Morthen Road Group Practice

Updated 2 June 2017

Morthen Road Group Practice has been in operation since the late 1970s. It moved to its present location in a renovated three storey office block in 1995. It has two branches Braithwell Surgery, Old School House, High Street, Braithwell, Rotherham, S66 7AU and Ravenfield Medical Centre, 8 Hollings Lane, Ravenfield, Rotherham, S65 4PU. We visited all three sites during this inspection.

The practice acquired Braithwell, a small converted single floor building, in 1981 which is situated in the centre of a small village. There is a dispensary at the Braithwell site which serves approximately 2000 patients.

The practice acquired Ravenfield Surgery in 1990. This is a purpose built, single storey, building with a large treatment room and minor operation suite. Patients throughout the practice requiring minor surgical procedures visit Ravenfield Surgery for this purpose.

The practice provides General Medical Services (GMS) for 11,450 patients in the NHS Rotherham Clinical Commissioning Group (CCG) area. They have a higher than average 40 to 80 year old age group and are located in the 3rd least deprived area nationally.

There are six GP partners, two female and four male. Two of the partners are in the process of registration with the CQC.

The practice employs a female salaried GP, four practice nurses and three healthcare assistants. Two practice nurses offer nurse triage and appointments for minor illnesses.

The practice is currently restructuring their management team to provide a practice manager, finance manager and information governance manager. The practice has employed the services of a business manager to support and facilitate these changes. There are two medical secretaries, administration team and a team of reception staff are also employed. There is a head receptionist at both Morthen Road and Ravenfield Surgeries.

Morthen Road surgery is open between 8am and 6.30pm, Monday to Friday and there are extended hours until 8.30 pm on a Wednesday.

Ravenfield is open 8am to 6pm except Tuesdays when it is open 8am to 2pm.

Braithwell is open 8am to 12pm Monday, Wednesday and Friday and 3.30pm to 6pm Tuesday and Thursday.

When the Ravenfield and Braithwell sites are closed, telephone calls are automatically passed through to the main site at Morthen Road, Wickersley. When all surgeries are closed patients are advised to call NHS 111 service.

Updated 2 June 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Morthen Road Group Practice on 16 May 2016. The overall rating for the practice was good but with requires improvement for safety. The full comprehensive report for the 16 May 2016 inspection can be found by selecting the ‘all reports’ link for Morthen Road Group Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 19 April 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 16 May 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 Good.

Improvements to meet regulations had been made since our last inspection on 16 May 2016 2016. Our key findings were as follows:

• The Department of Health guidance February 2015 relating to blinds and blind cords had been implemented to minimise the risk of serious injury due to entanglement.
• Records of stock checks of medicines to ensure they were fit for use as recommended in current guidance had been implemented.
• Systems to handle blank prescription forms had been improved in accordance with national guidance.
• The facilities for handwashing had been improved to minimise the risk of cross infection.
• An infection prevention and control (IPC) risk assessment and audits had been completed and action plans had been developed.

Additionally the practice had also made the following improvements:

• Records of controlled drugs had improved and were in line with the relevant legislation.
• Medicines standard operating procedures had been signed by relevant staff.
• Distribution of medical alerts had been improved to ensure dispensary staff were kept up to date.
• The decontamination and hand hygiene procedure had been reviewed and updated and were now practice specific.
• The roles of dispensing staff and work streams in the dispensary had been reviewed and improved.
• The business continuity plan was accessible for staff.
• Medical gas warning signs had been provided on the door to the room used for storage of liquid nitrogen at Ravensfield Surgery.
• The practice had also completed patient surveys in response to concerns raised by the inspector just prior to this inspection about telephone access to the practice. The survey was mainly positive but they were going to use this information to review this area.

The practice should make improvements in the following areas:

• Review and improve effectiveness of management monitoring procedures in the dispensary and for checks of emergency medicines to ensure the practice policies and procedures are consistently and effectively implemented.
• Update and share the standard operating procedure to govern stock check activity with dispensary staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 20 July 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.

• Data showed performance for diabetes related indicators was 85%, which was similar to the national average of 89%.

• The practice had achieved 100% across a number of areas relating patients with long term conditions.

• 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 20 July 2016

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

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk.

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

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

• The practice’s uptake for the cervical screening programme was 82%, which was higher than the CCG average of 77% and the national average of 74%.

• We saw positive examples of joint working with health visitors, for example, when following up children who did not attend for the immunisation programme.

Updated 20 July 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.
• Data showed high levels of performance for conditions experienced by older patients.

Updated 20 July 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.

• Extended hours were provided once per week until 8.30pm.

• 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.

• An in-house dispensary was provided at one rural branch site.

Updated 20 July 2016

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

• Latest published data showed 85% of patients diagnosed with dementia had had their care reviewed in a face to face meeting between March 2014 and March 2015. This was comparable to the national average.

• Performance for mental health related indicators was 99.7%, which was better than the national average of 93%.

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

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

• The practice offered three different types of service for patients with mental health problems provided by a psychological wellbeing practitioner, three counsellors and two mental health practitioners.

• The practice had also told 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.

• Staff had a good understanding of how to support patients with mental health needs and dementia. The staff had received training and an assessment of the premises had been undertaken to ensure the practice was dementia friendly.

Updated 20 July 2016

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

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability.

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

• The practice informed vulnerable patients about how to access various support groups and voluntary organisations and hosted carers drop in clinics with Carers Support.

• Shared care appointments were available to provide care and support for patients with alcohol or substance misuse.

• 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.