Giltbrook Surgery

Updated 10 March 2016

Giltbrook Surgery is situated approximately ten kilometres north-west of Nottingham, close to junction 26 of the M1 motorway.

The practice is run by a partnership between a GP and the practice manager.

The practice has two GPs (one male and one female), one of whom is a partner, and the other doctor is a part-time salaried GP. The practice has a nurse practitioner and a part-time practice nurse, and part-time health care assistant. The clinical team is supported by a full-time practice manager (who is also a partner) and a team of six administrative, secretarial and reception staff. The practice also currently have an apprentice in post to support the administration team.

The registered practice population of 4,297 are predominantly of white British background, and are ranked in the third least deprived decile. The list size is gradually increasing creating challenges in terms of their existing premises, which are being utilised to full capacity. The practice age profile is broadly in line with national averages but has slightly higher percentages of patients aged 40-74 years old, and slightly lower percentages of patients aged under 40.

The practice opens from 8am until 6.30pm Monday to Friday. GP morning appointments are available from 8.30am to between 11.30am and 1pm depending on which day, and afternoon surgeries run from 1.30pm to 6pm on a Monday and Thursday, and from 3pm to 6pm on Tuesday, Wednesday and Friday. Extended hours GP surgeries are provided from 7.30am to 8.30am on a Wednesday morning, and from 6.30pm until 8.15pm on a Monday evening. Occasional Saturday morning clinics are also provided in response to need, for example, when there is a bank holiday. The practice are considering the potential to extend the availability of Saturday clinical sessions.

The practice supports medical students as part of their eight week placement in general practice. It does not currently act as a training practice for GP registrars.

The practice has opted out of providing out-of-hours services to its own patients. When the practice is closed patients are directed to Nottingham Emergency Medical Services (NEMS) via the 111 service.

The practice holds a Personal Medical Services (PMS) contract to provide GP services which is commissioned by NHS England. A PMS contract is one between GPs and NHS England to offer local flexibility compared to the nationally negotiated General Medical Services (GMS). The practice also offers a range of enhanced services, including the monitoring of blood tests for patients with stable prostate cancer, which are commissioned by NHS Nottingham North and East CCG.

Updated 10 March 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Giltbrook Surgery on 28 January 2016. The overall rating for this practice is outstanding.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework (QOF) data, this relates to the most recent information available to the Care Quality Commission (CQC) at that time.

Our key findings were as follows:

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events, and we saw evidence that learning was applied from events.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Feedback from patients about their care, and their interactions with all practice staff, was consistently and strongly positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients said they found it easy to make an appointment with a GP. Routine appointments could be booked within a week, with urgent appointments being available the same day. Advanced bookings could be made without restriction on timescales.

• The practice used clinical audits to review patient care and we observed how outcomes had been used to improve services as a result.

• The practice had good facilities and was well-equipped to treat patients and meet their needs. The size of the building limited the number of services provided on site, but the practice were actively exploring opportunities for re-location in the future with service commissioners.
• The practice planned and co-ordinated patient care with the wider multi-disciplinary team to plan and deliver effective and responsive care to keep vulnerable patients safe. This approach had impacted on unplanned hospital admissions and attendance at Accident and Emergency.
• There was a strong and proactive leadership structure within the practice, and staff told us that they were well-supported and felt valued by the partners.

• High standards were promoted and owned by an enthusiastic and motivated practice team with evidence of highly effective team working.

• The practice reviewed the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example, it had reviewed its use of the patient name display facility in the waiting area in response to concerns about confidentiality.

We saw several areas of outstanding practice including:

• The practice had commenced a community pharmacy pilot project from November 2015. This placed a prescribing community pharmacist within the practice for two days each week. Although a full evaluation was awaited, the project had already received positive feedback from patients. More than 100 patients had been seen in the first two months and initial outcomes demonstrated improvements in care. For example, a reduction in the number of medications prescribed with between 10-15% patients having at least of one of their prescribed medications stopped.

• A ‘homely remedies for minor ailments’ system had been developed by the practice in conjunction with the pharmacist for use within a local care home. This enabled the care home to commence agreed drugs for minor ailments such as indigestion and constipation to ensure the patient received treatment at the earliest possible opportunity. This was used with the proviso that the GP was contacted if symptoms persisted beyond 48 hours.

• The practice undertook a comprehensive analysis of the Friends and Family Test (FFT) returns, and had formulated action plans in response to suggestions from patients to enhance patient satisfaction and experience. For example, in response to late running appointments, the practice were informing patients to book longer appointments if they had more than one issue to discuss, and were also auditing waiting times for each clinician.

• The practice had achieved highly in delivering NHS health checks and had consistently overachieved against target figures. For example, current data showed that the practice had achieved 124% of its target in the first three-quarters of 2015-16.

• We saw many examples in which the practice team delivered outstanding care for their patients to keep them safe and well. For example, checking vulnerable patients had access to heat and food during poor weather, and ensuring that patients with a mental health condition were collecting their prescribed medicines.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 10 March 2016

• All clinical members of the practice team had lead roles in chronic disease management. For those patients with the most complex needs and associated risk of hospital admission, the practice team worked with health and care professionals to deliver a multidisciplinary package of care.

• All patients with a long-term condition had a named GP and received a structured annual review to check their health and medicines needs were being appropriately met.

• Whilst the practice had performed well in most QOF clinical indicators, the achievement was below average for diabetes, chronic kidney disease and coronary heart disease. The overall achievement for diabetes indicators was 65% which was 22% below the CCG average and 24% below the national average. However, the practice were aware of this and had developed actions to address this. We saw practice data for the current year (which was not yet verified or published) but this demonstrated an improvement in QOF performance for diabetes indicators.

• The practice nurse worked closely with the local Diabetes Nurse Specialist. Monthly joint clinics were organised between the two nurses, which included the initiation of insulin for patients with diabetes.

• The practice had signed up to the ‘Year of Care’ programme for patients with diabetes from April 2016. This scheme aids the patient to self-manage their diabetes to a much greater extent, and facilitates a more constructive dialogue between the patients and clinicians with regards to the ongoing management of their condition.

• Ongoing liaison with the local respiratory nurse provided an expert resource for patients with chronic obstructive pulmonary disease and asthma. Patients were referred into the ‘Breathe Easy’ self-management programme, and for pulmonary rehabilitation when indicated. Self-management booklets produced by the CCG were available for these patients, and used to inform patients what to do if their symptoms worsened.

• QOF indicators for asthma were higher than CCG and national averages. For example, 85.7% of patients with asthma received a review in the preceding 12 months, compared to the CCG and national averages of 76.2% and 75.3% respectively.

• An ongoing pilot project in which a community pharmacist was working within the practice had allowed greater opportunities to review repeat medications for patients with more than one long term condition, or review patients who were receiving multiple medications.

Updated 10 March 2016

• Urgent appointments were available every day to accommodate children. The practice had a policy that all children under the age of five years old would be seen on the same day.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children who had a high number of A&E attendances. We were informed of examples when practice staff had referred children where safeguarding concerns had been identified. Effective liaison was in place between the practice and the health visiting team and school nurse.

• Immunisation rates were relatively high for all standard childhood immunisations, and in line with local averages. For example, vaccination rates for children under two years old ranged from 93.5% to 100% compared against a CCG average ranging from 91.7% to 100%. A named member of the practice team monitored uptake of childhood vaccinations to enable those who did not attend to be notified promptly.

• 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 with the practice nursing team were available outside of school hours, and the premises were suitable for children and babies. Toys were provided for children attending the surgery.

• Teenagers presenting at the surgery were seen on attendance whenever possible to ensure they were seen at the time of need.

• Family planning advice was available on site, and the practice referred patients requiring the fitting of coils and contraceptive implants to a local clinic in Nottingham.

• There were no dedicated baby changing facilities or room for breast feeding, but patients would be directed to an appropriate room to enable some privacy.

Updated 10 March 2016

• The practice offered proactive and personalised care to meet the needs of older people. Care plans were in place for older patients with more complex needs. Monthly multi-disciplinary meetings were held to review frail patients and those at risk of hospital admission to plan and deliver care appropriate to their needs.

• It was responsive to the needs of older people, and offered home visits and urgent appointments for those who needed them.

• The practice provided primary medical services to 14 residents at a local care home for older people. We spoke with a manager of this home who was very satisfied with the care provided by the GPs, and described the relationship with the practice as being extremely positive and responsive. They had quarterly meetings with the partners and had liaised with the community pharmacist based within the practice for advice and support.

• A ‘homely remedies for minor ailments’ system had been developed for use within the care home. This enabled the home to use agreed drugs for minor ailments such as indigestion and constipation to ensure the patient received treatment at the earliest possible opportunity. If symptoms persisted for more than 48 hours, the GP would be contacted.

• Flu vaccination rates for the over 65s were 75.4% which was slightly higher than the national figure of 73.2%.

• Nationally reported data showed that outcomes for patients for conditions commonly found in older people, including rheumatoid arthritis and heart failure were in line with or above local and national averages

• The practice prioritised older patients with no social support during adverse weather conditions and made sure they had access to food and heat.

Updated 10 March 2016

• 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. This included good access to GP appointments and extended hours surgery were provided each week, including occasional Saturday mornings when required.

• A nurse practitioner held daily telephone triage consultations which often meant patients’ concerns could be dealt with without the need for a face to face consultation at the practice.

• The practice was proactive in offering online services to book GP appointments and repeat prescriptions.

• Health promotion and screening was provided that reflected the needs for this age group. The practice had over-achieved its target for 40-74 year old patients’ health checks.

• Flu clinics were held on a Saturday morning to improve access to vaccinations for working patients.

• The practice’s uptake for the cervical screening programme was 87.4% which was above the CCG average of 86.2% and the national average of 81.8%.

Updated 10 March 2016

• The practice achieved 100% for mental health related indicators in QOF, which was above the CCG average of 93.8% and the national average of 92.8%

• 93.3% of patients diagnosed with dementia had had their care reviewed in a face-to-face consultation during 2014-15. This compared to a CCG average of 87.7% and a national average of 84%

• 86% of patients on the practice’s mental health register had received an annual health check during 2014-15.

• The practice regularly worked with multi-disciplinary teams in the management of people experiencing poor mental health, including those with dementia. The practice closely monitored patient compliance with their prescribed medications and took action to review any patients who were did not take them as prescribed.

• It carried out advance care planning for patients with dementia.

• The practice told patients experiencing poor mental health and patients with dementia about how to access services including talking therapies and various support groups and voluntary organisations. Some information was available for patients in the waiting area including a self-help directory.

• Health checks were offered to carers and contingency plans were considered in case the carer became unwell.

Updated 10 March 2016

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability. Homeless people could register with the practice.

• The practice informed us how they had arranged appointments specifically to meet individual needs – for example, by ensuring a patient with a learning disability could be seen when no other patients were waiting in the surgery, as this created anxiety for them.

• The practice provided care for residents in a local residential unit for patients with a learning disability. We spoke to staff at the home who praised the practice for being highly responsive to their clients’ needs, and also reported the high level of care and support that was provided.

• The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people and informed patients 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.

• The practice provided good care and support for patients nearing the end of their life. Patients were kept under close review by the practice in conjunction with the wider multi-disciplinary team, and a GP informed us that additional visits had been provided at the weekend to ensure continuity of care.

• The practice had carried out annual health checks for people with a learning disability, and 90% of patients had received an annual review in the last 12 months. It offered longer appointments for people with a learning disability.

• Annual training in learning disability awareness helped staff understand and respond to the needs of patients effectively.

• The practice was registered as a ‘safe house’ whereby any vulnerable individual could come into the surgery, until they could be collected by a family member or carer.