services and further support organisations.

• Data showed that appropriate diagnosis rates for patients identified with dementia were 100%, with an exception rate of 0%. There were 73 patients registered at the practice with a diagnosis of dementia, 94% had a care plan in place and all 68 eligible patients had received a medication review in a 12 month period.

Updated 30 June 2016

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• The practice had 121 patients on their palliative care register. The data provided by the practice highlighted that 120 of these patients (99%) had a care plan in place and 110 of the 118 eligible patients had received a medication review in a 12 month period.
• There were 27 patients on the practices learning disability register, most of these patients had care plans in place and 94% had received a medication review in a 12 month period. These patients were frequently reviewed in the practice also, 23 (85%) had received a review in a 12 month period.
• We saw that vulnerable patients and patients on the practices learning disability and palliative care registers were reviewed and discussed as part of the practices multi-disciplinary team meetings (MDT) meetings.