Avenue House and Hasland Partnership Also known as Avenue House Surgery and St Philips Drive Surgery

Updated 15 June 2016

Avenue House & Hasland Partnership provides care to approximately 14,244 patients from two locations within the Chesterfield area of North East Derbyshire:

• Avenue House Surgery.109, Saltergate. Chesterfield. Derbyshire. S40 1LE 
• Hasland Surgery.82, St Philips Drive. Hasland, Derbyshire. S41 0RG

These two surgeries merged as one practice in April 2014. Hasland Surgery was inspected by the CQC under our previous inspection regime in June 2013, and found to be compliant with the standards assessed. Our inspection on 22 April was based at the Avenue House site.

The surgery provides primary care medical services via a Personal Medical Services (PMS) contract commissioned by NHS England, and services commissioned by North Derbyshire Clinical Commissioning Group (CCG). Avenue House operates from modernised former residential premises which are maintained to a high standard. Hasland Surgery is a purpose built property which was extended in 2009.

The practice is run by a partnership of six GPs (three males and three females). The partners employ three salaried GPs (two males and one female). This equates to just over eight full time GPs working within the practice at the time of the inspection. The practice was using winter pressure funding provided by the CCG for an additional part-time salaried GP to increase capacity to see patients during the winter periods, and were considering if this would be made permanent.

The partnership is an established training and teaching practice and accommodates GP registrars (a qualified doctor who is completing training to become a GP); and medical students.

The practice employs two nurse practitioners and four practice nurses. The nursing team is complemented by four health care assistants and two phlebotomists The clinical team is supported by a practice manager, an assistant practice manager, and a team of 22 administrative and reception staff.

The registered practice population are predominantly of white British background. The practice is ranked highly within the CCG in terms of the deprivation status of their registered patients, although this figure is in line with national averages. The practice age profile has higher numbers of patients aged over 45 compared against the national average, and is showing an upward trend in terms of the percentage of registered older patients (65 years plus). The practice has higher numbers of patients with a learning disability, and a higher than average prevalence of mental health issues.

The practice opens from 8am until 6.30pm Monday to Friday. Scheduled GP morning appointments times are available from 8.30am to 11.00am approximately, and afternoon surgeries run from 3.30pm to 5.30pm, apart from one Wednesday afternoon each month when the practice closes for staff training. Extended hours GP appointments are available at Avenue House every Monday evening from 6.30pm to 8.30pm, and extended hours early morning appointments are available on three days each week between 7am and 8am. Hasland Surgery offers extended hours appointments every Monday evening between 6.30pm and 7.30pm.

The practice has opted out of providing out-of-hours services to its own patients. When the practice is closed patients are directed to Derbyshire Health United (DHU) via the 111 service.  

Updated 15 June 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Avenue House & Hasland Partnership on 22 April 2016. 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 an effective system in place for reporting and recording significant events. Learning was applied from events to enhance the delivery of safe care to patients.
• Risks to patients were assessed and well managed in conjunction with the wider multi-disciplinary team.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
• The practice team had the skills, knowledge and experience to deliver high quality care and effective treatment, and were supported to develop their roles via a robust appraisal process. A number of clinical staff had undertaken additional training to enhance their skills and had developed areas of special interest to support them in taking lead roles within the practice.
• Feedback from patients was consistently positive about the care they had received. Patients said they were treated with compassion, dignity and respect and they were actively involved in 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 told us they were able to access care and treatment when they needed to, and had a positive experience when making an appointment. Access to a preferred GP was significantly above local and national averages, and the practice always tried to offer continuity by the same GP consulting with the patient for routine, urgent and telephone appointments or home visits.
• The practice had good facilities and was well-equipped to treat patients and meet their needs. The premises were clean and tidy and the grounds were well maintained.
• There was a clear leadership structure and staff told us that they felt supported by management. The leadership and governance arrangements were robust and focused upon continuous improvement.
• The practice analysed and responded to feedback received from patients. Comments were used to adapt services where possible to best meet patients’ needs.
• There was an active patient participation group which influenced practice developments. For example, a clinician notice board had been prominently displayed at the reception desk to inform patients which GPs were on duty each day.
• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers and their Clinical Commissioning Group (CCG). For example, the practice was dedicated to supporting pilot projects within primary care and was supported by the CCG to trial new developments. For example, one GP had initiated a local project to help reduce the waste of prescribed medicines.
• The practice provided personalised care to those patients at end-of-life. Practice data showed that 92% of patients had died within their preferred place as a consequence of the planning and support offered by the practice working in conjunction with the wider health and social care teams.
• The practice mission statement of ‘helping the person by knowing the person’ was reflected in the continuity of care provided with the same GP. This included the named GP doing their own home visits wherever possible; urgent on the day appointments being allocated to the named GP wherever possible; and telephone consultations being undertaken by the named GP. National patient survey data indicated patients rated the practice highly on continuity of care.

The areas where the provider should make improvement are:

• The practice should ensure that all actions in respect of infection control audits are documented.
• Ensure that actions from significant event reviews are documented upon completion.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 15 June 2016

• QOF achievements for clinical indicators were higher than CCG and national averages. For example, the practice achieved 100% for diabetes related indicators, which was above the local and national averages of 96.7% and 89.2% respectively. Exception reporting rates relating to some individual indicators for diabetes were higher than average, although we saw these were appropriate and the practice were taking measures to engage patients to attend the practice for a review.
• The practice undertook annual reviews for patients on their long-term conditions registers. This occurred in the patient’s birthday month and included a review of the patient’s prescribed medicines to check if any changes were required.
• GPs held lead roles in managing long-term conditions, including a GP who specialised in heart problems. This GP also provided input at a local angina clinic which was attended by patients from across the locality.
• There were nurse-led clinics available including support for patients with diabetes, asthma and chronic obstructive airways disease.
• The practice worked closely with specialist nurses including the heart failure and diabetes specialist nurses.
• The practice provided INR monitoring at the practice and within patient’s homes. INR testing measures the length of time taken for the blood to clot to ensure that patients taking particular medicines were kept safe.
• The practice was working with their CCG to enhance care for housebound patients with a long-term condition. This involved working to a new specification, retraining and re-allocation of finances with an overall aim to improve care for this group of patients.

Updated 15 June 2016

• Meetings were held every six weeks between the GPs, practice nurses, and health visitors and midwives to discuss any vulnerable children. We spoke with the health visitor who informed us that the practice responded promptly to any issues raised, and were always responsive to younger people’s needs.
• Urgent appointments were available each day for unwell children, and telephone advice was offered to parents. Appointments were provided outside of standard school hours.
• The practice provided a joint new baby development and vaccination clinic. Nurses worked in pairs to minimise the potential stress for the baby and the parents. The nurses had produced an information leaflet for parents to advise them about the best way to hold their child during the procedure. This had been developed in response to a complaint that parents had felt that staff had not assisted them to support and hold their infant during the vaccination procedure.
• Immunisation rates for all standard childhood immunisations were comparable to local averages. For example, vaccination rates for children aged five and under ranged from 92.2% to 98.3%, compared against a CCG average ranging from 95.2% to 99.1%.
• The practice had a prominently placed display targeted at 14-19 year olds to encourage them to attend for an appointment with any health related concerns. This welcomed consultations either with parents or individually.
• The practice provided baby changing facilities, and there was a small play area for younger children. The practice welcomed mothers who wished to breastfeed on site, and provided a private room for them when possible.
• Chlamydia testing kits were readily available to encourage uptake from younger people. 

Updated 15 June 2016

• The practice had higher numbers of older people registered with them compared to the national average (for example 21.1% of patients were over 65, compared against a national average of 17.1%), although this was in line with the local average. Data indicated that there was an increase in registered older patients, particularly those aged 85 and above, and the practice ensured that their services were tailored to meet their needs.
• Each patient was allocated a named and accountable GP responsible for the co-ordination of their care.
• The practice held monthly multi-disciplinary meetings to discuss the most vulnerable patients and those at risk of hospital admission. This facilitated planning and the co-ordination of care to best meet their patients’ needs.
• The practice used bespoke care plans to provide clear information on individual needs, including patient preferences. This information was shared with out of hours’ services and other agencies to provide co-ordinated care for patients, and helped to reduce the number of unnecessary hospital admissions.
• Longer appointment times were available and home visits were available for those unable to attend surgery.
• The practice provided care to patients across five local residential and nursing homes for older people. The GP or nurse practitioner provided visits to these homes. We spoke to a representative of one of these homes who told us that the nurse practitioner visited every two weeks and undertook a ward round, and that the practice responded to any urgent patient needs on the same day. They described the relationship with the practice as extremely positive.
• 74% of patients aged over 75 had received an annual health check in the last 12 months.
• Flu vaccination rates for people aged 65 and over at 79.4% were slightly higher than the CCG average of 75.9%, and above the national average of 72.8%.

Updated 15 June 2016

• The practice offered on-line booking for appointments and requests for repeat prescriptions. The practice provided electronic prescribing so that patients on repeat medicines could collect them directly from their preferred pharmacy. The practice had encouraged 25% of their patients to register on-line which was higher than other local practices.
• The practice provided telephone access each morning to the patient’s preferred GP, and urgent telephone advice was available in the afternoon.
• Extended hours’ GP consultations were available at both locations. Both sites offered evening appointments once a week, and one site provided early morning appointment on three days each week.
• The practice offered health checks for new patients and NHS health checks for patients aged 40-74.
• The practice promoted health screening programmes to keep patients safe. For example, 64% of patients aged 60-69 had been screened for bowel cancer against a national average of 55.4%. This had been achieved by the practice promoting this by a targeted letter being sent to patients.
• Health Trainer sessions were held on site each week for advice regarding diet, smoking, alcohol and exercise.

Updated 15 June 2016

• The practice achieved 100% for mental health related indicators in QOF, which was 1.9% above the CCG and 7.2% above the national averages, with exception reporting rates generally in line with averages.
• 95.5% of patients with a diagnosed mental health problem had a care plan documented in the preceding 12 month period which was marginally above the CCG average of 93.3%, and above the national average of 88.3%. However, exception reporting at 21% was 3.6% higher than the CCG, and 8.4% higher than the national averages.
• 73.8% of people diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months. This was approximately 10% lower than local and national averages, although the exception reporting rate was marginally lower.
• 50% of patients on the practice’s mental health register had received an annual health check during 2014-15, and 62% of patients had a care plan in place.
• The practice had completed ‘Dementia Friends’ training for staff to improve their awareness of dementia and the support available to patients and their carers, and planned to qualify as a ‘dementia-friendly practice’. There was also a designated ‘Dementia Champion’ in the practice team, and a member of the PPG was a dementia advocate who trained staff in other practices.
• The practice had audited missed appointments for patients with dementia . Whilst the rate was low at 1.2%, the practice had agreed to develop a dementia-friendly letter for these patients with information on appropriate support groups and services
• A community psychiatrist nurse worked with the practice, and attended monthly multi-disciplinary meetings, to support patients experiencing poor mental health.
• The practice had a nominated carers champion and had developed links with the local Carers Association.   

Updated 15 June 2016

• The practice had undertaken an annual health review for 57% of patients with a learning disability in the last 12 months. All 52 patients that received a review had a care plan in place.
• The practice provided care to two local care homes for patients with a learning disability. One home cared for residents aged 19-36, mostly with autism and challenging behaviour, whilst the other cared for patients above 40. We spoke to a manager at the home for the younger people who spoke of a highly responsive service with two-weekly visits provided by the nurse practitioner, and gave examples where patients had achieved good outcomes.
• The practice worked in line with recognised standards of high quality end of life care Palliative care meetings were held every six weeks between the practice clinicians and district nurses and the Macmillan nurse. An analysis of patient deaths was undertaken for patients with cancer to ensure any learning points were considered, and ensure that best practice was shared with the whole team. Practice data showed that 92% of patients had died within their preferred place as a consequence of the planning and support offered by the practice working in conjunction with the wider health and social care teams.
• The practice adopted a co-ordinated approach to care by the use of locally developed care plans, which ensured key information was shared with other providers such as the out of hours service. The practice had been instrumental in the development of these care plans which were used extensively by other local practices.
• The practice supported the local homeless centre as the first point of call for their patients to register.
• The practice provided a joint substance misuse service with a support worker from a local provider.
• The practice had undertaken a best interest assessment on their patients with pronounced learning disabilities to consider if they should receive a cervical smear test.
• The practice was a recognised ‘safe haven’ for vulnerable people including those with a learning disability. This Derbyshire partnership scheme aimed to protect people from potential bullying or abuse. It helped them feel safe and confident when out in the community by having access to a place where they could be supported if required.