Stewart Medical Centre

Updated 13 September 2016

Stewart Medical Centre provides care to approximately 9,642 patients in Buxton, a town situated in the High Peak area of North Derbyshire. The practice provides primary care medical services via a Personal Medical Services (PMS) contract commissioned by NHS England and North Derbyshire Clinical Commissioning Group (CCG). The site operates from a purpose built two-storey detached building constructed in 1991, which has housed the practice for the last 15 years.

The practice is run by a partnership of two male GPs and the partners employ five female salaried GPs. The practice also hosts a retained GP. This is a part-time GP working to retain their skills and to keep up to date with the view of returning to NHS general practice in the future. Further to a recent successful teaching practice accreditation visit, the surgery were to host year 2 foundation doctors from August 2016. These are qualified doctors undertaking a two-year training programme before choosing to work as a GP or within a hospital specialty.

The nursing team comprises of four practice nurses, three of whom are able to prescribe specific medicines. The fourth practice nurse is designated as a treatment room nurse, and the practice also employ a health care assistant. The clinical team is supported by a business manager and an operations manager, with a team of 12 administrative and reception staff. The practice employs two cleaning staff.

In addition, the practice currently hosts two dementia support workers as part of a pilot scheme to enhance care and support for patients with dementia and their carers.

The practice age profile is mostly comparable to national figures, although it has slightly lower percentages of patients aged 25-40. The registered patient population are predominantly of white British background, and the practice is ranked in the fourth lowest decile for deprivation status. Whilst predominantly sited in an area of relatively high affluence, the practice also serves one of the most deprived wards within the county.

The practice opens daily from 8am until 6.30pm.Extended hours opening operates every Wednesday morning when the practice opens from 7am. Additionally, the practice provides a weekend surgery on the third Saturday of every month when the practice is open between 8am and 12.15. The practice closes one Wednesday afternoon each month for staff training.

Scheduled GP morning appointments times are usually available from approximately 8.10am until 12.30am. Afternoon GP surgeries run approximately from 3.10pm to 6pm. On the monthly Saturday session, two GPs are available for consultations between 8.10am to 10.50am. Two nurses are on duty for the Saturday clinics and will see patients between 8am and 11.45am. Appointments are available from 7am every Wednesday morning to see a GP or a nurse.

The practice has opted out of providing out-of-hours services to its own patients. When the practice is closed, patients with urgent needs are directed via the 111 service to a locally based out-of-hours and minor injuries unit in Buxton operated by Derbyshire Health United (DHU). This opens from 6.30pm to 10.30pm each weekday, and from 9.30am until 10.30pm at weekends and bank holidays. The nearest Accident and Emergency (A&E) unit is based in Stockport. 

Updated 13 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Stewart Medical Centre on 1 August 2016. Overall, the practice is rated as good.

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

• There was a system in place for the reporting and recording of significant events. Learning was applied from events to enhance the delivery of safe care to patients.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• A programme of clinical audit reviewed patient care and ensured actions were implemented to improve services as a result.
• The practice planned and co-ordinated patient care with the wider multi-disciplinary team to deliver effective and responsive care to keep vulnerable patients safe.
• The practice had an effective appraisal system in place and was committed to staff training and development. The practice team had the skills, knowledge and experience to deliver high quality care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. The practice analysed and acted on feedback received from patients.
• Patients mainly provided positive views on their experience in making an appointment to see a GP or nurse.
• The practice offered a range of options to consult with a clinician. A GP triaged calls for requests to be seen on the day, and ensured that any patient requiring an urgent appointment was seen. Appointments could be booked in advance and telephone consultations were available. Longer appointments were available for those patients with more complex needs.
• The practice was maintained to a high standard with good facilities and was well-equipped to treat patients and meet their needs.
• There was a clear leadership structure in place and the practice had a governance framework which supported the delivery of good quality care. Regular practice meetings occurred, and staff said that GPs and managers were approachable and always had time to talk with them.
• The practice had submitted a successful funding request to pilot two dementia support workers within primary care. The pilot scheme was to be formally evaluated to assess the outcomes it had achieved for patients and their carers.
• Information about how to complain was available upon request and was easy to understand. Improvements were made to the quality of care as a result of any complaints received.

We saw the following area of outstanding practice:

• The practice had developed an expert patient programme. This enabled patients with a new diagnosis to be able to speak with another patient with personal experience of dealing with the same condition.

The areas where the provider should make improvement are:

• The practice needed to ensure that records clearly documented the follow-up actions taken with children who could be vulnerable, and had not attended a hospital appointment.
• The practice reviewed patients who had been prescribed high-risk medicines and there was monitoring in place to ensure prescribing remained safe. The system in place needed to be strengthened to ensure that reviews were always undertaken within recommended timescales.
• Review the documented evidence to support staff induction programmes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 13 September 2016

• The practice undertook annual reviews for patients on their long-term conditions registers. The recall system had recently been restructured in response to comparatively lower QOF attainment, and this had impacted positively on outcomes.
• QOF achievement for 2014-15 for conditions including asthma, hypertension and dementia were below the CCG and national averages. However, the practice was able to explain the lower achievement and had developed actions to enhance their performance. We observed practice data (subject to external verification) that demonstrated performance was improving.
• There was a lead designated GP and/or nurse for all the clinical domains within QOF.
• The practice had developed an ‘expert patient’ programme to support patients following the diagnosis of a new condition. This enabled patients to talk to someone with personal experience of living with a particular condition, and to discuss any issues or concerns from a non-medical perspective. 

Updated 13 September 2016

• The GPs held a weekly baby clinic on site. Dual appointments were provided for post-natal reviews and eight-week baby checks as a ‘one-stop shop’ for new parents.
• The midwife held an ante-natal clinic on site every week.
• Childhood immunisation rates were generally in line with local averages. For example, rates for the vaccinations given to children at five years of age ranged from 93.2% to 98.6% (local average 96.5% to 99.1%). Appointments for vaccinations were extended to 20 minutes to ensure the accuracy of the procedure, and also to allow time for parents to ask any questions.
• The health visitor attended a meeting with the lead GP for child safeguarding once a month to discuss any concerns. Child protection alerts were used on the clinical system to ensure clinicians were able to actively monitor any concerns. Arrangements to follow up on children who failed to attend for hospital appointments required strengthening.
• Appointments for children were available outside of school hours.
• There was a notice board in the waiting area dedicated to younger person’s health. In addition, a practice leaflet was available providing information on services which young people may wish to access confidentially such as healthy eating, drug use, and bullying.
• Family planning services were provided to fit and remove intrauterine devices (coils) and implants, and advice and support was available for all aspects of contraception.
• The practice worked within their local community to promote health – for example, representatives had attended a local nursery to discuss health matters.
• The practice had baby changing facilities, and welcomed mothers who wished to breastfeed on site.

Updated 13 September 2016

• The practice had been involved in an enhanced access pilot scheme for those with a deteriorating illness. This gave the practice direct access to the physician for older age patients for telephone advice; and access to an urgent outpatient review, rather than admitting the patient to hospital.
• The practice team worked closely with a community matron and care co-ordinator to plan and oversee the management of their most vulnerable patients, including those who were at risk of a hospital admission. This was enhanced further by weekly meetings attended by health and care professional staff from the wider health, social and voluntary communities, to plan and co-ordinate care to meet their patients’ needs.
• Care plans were in place to identify individual patient need, and summary records were shared with relevant services to ensure the patient received the right care at the right time.
• Longer appointment times could be arranged for those patients with complex care needs, and home visits were available for those unable to attend the surgery.
• The practice provided care for residents at two local care homes, and fortnightly visits were undertaken to each home by a practice nurse. Any urgent requests for a consultation were undertaken within 24 hours by a GP.
• The practice shared the medical cover provided to a ward at a local residential unit with another local GP surgery, and visited these patients twice each week.
• Uptake of the flu vaccination for patients aged over 65 was 71%, which was in line with local (73.9%) and national (70.5%) averages.

Updated 13 September 2016

• The practice offered on-line booking for appointments and requests for repeat prescriptions. The practice provided electronic prescribing so that patients on repeat medicines could collect them directly from their preferred pharmacy.
• Extended hours’ GP and nurse consultations were available. Early morning appointments were available one day each week to accommodate the needs of working people. Additionally, appointments to see a GP or the nurse were available on one Saturday morning each month.
• Telephone consultations were available each day, meaning that patients did not have to travel to the practice unnecessarily.
• The practice promoted health screening programmes to keep patients safe. Although performance for cervical and breast screening was slightly lower than average figures, the practice was able to explain this and describe how this was being addressed.
• The practice offered a flexible approach towards health checks and any patient could request to have one undertaken.
• The practice had attended the local university’s ‘Freshers’ Fair’, to provide advice and support on younger people’s health, and to ensure that students knew how to access local primary care services. 

Updated 13 September 2016

• The practice achieved 85.4% for mental health related indicators in QOF, which was 12.7% below the CCG and 7.4% below the national averages. Exception reporting rates for mental health were higher at 22.5% (local 14.5%; national 11.1%) although the practice were able to explain the reasons for this.
• 91.8% of patients with poor mental health had a documented care plan during 2014-15. This was marginally below the CCG average by 1.4%, and 3.3% higher than the national average, although exception reporting rates were higher.
• Access to counselling and associated talking therapies was available by GP or self-referral. Patients could attend these services in the local area.
• The practice lead GP for mental health was also the CCG’s designated clinical lead for mental health.
• The practice had established strong links with local mental health care teams. A community psychiatric nurse (CPN) attended multi-disciplinary meetings to review and discuss any patients with ongoing mental health needs.
• Appointments were available on the day for patients experiencing acute mental health difficulties. This was facilitated via the senior clinician triage system.
• 91% of people diagnosed with dementia had had their care reviewed in a face-to-face meeting in the last 12 months. This was above local and national averages by approximately 7%, with comparable exception reporting rates.

• The practice staff had received training from the Alzheimer’s Society to become ‘Dementia Friends’. This had involved the PPG who had reviewed patient-facing issues such as improved signage further to the training. Reception rang patients with dementia to remind them of their upcoming appointment.
• The practice used self-management techniques to improve anxiety management.
• The practice provided care to 20 patients in local home, 12 of whom were included on the practice dementia register. The practice dealt with individual patient needs as required, but were in the process of working to review future arrangements.
• The practice worked with local charity projects that promoted well-being and support for people with mental health difficulties. 

Updated 13 September 2016

• The practice was mindful that their catchment area incorporated pockets of community deprivation. They had been supportive of a local Sure Start scheme (aimed at giving children the best possible start in life) that had recently closed; however, the practice continued to provide high levels of support to this population in recognition of their health needs.
• The practice had undertaken an annual health review in the last 12 months for 48.6% of patients with a learning disability However, a manual check of records by the practice team demonstrated this figure was 84%, indicating that there may be an issue with coding.
• Longer appointments and home visits were available for vulnerable patients, and same day access to a GP was provided for any vulnerable patients with acute needs. The practice encouraged concerned relatives or support workers to contact the practice on the patient’s behalf. Failed attendance was used an opportunity to look into the reasons behind this, and to educate the patient or manage their situation differently.
• There was a designated lead GP for palliative care. Patients with end-of-life care needs were reviewed either at weekly multi-disciplinary team meetings, or at designated monthly palliative care meetings. These patients had supporting care plans in place. Community based staff informed us that the GPs were caring and highly responsive to these patients, and ensured that any needs were acted upon promptly.
• The practice supported homeless patients to register at the practice. Residents at a local women’s refuge were encouraged to register with the practice.
• Staff had received adult safeguarding training and were aware how to report any concerns relating to vulnerable patients. There was a designated lead GP for adult safeguarding.