The Gate Surgery

Updated 22 June 2017

The provider, Gateway Primary Care C.I.C. (Community Interest Company) is a social enterprise. The practice provides services under an Alternative Provider Medical Services contract (APMS - a locally negotiated contract open to both NHS practices and voluntary sector or private providers) for 7,300 patients from a group of surgeries within the Rotherham CCG. The main surgery operates a specialised contract for the CCG, providing services to asylum seekers, homeless, travellers and a transition home for prisoners who have been high risk but are being released into the community.

The services comprise of the main Surgery:

The Gate Surgery

Chatham house

Doncaster Gate

Chatham Street

Rotherham

S65 1DJ

And two branch surgeries;

Rosehill Medical Centre

52 Rosehill Road

Rawmarsh

Rotherham

S62 7BT

And

Canklow Road Surgery

Henderson Place

Rotherham

South Yorkshire,

S60 2JH

Canklow Road Surgery had moved into new premises since the last inspection which were situated across the road from the previous surgery. This provided improved facilities for both patients and staff.

We visited all three sites during this inspection. All premises have access to car parking facilities and there is access available for wheelchairs and disabled toilet facilities.

The patient population is significantly higher than average in the under 50 year old age group and significantly lower than average in the over 50 year old age groups. The practice is situated in one of the most deprived areas nationally. Over half of the practice population at the main site have English as their second language.

There are five salaried GPs, two female and three male. There is a management team including a performance manager, business manager, clinical manager and a managing director. The nursing team comprises of an advanced nurse practitioner, four practice nurses and two health care assistants. There are ten reception/administration staff.

The reception at each site is open 8am to 6.30pm Monday to Friday and appointments are available 8.30am to 11am and 3pm to 5.30pm. Additionally the health care assistant provides a phlebotomy service 7am to 8am on a Wednesday at Canklow Road Surgery and 6.30am to 8am at Rosehill Medical Centre. A GP provides early morning appointments at The Gate surgery from 7am on a Tuesday. The reception opens 15 minutes before the early morning surgeries commence.

When the practice is closed between 6.30pm and 8am patients are directed to contact the NHS 111 service.

Updated 22 June 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Gate Surgery on 28 September 2016. The overall rating for the practice was good but with requires improvement for safety. The full comprehensive report for the 28 September 2016 inspection can be found by selecting the ‘all reports’ link for The Gate Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 17 March 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 28 September 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated as Outstanding.

There are a number of outstanding areas highlighted in our inspection report 28 September 2016. We found at both our inspections all the staff were passionate about the service and were proactive in seeking ways to assist patients and the local community. It was clear the staff worked hard to provide a good quality and equitable service in order to improve care and the quality of life for some of Rotherham’s most marginalised and vulnerable groups. Whilst provision of services to the patient group was potentially very challenging the staff enjoyed their work and felt supported in their roles and this was testament to the energy and enthusiasm for the service shown by the Registered Manager.

At this inspection we found the management team had reviewed their last inspection report in detail and had responded to all shortfalls identified not only to meet legal requirements but they had also responded to all minor points in the report. They had taken immediate action following the last inspection to improve and had continued to review and improve policies and procedures and systems where necessary.

Our key findings at this inspection were as follows:

The provider had made the following improvements to meet legal requirements:

• Systems to manage blank prescriptions had been improved to ensure these met NHS Protect guidance.
• Storage arrangements for vaccines had been improved to ensure these met Public Health England guidance. Arrangements for monitoring the temperature of vaccines when they were transported from the surgery had also been reviewed and improved.

The provider had also made the following improvements:

• A programme of refurbishment had been completed at Rosehill Medical Centre to improve infection prevention and control.
• Security arrangements had been reviewed and improved at the branch surgeries to control access
• Information had been included in complaint response letters to patients on how to escalate a complaint if they are not satisfied with the response from the practice. The practice policy and procedure and web site had also been updated with this information.
• The chaperone policy had been reviewed and updated with more guidance for staff.
• A member of reception staff had been employed to provide additional cover at branch surgeries.

The practice had continued to find innovative ways of working to improve care for their patients and at this inspection we found additional areas of outstanding practice:

• The practice had completed an audit prior to the last inspection to look at patients who had a confirmed diagnosis of human immunodeficiency virus (HIV) and if they had been offered the vaccinations as per the British HIV Association Guidance. In response to the initial audit they had implemented processes to improve the uptake of vaccinations and had invited all patients with the diagnosis to attend. A second audit since the last inspection showed an  increase in the number of patients who were offered vaccinations and uptake of the vaccinations. For example, HIV positive patients being offered outstanding vaccinations had increased from 0% to 100% and the uptake of HPV vaccination (for patients under the age of 26 years) had increased from 5% to 50%.
• Due to their specific patient population needs the practice offered screening and vaccination over and above the programme offered to new-born babies of parents diagnosed with Hepatitis B. All children of parents with this diagnosis, regardless of their age, were offered screening and vaccination at this practice. The practice had identified and offered screening for 57 children in this category, of these 37 had accepted screening. Even if parents declined screening for their child vaccinations were always offered. Of the 57 eligible children a potential total of 285 vaccinations can be given (based on a programme of up to 5 vaccines which not all children would need). The practice had given 207 vaccinations to this cohort with some children still requiring further scheduled vaccinations.

Additionally since the last inspection the practice had also taken the following actions to improve patient care:

• The practice had developed an in-house dementia team following a reduction in the service previously provided externally. The team included clinical and administration staff who had received specific training for this role. The practice had audited their records to identify patients who may be at risk of developing or were living with dementia. The practice had reviewed the care provided and was in the process of working with the patients and their carers to ensure the patients received the required assessments, treatment and support. They had developed systems to ensure on-going monitoring and regular review of their care.
• At the last inspection we did not identify any concerns about how the appointment system was managed although there were varied levels of patient satisfaction. However, we found the practice had been working to improve patient experience in relation to access to appointments in response to patient survey outcomes. Since the last inspection the practice had commenced the Productive General Practice programme. (Productive General Practice is a new programme from the NHS Institute which aims to support general practices in realising internal efficiencies, while maintaining quality of care and releasing time to spend on more value added activities.) The practice had used this system to further review their appointment system. Following an audit they had commenced a nurse practitioner triage system. This had been further audited and showed significant savings equating to 56 GP appointments. The practice had also increased the number of appointments available by 100 per week across the three sites. The practice was continuing to monitor patient satisfaction with the system.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Updated 29 November 2016

The practice is rated as good for the care of people with long-term conditions.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

• Performance for diabetes related indicators was 66%, 16% lower than the CCG average and 22% lower than the national average. Performance in other areas, including asthma, chronic obstructive airways disease (COPD), hypertension and depression, was 100%, slightly above average. The practice population offered a number of challenges to management of health care needs. To minimise the risk posed by these challenges the practice used every opportunity to provide care for patients often having to be flexible and opportunistic in their approach. For example, if a patient attended for an appointment they would check if reviews, routine blood tests or treatment were due and complete these at the same time.

• A thorough new patient assessment process had been developed and patients were given an hour long appointment. This process included a full health and social care needs assessment and any treatment, blood tests or health reviews which were necessary at the same appointment. This process reduced the need for patients to re-attend for routine screening and increased the chances of identifying patient’s health needs and providing interventions to reduce risks to patients and others.

• Longer appointments and home visits were available when needed.

• All these patients had a named GP and 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 22 June 2017

The provider had resolved the concerns for safety identified at our inspection on 28 September 2016 which applied to everyone using this practice, including this population group. The population group ratings have been updated to reflect this.

• There were systems in place 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 A&E attendances. The practice monitored children on the child protection register at regular intervals, depending on their age. For example, children up to two years of age were monitored on a three monthly basis and if they had not seen a clinician in that time they were referred to the health visitor.
• Due to the practice patient profile the practice had developed a detailed new patient assessment record which identified patients who may be at risk of female genital mutilation (FGM) and a register of children in this risk category was maintained. There was also a clinical lead specifically for this area.
• Immunisation rates were slightly below CCG and national average for standard childhood immunisations, however, the practice took every opportunity to ensure children received their vaccinations
• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals.
• The practice’s uptake for the cervical screening programme was 78%, which was comparable to the CCG average of 83% and the national average of 82%.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• We saw positive examples of joint working with midwives and health visitors. The practice hosted weekly clinics at The Gate Surgery with specialist health visitors for the asylum and European Union migrant patient population to improve communication.
• The practice hosted specialist sexual health nurse clinics weekly in line with the post-natal checks for contraception advice. They also offered a walk-in service for condoms. Public health policy stated this is to be offered to patients under 19 years of age but due to the health issues of the practice patient population they offered this service to all patients irrespective of age.

• Due to their specific patient population needs the practice offered screening and vaccination over and above the progamme offered to new born babies of parents diagnosed with Hepatitis B. All children of parents with this diagnosis, regardless of their age, were offered screening and vaccination. The practice had identified and offered screening for 57 children in this category, of these 37 had accepted screening. Even if parents declined screening for their child vaccinations were always offered. Of the 57 eligible children a potential total of 285 vaccinations can be given (based on a programme of up to 5 vaccines which not all children would need). The practice had given 207 vaccinations to this cohort with some children still requiring further scheduled vaccinations.

Updated 29 November 2016

The practice is rated as good for the care of older people.

• The practice offered proactive, personalised care to meet the needs of the older people in its population.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

• The practice visited care homes registered with the practice on a weekly basis to review patients care needs and medicines.

Updated 29 November 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

• 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.

• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

• The health care assistant provided a phlebotomy service 7am to 8am on a Wednesday at Canklow Road Surgery and 6.30am to 8am at Rosehill Medical Centre. A GP provided early morning appointments at The Gate surgery from 7am on a Tuesday.

Updated 22 June 2017

The provider had resolved the concerns for safety identified at our inspection on 28 September 2016 which applied to everyone using this practice, including this population group. Additionally we identified the practice had taken action since the last inspection to improve care for patients in this population group. The population group ratings have been updated to reflect this.

• Performance for mental health related indicators was 88%, 2% below CCG average and 4% below national average.
• Performance for depression was 100%, 6% above the CCG average and 8% above the national average. Prevalence of depression in the patient population 5% higher than CCG and 7% higher than national averages.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health. All three surgeries hosted improving access to psychological treatment (IAPT) counselling services.
• The practice had informed patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• The practice had a significantly lower than average number of older patients with only 10% of patients being over 65 years of age. The practice had a register of patients living with dementia and regularly checked for those who may be at risk.
• Staff had a good understanding of how to support patients with mental health needs and those living with dementia. The practice had developed an in-house dementia team following a reduction in the service previously provided externally. This included clinical and administration staff who had received specific training for this role. The practice had audited their records to identify patients who may be at risk of developing or had developed dementia and reviewed their care ensuring all the patients had received the required assessments. They had developed care plans and systems to monitor their care.

Updated 29 November 2016

The practice is rated as outstanding for the care of people who circumstances may make them vulnerable.

• The practice population included a high percentage of patients from vulnerable groups such as asylum seekers, homeless patients and travellers which offered a number of challenges to management of health care. The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs. To minimise risks to patients the practice had developed the service so they could be flexible and opportunistic in their approach. They supported the patients in a variety of ways to try to minimise the impact of their circumstances on their health. For example, the practice provided outreach clinics, provision of a food and clothing bank, winter rescue packs for homeless patients and they had developed community allotments on a piece of waste ground at one of the surgeries.
• The practice offered longer appointments for patients with a learning disability.
• The practice informed vulnerable patients about 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 systems to safeguard patients had been developed to meet the specific risks of the patient population.
• The homeless were able to use the practice as a mail point which allowed the receipt of mail such as hospital appointments and benefits.
• The practice assisted with social needs such as benefits, housing and asylum issues and acted as patients advocate. They also assisted with taxi fares for hospital appointments and for attending the surgery.
• Although the practice did not offer appointments at weekends The Gate Surgery opened on a Saturday, in the winter months, to offer soup, warmth and a meeting place for vulnerable patients.
• The practice hosted joint drug and alcohol services at The Gate Surgery three to four times per week and walk-in leg ulcer clinics.