Archived: The Limes Surgery

Updated 22 September 2016

The Limes Surgery provides primary medical care for approximately 9,500 patients living in Hoddesdon, Hertfordshire.

The practice provides services, including minor surgery, under a General Medical Services (GMS) contract agreed nationally. The practice population is predominantly White British. The practice also serves a small ethnic population mostly of Italian and Eastern European origin.

The practice has six GPs (two males and four females) two of whom are GP partners. The practice employs two practice nurses and a health care assistant. There is a practice manager who is supported by a team of administrative and reception staff. A health visitor and a community midwife from the local NHS community team support patients at this practice.

The practice is open Monday to Friday from 8am until 6.30pm. Extended hours are provided on Thursday evenings between 6.30pm and 7.15pm and Wednesday mornings when the practice opens at 7.15am. The out of hours service is provided by Hertfordshire Urgent Care via the NHS 111 service.

Updated 22 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced focused inspection at The Limes Surgery on 23 August 2016. This was to check that improvements had been made following the breaches of legal requirements we identified from our comprehensive inspection carried out on 27 January 2016.

This report only covers our findings in relation to the areas requiring improvement as identified on inspection in January 2016. You can read the report from this comprehensive inspection, by selecting the 'all reports' link for The Limes Surgery on our website at www.cqc.org.uk. The areas identified as requiring improvement during our inspection in January 2016 were as follows:

• Ensure that systems designed to assess the risk of and to prevent, detect and control the spread of infection were fully implemented.
• Ensure that all applicable staff received appropriate checks through DBS (Disclosure and Barring Service) and that the required information was available in respect of the relevant persons employed.
• Ensure that all staff employed were supported, receiving the appropriate appraisal and have documentary evidence of role specific training completed.
• Ensure an appropriate system was in place for the safe use and management of emergency medicines and prescription pads.

• Review and update procedures and guidance so they reflected current legislation and guidance.
• Introduce systems to alert the practice of emerging risks such as in infection control, arrangements to deal with emergencies, staff recruitment including DBS checks, staff appraisal and training.
• Should review and make improvements to the disabled patient toilet facilities provided in line with the requirements of the Equality Act 2010.

Our key findings on this focused inspection across the areas we inspected were as follows:

• Systems and processes were in place to assess the risk of and to detect, prevent and control the spread of infection. For example, the practice had introduced a new infection control audit template and were completing an audit on a regular basis.
• The practice had risk assessed the roles of all non-clinical staff and appropropriate checks had been undertaken through DBS where applicable.
• All staff had received an appraisal and the practice had an up-to-date training log in place for all staff which evidenced role specific training, such as safeguarding
• The practice had appropriate systems in place for the effective management of emergency medicines and prescriptions.
• Practice policies were specific, kept up-to-date and reflected current legislation and guidance.
• Systems to manage risks including recruitment, staff training, appraisals and dealing with emergencies were in place and found to be adequate.
• Steps had been taken to review and make improvements to the disabled patient toilet facilities. For example, an emergency call bell had been installed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 22 September 2016

At our comprehensive inspection on 27 January 2016 we found that nursing staff had lead roles in chronic disease management. For example there were nurse-led clinics for diabetes, asthma and chronic obstructive pulmonary disease (COPD). Patients at risk of hospital admission were identified as a priority. 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 example, 99% of patients diagnosed with diabetes, had received an influenza immunisation in the preceding 12 months. 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.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 23 August 2016 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of people with long-term conditions as they received care that was safe and well-led.

Updated 22 September 2016

At our comprehensive inspection on 27 January 2016 we found that 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. Immunisation rates were relatively high for all standard childhood immunisations. Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this. The practice offered cervical screening and had performed this on 82% of the population who met the criteria for this test in the last five years. Appointments were available outside of school hours and the premises were suitable for children and babies.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 23 August 2016 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of families, children and young people as they received care that was safe and well-led.

Updated 22 September 2016

At our comprehensive inspection on 27 January 2016 we found that 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. For the fit older person the practice offered annual checks, and for those on regular medications or with chronic conditions conducted face-to-face reviews every six months as a routine. The practice worked closely with the community matron, district nurses and the community team to ensure delivery of care to the housebound and those with poor mobility. The practice offered influenza immunisation to all over 65s, including the housebound.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 23 August 2016 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of older people as they received care that was safe and well-led.

Updated 22 September 2016

At our comprehensive inspection on 27 January 2016 we found that 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 offered appointments early in the morning and later in the evening one day a week to provide access to appointments for those patients who work during the day. The practice was proactive in offering on line services as well as a full range of health promotion and screening that reflects the needs for this age group.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 23 August 2016 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of working age people as they received care that was safe and well-led.

Updated 22 September 2016

At our comprehensive inspection on 27 January 2016 we found that staff had a good understanding of how to support patients with mental health needs and dementia. The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. The practice carried out advanced care planning for patients with dementia. Eighty-two percent of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average. The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. Ninety-four percent of patients on the mental health register had a comprehensive care plan in place and documented in their records. The practice had a system in place to follow up patients who had attended A&E where they may have been experiencing poor mental health. The practice offered emergency appointments with a GP in a crisis situation.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 23 August 2016 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of people experiencing poor mental health as they received care that was safe and well-led.

Updated 22 September 2016

At our comprehensive inspection on 27 January 2016 we found that the practice held a register of patients living in vulnerable circumstances including those with a learning disability. The practice offered longer appointments for patients with a learning disability. The practice had designated GPs to ensure continuity of care for vulnerable patients resident in care homes. The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. The practice informed vulnerable patients about how to access various support groups and voluntary organisations. The practice offered regular reviews of carers’ needs and offered support and care to long-term carers. 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.

However, breaches of legal requirements were identified and improvements needed to be made to ensure the practice provided safe services and was well-led. During our focused inspection on 23 August 2016 we found the practice had taken action to improve. Consequently the practice is rated as good for the care of people whose circumstances may make them vulnerable as they received care that was safe and well-led.