Archived: Ashgate Medical Practice

Updated 21 November 2016

Ashgate Medical Practice provides care to approximately 14,200 patients from three sites in the Chesterfield area of North East Derbyshire. The practice serves a mainly urban population but also has some patients within a semi-rural location on the edge of the Peak District national park. We visited the main site at Ashgate Manor for the inspection but there are also two branch sites:

• Holme Hall Surgery, Wardgate Way, Chesterfield. S40 4SL.
• Whittington Medical Centre, High Street, Old Whittington, Chesterfield. S41 9JZ.

The practice is run by the Chesterfield Medical Partnership and the surgery provides primary care medical services via a Personal Medical Services (PMS) contract commissioned by NHS England and North Derbyshire Clinical Commissioning Group (CCG). The practice operates from a new multi-occupancy purpose-built detached building, constructed in 2013.

The practice is run by a partnership of five GPs (three males and two females) and a sixth female partner who is also the practice director. The partners employ five salaried GPs (three female and two males).

The nursing team comprises of four nurse practitioners, three practice nurses, and three health care assistants. The partnership also directly employs a full-time community matron. The clinical team is supported by a practice director and a practice manager, with a team of 24 secretarial, administrative and reception staff. The practice also employs four housekeeping staff.

The practice received training status in July 2016 and GP registrars will commence placements on site by autumn 2016. It is also a teaching practice and accommodates placements for medical students, with plans in place to support nursing student placements next year.

The registered practice population are predominantly of white British background, with 2.6% of patients recorded as being of non-white ethnicity. The practice is ranked in the fifth more deprived decile for deprivation status with a deprivation score (2015) of 24.5 (the local average is 18; England average is 21.8). The practice age profile demonstrates higher numbers of patients aged 45 and over. For example 20.6% of the practice population are aged 65 and above, which is comparable to the CCG average of 21.7%, and slightly above the national average of 17.1%. The practice has slightly less numbers of patients aged below 45 compared with national figures.

The practice’s main site at Ashgate Manor opens from 8am until 6.30pm Monday to Friday. The practice closes on one Wednesday afternoon each month for staff training. Extended hours opening is available at Ashgate Manor on a Thursday morning from 7am and on Tuesday evenings until 8.30pm. The branch site at Whittington also offers early morning phlebotomy appointments on a Thursday morning from 7am.

The practice has opted out of providing out-of-hours services to its own patients. When the practice is closed patients are directed to Derbyshire Health United (DHU) via the 111 service.  The 111 service and the out-of-hours consultation facility for Chesterfield are located within the same building, and this has been beneficial in establishing good communication with the practice.

Updated 21 November 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Ashgate Medical Practice on 31 August 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. The practice had adapted a system from a neighbouring practice termed learning opportunities to share (LOTS) to encourage incident reporting at all levels within the practice. This encouraged staff to raise events, however minor or significant, with the resulting impact of issues increasingly being reported. Learning was applied from all 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 regular programme of clinical audit and research 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 the patient and staff feedback they received, and worked with a proactive Patient Participation Group (PPG) to enhance patient experience.
• Information about how to complain was readily available to patients. Improvements were made to the quality of care as a result of any complaints received.
• Results from the national GP survey and feedback from patients we spoke with during the inspection demonstrated some dissatisfaction with the appointment system. The practice was aware that access was problematic and had taken action to address this. This matter remained under review by the practice as they strove to improve access.
• Longer appointments were available for those patients with more complex needs. A GP triaged calls and ensured that any patient requiring an urgent appointment was seen on the same day.
• There were elements of the practice’s quality monitoring arrangements, and the actions taken to reduce risks, that required strengthening. For example, the practice had not arranged for Disclosure and Barring Service (DBS) checks on two staff who had been trained to act as chaperones. In addition, some medicines management issues such as the checking of medicine expiry dates lacked sufficient oversight and required more robust management. However, the practice took immediate action to rectify these issues.
• The practice had modern purpose-built facilities that were 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 the GPs and managers were approachable and always had time to talk with them.
• The practice had a clear vision for the future and the aspirations of the partners were in line with the CCG strategy of delivering high quality care closer to the patient’s home.

We saw the following area of outstanding practice:

• The practice had commenced an in-house pharmacy pilot project from September 2015. This placed a prescribing community pharmacist within the practice for four days each week. The pharmacist had made 2,173 patient contacts between September 2015 and April 2016, approximately 75% of which were face to face consultations. This had a significant impact in releasing additional GP consultation capacity, and providing expert advice and support to patients and the practice team with regards to medicines related issues.

The areas where the provider should make improvement are:

• Consider the frequency and oversight of regular reviews for emergency medicines so that they are available when needed.
• Review procedures to monitor prescriptions, including the destruction of prescriptions assigned to a named GP after leaving the practice.
• Ensure the practice cold chain policy is implemented, supported by staff training, and with regular monitoring arrangements to provide assurance that it is being followed.
• Review procedures to ensure all staff who act as a chaperone receive appropriate DBS clearance. 

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 21 November 2016

• The practice generally had a higher prevalence of most long-term conditions and designed service delivery around the needs of their patients.
• The practice achieved 78.1% for diabetes related indicators during 2014-15, which was below the local average of 96.7% and below the national average of 89.2%. However the rates of exception reporting were generally lower.
• Patients received an annual review of their conditions including their prescribed medicines. This review was done within the patient’s home if they had difficulties in travelling to the practice.

• Patients with multiple conditions were usually reviewed in one appointment to avoid them having to make several visits to the practice.

• The practice provided a range of services on site for patients with a long-term condition. This included spirometry (to assess breathing difficulties); foot checks for patients with diabetes; and insulin initiation.
• Specialist nurses provided input and advice to the practice for patients with more complex needs. This also supported the ongoing development of the practice nursing team who had undertaken additional training to enhance their knowledge and skills in treating patients with a long-term condition. 

Updated 21 November 2016

• The community health visitor and midwife attended a meeting with practice clinicians once a month to discuss any child safeguarding concerns.
• Child protection alerts were used on the clinical system to ensure clinicians were able to actively monitor any concerns related to any vulnerable children.
• Childhood immunisation rates for the vaccinations given to infants aged five and below ranged from 95.2% to 100% (local average 95.2% to 98.9%).
• Requests for child consultations were prioritised, and children under five years of age would always be offered an appointment on the same day.
• Appointments were available outside of school hours
• The practice provided family planning services to fit and remove intrauterine devices (coils) and implants, and clinicians provided advice on all aspects of contraception.
• A separate baby care room provided nappy changing facilities, and privacy for mothers who wished to breastfeed on site.

Updated 21 November 2016

• The practice had slightly higher numbers of older people registered with them compared to the national average (for example, 20.6% of patients were over 65, compared against a national average of 17.1%). The practice ensured that their services were tailored to meet the needs of their older patients.
• The practice employed a full-time community matron to focus upon the needs of older patients to avoid hospital admissions and to facilitate discharges from secondary care.
• The practice provided a number of in-house services to prevent older patients from travelling to a hospital or other locations to access them. This included wound care, ECGs, phlebotomy, and 24 hours blood pressure monitoring.
• The practice had an integrated approach in working with other professionals to plan and deliver care, and held fortnightly multi-disciplinary meetings to review their most vulnerable patients.
• Longer appointment times were available and home visits were available for those unable to attend the surgery. Nurse practitioners undertook home visits for some acute health care needs with appropriate support and advice being provided by GPs.
• Fortnightly visits were provided by a named GP or a nurse practitioner to a local care home aligned to the practice. The practice responded to any urgent patient needs on the same day. The practice provided data to demonstrate a reduction in hospital admissions from the home from 35 in 2013-14, to 14 in 2015-16. Accident and Emergency (A&E) attendances had reduced by 50% within this timescale. This indicated that the input the practice team provided to the care home had impacted positively upon secondary care admission rates.
• Uptake of the flu vaccination for patients aged over 65 was 75.8% which was in line with local (73.9%) and national (70.5%) averages.

Updated 21 November 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 consultations were available at the main site. Early morning and evening appointments were available on one day each week to accommodate the needs of working people.
• The practice held ‘drop-in’ blood clinics to offer more flexible access for patients. However, bookable appointments were also available if patients preferred this option.
• The practice promoted health screening programmes to promote patients’ wellbeing. For example, screening uptake for cervical, bowel and breast cancer was in line with local and national averages.
• The practice offered health checks for new patients and NHS health checks for patients aged 40-74.
• The practice referred patients to health trainer sessions for support and advice including weight management, smoking cessation, and alcohol consumption.

Updated 21 November 2016

• The practice achieved 96.5% for mental health related indicators in QOF, which was 1.6% below the CCG average and 3.7% above the national average. This was achieved with lower levels of exception reporting.
• 93% of patients with poor mental health had a documented care plan during 2014-15. This was in line with the CCG average of 93.3% and slightly above the national average of 88.3%. This was achieved with much lower exception reporting at 5.4% (local 17.4%; national 12.6%).
• The practice sought expert advice to support patients with complex needs when this was required. For example, a consultant based in Sheffield had visited the practice to discuss a patient’s care, and a psychiatrist attended the multi-disciplinary team meeting by invitation.
• The practice had developed an approach with patients who regularly accessed health services to call them for regular reviews with the same GP to manage their condition, thereby preventing a build-up of anxiety and subsequent chaotic behaviour.
• 82.7% of people diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months.
• Staff had undertaken ‘dementia friends’ training, to enhance their knowledge of support available to patients with dementia and their carers. Members of the PPG had also participated within the training.
• A representative from the community mental health team usually attended multi-disciplinary meetings to review and discuss any patients with ongoing mental health needs. 

Updated 21 November 2016

• The practice had undertaken an annual health review in the last 12 months for 90% of eligible patients with a learning disability.
• The practice provided care to a home for people with a learning disability, and a named GP visited people on a fortnightly basis.
• Longer appointments (often on an opportunistic basis) and home visits were offered to vulnerable patients when required.
• The practice provided high quality end of life care. Patients with palliative care needs were reviewed at regular multi-disciplinary team meetings, and had supporting care plans in place. A member of the district nursing team informed us that the GPs were caring and were responsive to their patients’ needs.
• Staff had received adult safeguarding training and were aware how to report any concerns relating to vulnerable patients.
• Homeless patients were able to register with the practice.
• The YMCA was moving into the shared building on the day of our inspection. The practice was considering how they might be able to support individuals who accessed the YMCA, for example, with work experience opportunities.