Archived: The Mandeville Practice

Updated 27 August 2015

The Mandeville Practice is a purpose built premises with car parking for patients and staff. There was easy access for patients/carers with a ramp and a lift. All patient services are on both the ground and first floor. The practice comprises of 13 consulting rooms, two treatment rooms, two patient waiting areas together with administrative and management office and meeting spaces.

The practice did not have a registered manager since January 2015 but there was an ongoing registration application for one to be added and it was processed in February 2015. The practice informed us they were in a recruitment crisis due to old GPs retiring and facing difficulties in recruiting new GPs. The practice was in discussion with NHS England over a possible list closure to new patients, preventing increased demand while they tried to deal with their staffing problems. There are five GP partners at the practice and three salaried GPs. Three GPs are male and five female. The practice employs five practice nurses, two health care assistants and a part time pharmacist. The practice manager is supported by operations and patients liaision manager, reception manger and a team of administrative and reception staff. Services are provided via a General Medical Services (GMS) contract (GMS contracts are negotiated nationally between GP representatives and the NHS).

The practice has a patient population of approximately 16,860. The practice population of patients aged between 25 and 39 is slightly higher than average and there are less than average aged above 55. The population of patients aged between 0 and 4 years is higher than the local average.

The local community has high areas of deprivation and the staff were aware of the needs of this section of the population. The appointment system allowed advanced appointments to be booked either four weeks or 48 hours in advance. Urgent appointment slots were also available.

Services are provided from:

The Mandeville Practice

Hannon Road

Aylesbury

Buckinghamshire

HP21 8TR

The practice has opted out of providing out of hours services to their patients. There are arrangements in place for services to be provided when the surgery is closed and these are displayed at the practice, in the practice information leaflet and on the patient website. Out of hours services are provided during protected learning time by Bucks Urgent Care or after 6:30pm, weekends and bank holidays by calling NHS 111.

We carried out an announced comprehensive inspection of the practice on 2 July 2015. We visited The Mandeville Practice during this inspection. This was the first inspection of the practice since registration with the CQC.

Updated 27 August 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Mandeville Practice, Hannon Road, Aylesbury, Buckinghamshire, HP21 8TR on 02 July 2015. Overall the practice is rated as requires improvement.

Specifically, we found the practice to require improvement for providing effective and well led services. It was good for providing safe, responsive and caring service. The concerns which led to these ratings apply to all population groups using the practice.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
• Risks to patients were assessed and well managed, with the exception of those relating to read coding issues and patients medicine reviews with long term conditions.
• Data showed patients outcomes were low for learning disabilities health checks and long term conditions medicine reviews. 
• Some audits have been carried out but the practice was struggling to carry out repeat audits which was making it difficult to identify improvement areas and monitor continuous progress effectively.
• The practice did not have registered manager in place.
• The practice has made a request to NHS England for a possible list closure of registering new patients. The practice informed us that they were facing recruitment crisis since April 2014 due to sickness, old partners retiring and were struggling to recruit new GPs.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Information about services and how to complain was available and easy to understand.
• Urgent appointments were usually available on the day they were requested. However patients said that they sometimes had to wait a long time for non-urgent appointments with a named GP.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice proactively sought feedback from staff and patients, which it acted on.

The areas where the provider must make improvements are:

• Ensure there are formal governance arrangements in place including systems for assessing and monitoring all risks and the quality of the service provision.
• Resolve the read coding issue to ensure improvements to clinical practice can be identified and actions implemented.
• Implement and improve a system of clinical audit cycles to ensure effective monitoring and assessment of the quality of the service.
• Ensure regular medicine reviews are undertaken for patients with long term conditions.
• Ensure the comprehensive written business plan and strategy are reviewed regularly to adjust succession planning and recruiting new GPs, in order to address capacity and consistency concerns.

In addition the provider should:

• Improve the availability of non-urgent appointments with a named GP.
• Ensure personalised care plans for patients with learning disabilities are developed, which should be readily available when required and accessible by external relevant organisations
• Continue to closely monitor the staffing levels and take appropriate action to minimise the impact of patient care and treatment.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 27 August 2015

The practice is rated as requires improvement for the care of people with long-term conditions. The provider was rated as requires improvement for effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group. There were clinical leads for chronic disease management and patients at risk of hospital admission were identified as a priority. Longer appointments and home visits were available when needed. For example, practice nurses had visited patients at their homes with long term renal issues which prevented them from visiting surgery and carried out ECG (ECG is an electrocardiogram test that checks for problems with the electrical activity of your heart) and immunisations. However, not all these patients had a named GP and data showed patients outcomes were low for long term conditions medicine reviews. Due to a fault with the coding system, lack of repeated audits and capacity issues it was difficult to identify and monitor patients health and care needs effectively.

Updated 27 August 2015

The practice is rated as requires improvement for the care of families, children and young people. The provider was rated as requires improvement for effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group. 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. 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. Staff were aware of the legal requirements of gaining consent for treatment for those under 16. Chlamydia testing kits were available in accessible location for under 25s. Appointments were available outside of school hours and the premises were accessible for prams and buggies. However, the next day routine appointments were not offered and patients had been asked to wait up to four weeks if they wanted to see their named GP. Antenatal appointments and postnatal clinics were available. The practice worked with health visitors to share information and provide a continuity of care for new babies and families. The uptake of childhood immunisations was high and close to or above the national average for different vaccines. Flu vaccination uptake was 40% for pregnant women.

Updated 27 August 2015

The practice is rated as requires improvement for the care of older people. The provider was rated as requires improvement for effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group. The practice offered proactive, personalised care to meet the needs of the older people in its population. For example, the practice was working collaboratively with two other local surgeries. Two practice nurses were appointed over three surgeries who visits patients in their own homes to manage the holistic needs of this patient group. Patients over 75 had a named GP to promote continuity of care. Flu vaccinations rates for over 65 were below the national average. The premises were accessible to those with limited mobility but doors were not automatic and waiting area was congested. However, the practice had applied for a grant to improve the premises but this was not approved by NHS England. It was responsive to the needs of older people and offered rapid access appointments for those with enhanced needs. The practice had a white TLC (tender loving care) board in the admin office for patients on end of life register to ensure priority appointments. There was a register to manage end of life care and unplanned admissions. There were good working relationships with external services such as district nurses. However, the practice did not have adequate system in place to monitor and improve quality and identify risk.

Updated 27 August 2015

The practice is rated as requires improvement for the care of working-age people (including those recently retired and students). The provider was rated as requires improvement for effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group. 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 appointments were available on three evenings during weekdays until 7:30pm but there were no early opening hours for working age people. The practice had offered early morning appointments to patients previously but the demand for appointments was not seen and many of the patients who booked appointments at this time failed to turn up. A decision was made to offer appointments in the evening only. Extended appointments were not offered over the weekend. The practice was proactive in offering online services. Health promotion advice was offered but there was a low uptake for both health checks and health screening which were not reflecting the needs for this age group. For example, only 10% patients attended NHS health checks aged 40 to 75 years old. Extra flu clinics were offered on some Saturdays during flu season.

Updated 27 August 2015

The practice is rated as requires improvement for the care of people experiencing poor mental health (including people with dementia). The provider was rated as requires improvement for effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group. Eighty two per cent of people experiencing poor mental health had received care plan in last 12 months. The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia.

The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. It had a system in place to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health. Staff had received training on how to care for people with mental health needs and dementia. However, mental capacity act training had not been completed but it was scheduled to be held after few months.

Updated 27 August 2015

The practice is rated as requires improvement for the care of people whose circumstances may make them vulnerable. The provider was rated as requires improvement for effective and well led. The concerns which led to these ratings apply to everyone using the practice, including this population group. The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability. It had not carried out the enhanced service to provide annual health checks for people with a learning disabilities, for example, there was evidence that health checks were only completed for seven patients out of 49 patients on the learning disability register. It offered longer appointments for people with a learning disability. Disabled patients were considered in the design and layout of the building; including accessibility to reception, waiting areas and treatment rooms.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. It had told vulnerable patients about how to access various support groups and voluntary organisations. Most staff knew how to recognise signs of abuse in vulnerable adults and children. Most 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. A translation service was available for patients who did not speak English. Flu vaccination uptake was 41% for carers.