The White House Surgery

Updated 20 November 2017

The White House Surgery (also known locally as Dr Morton & Partners) is based in Moreton-in-Marsh, a town and civil parish of Gloucestershire. In 2014, the practice moved from the high street in Moreton-in-Marsh to its current premises, The Four Shires Medical Centre. The Four Shires Medical Centre is a health care campus with a local community hospital, and is so named because the Four Shire stone marked the boundary of the historic counties of Gloucestershire, Warwickshire, Worcestershire and Oxfordshire. The White House Surgery shares a large, purpose built building with another GP practice, and its patients are drawn from the four counties.

The practice provides its services to approximately 4,500 patients under a General Medical Services (GMS) contract. (A GMS contract is a contract between NHS England and general practices for delivering general medical services and is the commonest form of GP contract). The practice also has a branch surgery and approximately 800 of registered patients use the branch. Both the practice’s main site and branch surgery had a dispensary on site. The practice delivers its services from the following addresses:

The White House Surgery,

Stow Road,

Moreton in Marsh,

Gloucestershire,

GL56 0DS .

And,

The Surgery,

Greenway Road,

Blockley,

Gloucestershire,

GL56 9BJ.

There are four consulting rooms and three treatment rooms located on the ground floor, along with rooms for phlebotomy, psychiatry services, dispensing, midwifery and a baby clinic. The reception room is also situated on the ground floor. There is a patient lift and the building is suitable for disabled access. A large waiting room contains a plasma screen that relays NHS health information. The premises recently experienced a flood from a burst pipe and at the time of our inspection, the practice was undergoing remedial work. There were no disruptions to the services available to patients.

The practice partnership includes two male GPs. They also employ a salaried female GP. The nursing team includes an advanced nurse practitioner (who is also a non-medical prescriber), a practice nurse and a health care assistant. The dispensary team includes a dispensary manager and four dispensers. The practice management and administration team includes a practice manager, a systems manager, two medical secretaries, a lead receptionist and three receptionists (one of whom also provides phlebotomy services).

The general Index of Multiple Deprivation (IMD) population profile for the geographic area of the practice, shows the practice is in the second least deprivation decile. (An area itself is not deprived: it is the circumstances and lifestyles of the people living there that affect its deprivation score. Not everyone living in a deprived area is deprived and that not all deprived people live in deprived areas). The practice has a higher than average patient population aged 50 and above. Average male and female life expectancy for the practice is 82 and 87 years respectively, which is above the national average of 79 and 83 years.

The practice is open from 8am to 6.30pm Monday to Friday. Appointments with a GP are from 8.30am to 5.30pm. Appointments in the morning were routinely 15 minutes long and 10 minutes in the afternoon. Extended hours are available from 6.30pm to 7.30pm on Monday evenings. The branch surgery is open from 8.30am and 12.30pm from Monday to Thursday.

The practice has opted out of providing out of hours services to its patients. Patients can access the out of hours services provided by CareUK via the NHS 111 service.

This inspection is part of the CQC comprehensive inspection programme and is the first inspection of The White House Surgery.

Updated 20 November 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The White House Surgery on 10 October 2017. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• GPs at the practice supported the community hospital located on the same site and undertook regular ward rounds, two to three times a week on a rotational basis.

• GPs who were skilled in specialist areas such as geriatric medicines and allergies, used their expertise to offer additional services to patients.

• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

• Improve the recording of information such as minutes of meetings to ensure these are clear about the information discussed

• Review and improve systems and processes in relation to medicines management, staff training and appraisal.

• Implement the identified actions to improve the number of patients identified as carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 20 November 2017

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

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

• The percentage of patients on the diabetes register with a record of a foot examination and risk classification was 99% compared to the clinical commissioning group (CCG) average of 91% and the national average of 89%.

• The percentage of patients with chronic obstructive pulmonary disorder (a chronic lung disease) who have had a review in the last 12 months (2015/16) was 91% compared to the CCG average of 93% and national average of 90%.

• The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs. Those patients were also discussed at weekly clinical meetings.

• There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.

• All these patients had a named GP and there was a system to recall patients for 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 20 November 2017

The practice is rated as good for the care of families, children and young patients.

• From the sample of documented examples we reviewed we found there were systems 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 accident and emergency (A&E) attendances.

• Immunisation rates were relatively high for all standard childhood immunisations.

• Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals.

• The practice provided support for premature babies and their families following discharge from hospital.

  Appointments were available outside of school hours and the premises were suitable for children and babies.

• The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics. The practice hosted a weekly midwife clinic.

• The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications.

• One of the GPs could offer allergy testing and held a clinic for this for patients who suffered allergies.

Updated 20 November 2017

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

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

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

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

• The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.

• The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.

• Where older patients had complex needs, the practice shared summary care records with local care services. For example, patients who were frail were discussed and treatment plans were amended as necessary with community staff and the out of hours service.

• Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible.

Updated 20 November 2017

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

• The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours and telephone appointments.

• 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 practice supported a local training facility which had a number of students from the Middle East. One of the GPs could communicate with those patients in Arabic.

Updated 20 November 2017

The practice is rated as good for the care of patients experiencing poor mental health (including people with dementia).

• The practice carried out advance care planning for patients living with dementia.

• 82% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was comparable to the clinical commissioning group (CCG) of 86% and national average of 84%.

• The practice specifically considered the physical health needs of patients with poor mental health and dementia.

• The practice worked closely with the Mental Health Community Team and could refer patients to the local crisis team and Gloucestershire counselling services. The practice had also identified private counsellors to whom, patients who were bereaved or required cognitive behavioural therapy could be referred.

• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.

• 79% of patients with severe mental health problems had a comprehensive care plan documented in their record in the last year (2015/16) which was below the CCG average of 93% and national average of 89%. Data from the practice for the year 2016/17, which was unverified, showed that this figure had improved. For example, 100% of patients had a care plan documented in their record.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.

• Patients at risk of dementia were identified and offered an assessment.

• The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.

• The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

• Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.

Updated 20 November 2017

The practice is rated as good for the care of patients whose circumstances may make them vulnerable.

• The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability. The practice recognised that there was high number of patients who were travellers and had now settled in permanent accommodation locally. The practice discussed those patients beliefs and religions at weekly meetings to ensure staff understood this and supported patients appropriately.

• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable. The practice held Gold Standard Framework weekly meeting for patients on the palliative care register.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients.

• The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.

• Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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.