West Oak Surgery

Updated 7 November 2016

West Oak Surgery provides care to approximately 5,500 patients and is situated in the residential and commercial area of Mapperley within the Gedling borough, to the north-east of the city of Nottingham. The registered patient list has increased by 5.75% over the last 12 months.

The registered patient population are predominantly of white British background. The practice age profile demonstrates slightly higher number of patients aged 30-60 years old, and marginally lower numbers of patients aged 65 and over in comparison to the local and national averages. The practice is ranked in the third least deprived decile and serves a large residential area. Deprivation scores (2015) at 13.4 are below the national average (21.8), and local rates (17).

The practice provides primary care medical services via a General Medical Services (GMS) contract commissioned by NHS England and Nottingham North & East Clinical Commissioning Group (CCG). The practice operates from a former residential property which has been extended and refurbished to a high standard. All patient services within the practice are provided on the ground floor of the building, whilst the upper floor is utilised for administration.

The practice is run by a partnership of two GPs (both males), one of whom has recently retired but has retained their partnership status until a new partner has been found. The retired partner does not provide any clinical input with patients. The partners employ a female salaried GP who works part-time. The practice use regular GP locum sessions with two GPs currently providing sessional input each week. The practice also hosts visiting medical students.

The nursing team consists of two part-time practice nurses who work on separate days to provide nursing cover throughout the week. A part-time health care assistant supports the nursing team. The clinical team is supported by a practice manager with a team of nine administrative and reception staff, including an apprentice.

The practice opens at 7.45am each morning, and the reception opens for telephone calls from 8am until 6.30pm Monday to Friday. The practice closes on six afternoons each year for staff training.

GP consultations commence each morning from 8.30am and the latest GP appointment is available at 5.30pm.

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

Updated 7 November 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at West Oak Surgery on 10 October 2016. Overall, the practice is rated as good.

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

• There was an effective 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.
• The practice had systems in place to safeguard children and vulnerable adults. Notes from child safeguarding meetings were recorded.

• Clinicians mostly kept themselves updated on new and revised guidance and discussed this at clinical meetings. However, we observed that recent NICE guidance relating to menopause had not been considered, although the practice took steps to ensure updates were not missed following our inspection.
• We saw some evidence of a programme of clinical audit that reviewed care and ensured actions were implemented to enhance outcomes for patients. Some audits needed to be repeated to assess impact of actions taken and whether this had improved outcomes for patients.
• Patients told us they were treated with compassion, dignity and respect. They also said they were involved in their care and decisions about their treatment. This was corroborated bythe outcomes of the latest national GP patient survey and CQC comment cards.
• The practice planned and co-ordinated patient care with the wider health and social care multi-disciplinary team to deliver effective and responsive care to keep vulnerable patients safe. Monthly meetings took place to discuss and review patients’ needs.
• The practice had an effective appraisal system in place and supported staff training and development.
• The practice team had the skills, knowledge and experience to deliver high quality care and treatment.
• There were arrangements were in place to assess and manage risk. The identification of new or emerging risks required strengthening.
• Feedback from patients we spoke with on the day, and from CQC comment cards, demonstrated that people were generally well satisfied with access to GP appointments.
• The practice had good facilities and was well-equipped to treat patients and meet their needs. The premises were accessible for patients with mobility difficulties.
• There was a clear leadership structure in place. Regular practice meetings occurred, and staff said that GPs and managers were approachable and always had time to talk with them.
• The partnership had a vision for the future and had developed clear practice values for the practice team. There was a written five-year forward plan, and the practice proactively engaged with other practices and their Clinical Commissioning Group (CCG).
• The practice had an open and transparent approach when dealing with complaints. Information about how to complain was available, and improvements were made to the quality of care as a result of any complaints received.
• The practice had a patient participation group (PPG) which had been recently formed and was meeting on a quarterly basis.

The areas where the provider should make improvement are:

• Strengthen oversight and governance systems to improve the identification and mitigation of identified risks in a timely way.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 7 November 2016

• The practice undertook annual reviews for patients on their long-term conditions registers, including a review of their prescribed medicines.
• The call and recall system was co-ordinated by the administration team. Patients were seen as part of the routine appointment system, rather than by dedicated clinics. This gave more flexibility for patients in attending at a time that was suitable for them.
• Patients with multiple conditions were usually reviewed in one appointment to avoid them having to make several visits to the practice.
• QOF achievements for clinical indicators were generally above CCG and national averages. For example, the practice achieved 99.5% for diabetes related indicators, which was 12.2% higher than local averages, and 10.3% above the national average in 2014-15. There was a lead designated GP or nurse for the clinical domains within QOF.
• A diabetes nurse specialist attended on a monthly basis to provide input for patients as part of a joint clinic with the practice nurse. This included the initiation of insulin (teaching patients how to inject and manage their insulin regime) for patients with type 2 diabetes.
• The practice had access to specialist respiratory nurses for advice in the management of patients with breathing difficulties.
• Patients with chronic obstructive airways disease were provided with rescue pack medicines (which contain a supply of standby medicines to commence if the condition gets worse before the patient is able to see a GP) in response to an observed increase in respiratory infections locally.
• Practice protocols for the management of specific conditions were available based upon NICE guidelines. For example, there were protocols to be followed for patients with hypertension and thyroid disease.

Updated 7 November 2016

• The practice had an identified lead GP for child safeguarding. The health visitor and school nurse attended a monthly meeting with the lead GP and practice nurse to review and discuss any child safeguarding concerns. Notes were recorded from the discussions but no formal minutes were available. Child protection alerts were used on the clinical system to ensure clinicians were able to actively monitor any concerns related to any vulnerable children.
• Antenatal care was shared between midwives and the GPs. An antenatal pack was used for patients providing advice including information on screening and diet.
• The practice provided eight-week baby checks, and regular joint baby clinics run by a GP and nurse were held twice a month.
• Childhood immunisation rates were high and marginally above local averages. Overall rates for the vaccinations schedule given to children up to five years of age ranged from 95.9% to 100% (local averages 88.7% to 98.5%).
• Same day appointments were provided for babies or children who were unwell.
• The practice provided contraceptive advice and were able to fit implants in-house. The practice undertook coil removals, whilst coil fittings were available at two nearby venues. 
• The practice had baby changing facilities, and a small play area was available for children. The practice welcomed mothers who wished to breastfeed on site, and offered a private room to facilitate this if requested.

Updated 7 November 2016

• The practice offered personalised care to meet the needs of older people. Care plans were in place for older people with complex needs, and the practice worked collaboratively with other providers to deliver tailored care packages to patients. Monthly multi-disciplinary meetings were held to review frail and vulnerable patients to plan and deliver care appropriate to their needs.
• The practice proactively used electronic systems to identify vulnerable patients at risk of unplanned hospital admissions, and developed care plans to ensure they were supported to stay in their own homes. This included, for example, the identification of patients at risk of falls with referrals for further assessment, tests, appropriate medicines, or support.
• Older patients with multiple health issues received an annual (or more frequent if required) medicines review to re-assess their condition and to ensure the medicines remained suitable for their needs. This would be arranged at the patient’s home if necessary.
• Established links between the practice and a consultant for older patients provided an expert opinion when this was required. The consultant undertook home visits for patients to assess their needs, to prevent them travelling to the hospital or being admitted.
• The practice worked with the Parkinson’s disease specialist nurse for patients who may need an expert opinion on their ongoing care and management.
• Longer appointment times could be arranged for patients with complex care needs. Home visits were provided for those unable to attend the surgery.
• Uptake of the flu vaccination for patients aged over 65 was 74.20%, which was slightly above local and national (71.7% and 70.5% respectively). 

Updated 7 November 2016

• Telephone consultations and advice were offered each day when this was appropriate, so that patients did not always have to attend the practice for a face-to-face consultation.
• The practice offered on-line booking for appointments and requests for repeat prescriptions. Participation in the electronic prescription scheme meant that patients on repeat medicines could collect them directly from their preferred pharmacy.
• The practice provided health assessment checks and had achieved 94.2% of its target number of NHS health checks during 2014-15.
• The practice actively promoted health-screening programmes to keep patients safe. The practice’s uptake for the cervical screening programme was 86.8%, in line with the CCG average of 86.2% and above the national average of 81.8%. Uptake of breast cancer screening was encouraged, and rates were higher than local and national averages.
• Extended hours surgeries were not available at the time of our inspection. However, this was not highlighted as a need by patients we spoke with during the inspection. The national GP survey indicated that 80% of patients were happy with the practice’s opening times (compared to the local and national average of 76%).

Updated 7 November 2016

• The practice achieved 100% for mental health related indicators in QOF, which was 6.2% above the CCG and 7.2% above the national averages. Exception reporting rates at 16.1% were slightly higher compared against local (14.8%) and national rates (11.1%).
• 100% of patients with severe and enduring mental health problems had a comprehensive care plan documented in the preceding 12 months according to 2014-15 QOF data. This was higher than the CCG average of 86.4% and the national average of 88.5%, but with higher levels of exception reporting at 23% (CCG 18.6%; England 12.6%). However, the practice were able to provide data for 2015-6 showing 92.3% of patients with a documented care plan, with showed exception reporting to be 16% and in line with averages.
• The practice worked with local community mental health teams, including the crisis team, where appropriate.
• The practice told patients experiencing poor mental health and patients with dementia about how to access local services, support groups and voluntary organisations. Information was available for patients in the waiting area. The practice promoted local counselling and associated talking therapies’ services.
• The practice monitored patients taking medicines initiated within secondary care in line with shared care protocols.
• 100% of people diagnosed with dementia had had their care reviewed in a face-to-face meeting in the last 12 months. This included physical and mental health, smoking cessation and cervical screening where appropriate. The 100% achievement was significantly above local and national averages of 87.8% and 84% respectively. This was achieved with lower exception reporting rates at 4%, compared to local rates of 9% and the national average of 8.3%.

Updated 7 November 2016

• Patients with end-of-life care needs were reviewed at a monthly multi-disciplinary team meeting including a lead GP, district nurses, and a Macmillan nurse.
• The practice used care plans for the most vulnerable patients including those at end of life. A specific template was used for patients at the end of life to ensure key information was available to the ambulance service, the out of hours’ provider, and social services to ensure continuity of care for the patient. This included the patient’s preferred place of care and whether a Do Not Attempt Resuscitation order was in place.
• Newly bereaved relatives or carers were contacted by the practice to see if any support may be required.
• 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.
• The practice had undertaken an annual health review for 100% of their patients with a learning disability in 2014-15.
• Leaflets were available for female patients with a learning disability to encourage them to receive a cervical smear.
• Patients receiving a new diagnosis of cancer were followed up with a consultation and cancer care review.
• The practice had low number of patients whose first language was not English. These patients were able to access interpreter services if required.
• Homeless people could register with the practice.