Dr M Ninan and partners Also known as Darwen Healthcare

Updated 8 November 2016

Dr C R Dalton’s Practice, also known as Darwen Healthcare, is housed on the first floor of Darwen Health Centre along with two other GP practices and a range of other community healthcare services. A pharmacy also occupies the premises on the ground floor. There is a car park for patients with allocated disabled spaces, and there is a lift to facilitate access to the first floor for patients experiencing mobility difficulties.

The practice delivers primary medical services to a patient population of approximately 12,480 patients under a General Medical Services (GMS) contract with NHS England. It is part of the NHS Blackburn with Darwen Clinical Commissioning Group (CCG). In addition to its GMS contract, the practice provides the GP with special interests (GPwSI) cardiology service for the whole Blackburn with Darwen CCG population and also the community anticoagulation service, with other GP practices in the local area referring their patients into these services.

The average life expectancy of the practice population is above the local average and slightly below the national average (81 years for females, compared to the local average of 80 and national average of 83 years, 77 years for males, compared to the local average of 76 and national average of 79 years).

The age distribution of the practice’s patient population is broadly in line with local averages. However, the practice does cater for a higher percentage of patients who experience a long standing health condition (64.3%, compared to the local average of 55.6% and national average of 54%).

Information published by Public Health England rates the level of deprivation within the practice population group as four on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

The practice is staffed by six GP partners (five males and one female) and two female salaried GPs. In addition the practice employs three nurse practitioners, three practice nurses, a senior health care assistant (HCA) and two HCAs. Clinical staff are supported by a practice manager and a team of 26 administration and reception staff.

The practice trains final year GP trainees, foundation year two trainees, medical undergraduate students and has recently started to offer student nurse placements and has become involved in the physician associates training programme.

The practice is open between 8am and 6.30pm Monday to Friday, with surgeries offered between 8.30am and 11.30 each morning and 12 noon until 6.00pm each afternoon. Extended hours appointments are available on Monday evenings between 6.30 and 8pm.

Outside normal surgery hours, patients are advised to contact the out of hour’s service by dialling 111, offered locally by the provider East Lancashire Medical Services.

Updated 8 November 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr C R Dalton’s Practice (also known as Darwen Healthcare) on 31 August 2016. Overall the practice is rated as outstanding.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. We saw that learning opportunities from internal and external incidents were maximised.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. Training was proactively identified for staff as part of staff and service development and we saw that the training resulted in changes to practice to improve patient care and outcomes. These changes were monitored to demonstrate their effectiveness.
• The practice used innovative and proactive methods to improve patient outcomes, for example around pre-diabetes.
• Patients praised the practice highly and said they were treated with compassion, dignity and respect and that they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients 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.
• The organisation was flexible to best meet the needs of its patients. The practice had tailored its staffing structure and the roles within it according to the needs of the service in order to streamline processes and improve the quality of care.
• The practice had strong and visible clinical and managerial leadership and governance arrangements.
• Staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

We saw three areas of outstanding practice:

• We saw that the practice conducted audits regularly to ensure that best practice was being followed when staff were asked to act as chaperones. The audits examined whether the chaperones themselves recorded their presence at the consultation in the electronic patient record in free-text format as well as selecting a pre-created read-code box in the software. These audits demonstrated that as well as the chaperone’s presence being coded appropriately in the records 100% of the time, the use of free-text descriptions to supplement the coding had improved from a rate of 66% to 91% of the time over the previous year.

• The reflective and learning ethos of the practice was thoroughly embedded. The practice was proactive in maximising learning following complaints and incidents. We saw that not only was appropriate action taken to mitigate against an incident being repeated, but that the opportunity was taken to scrutinise that aspect of the service and assess whether further improvements could be made. For example, following a complaint regarding a delayed issue of a death certificate, not only was the administration protocol for such an event updated to mitigate against reoccurrence, but processes around end of life care were holistically examined and the practice produced a bereavement pack to ensure improved care and advice was offered to families who had suffered a bereavement.

• A recent audit around the diagnosis and coding of diabetes and pre-diabetes demonstrated that 95 new diabetes diagnoses had been made in the previous 12 months. In addition the practice increased the number of pre-diabetic patients identified from 83 in June 2015, to 325 in June 2016. When these pre-diabetic patients had clinical tests repeated following their identification, 66% of them showed a reduced risk of developing diabetes as a result of the lifestyle advice the practice had given to them.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 8 November 2016

The practice is rated as outstanding 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.

• The nursing team had dedicated administrative support from non-clinical staff who took responsibility for recalls for annual review appointments. If patients did not respond to letter invites, then the admin team would follow this up by contacting the patients by telephone.

• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. The practice operated separate patient lists for the GPs to ensure continuity of care, and promote ownership of the outcomes for the GPs. The practice actively monitored the percentage of medication reviews completed by each GP each month for their individual patient list.

• Longer appointments and home visits were available when needed. For patients with complex needs, reviews for their multiple health needs were combined into one single review appointment, which could be up to 40 minutes long in order to minimise their need to visit the practice.

• Annual reviews were offered in the patient’s month of birth to make the appointment date more memorable and maximise attendance.

• 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.

• The practice provided the community anti-coagulation service and hosted the community GP with Special interest arrhythmia / atrial fibrillation clinic where patient’s anticoagulation medication was monitored and dosage changed as required. This service was offered to patients registered throughout the Blackburn with Darwen CCG area.

• The practice had engaged in quality improvement work which demonstrated marked improvements in patient outcomes for those diagnosed with pre-diabetes.

Updated 8 November 2016

The practice is rated as outstanding 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, 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. The practice told us how they had updated the recall and appointment system for childhood immunisations and this had resulted in an even higher uptake more recently.

• 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’s uptake for the cervical screening programme was 81%, which was comparable to the CCG average of 80% and the national average of 82%. The practice had updated its appointment system for these clinics also following a demand and capacity audit. Appointments were planned around times of highest demand in order to maximise their uptake.

• 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, health visitors and school nurses.

• The practice hosted the Darwen locality Paediatric clinic on a weekly basis which was run by the East Lancashire Hospitals Trust advanced paediatric nurses and was available to its own patients as well as those from other practices in the locality.

Updated 8 November 2016

The practice is rated as outstanding 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.

• One of the nurse practitioners had dedicated time available each day to offer home visits.

• The practice maintained a palliative care register for patients approaching the end of life, and their needs were discussed regularly at the practice’s monthly multidisciplinary team meeting.

• Strong links with the local hospice were maintained and two of the GPs worked sessions at the hospice to support patients nearing the end of life and offer continuity of care. These patients were from other practices as well as their own.

• Patients over the age of 75 were offered annual health checks, with 75% attending these appointments over the previous year.

Updated 8 November 2016

The practice is rated as outstanding 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. New patients were able to part-complete their registration form online. Patients were also able to book appointments and order prescriptions over the internet.

• Extended hours appointments were offered on a Monday evening until 8pm for those patients who could not attend during normal working hours.

• Telephone consultations were also offered for those patients requiring medical advice but who could not attend the practice in person.

Updated 8 November 2016

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

• The percentage of patients diagnosed with dementia whose care had been reviewed in a face to face review in the preceding 12 months was 89% compared to the CCG average of 88% and national average of 84%.

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

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

• The practice had 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 practice worked closely with the local alcohol and drug misuse team, who provided a weekly clinic from the practice.

Updated 8 November 2016

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

• The practice held a register of patients living in vulnerable circumstances including asylum seekers, travellers and those with a learning disability.

• The practice offered longer appointments for patients with a learning disability, and offered them an annual review of their health needs. Following staff attendance at a training event the practice had updated its appointment protocol for this patient group in order to maximise attendance. This change had resulted in an increased attendance rate from 61% to 94%.

• 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.

• 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 practice held a register of patients with caring responsibility. There were two practice carers champions and they proactively offered all carers an annual review of their health needs with an 80% uptake of these appointments.