Archived: Dr Su Su Thwe Also known as The Surgery

Updated 27 April 2017

The practice is located on Ballard's Lane, West Finchley, close to West Finchley underground station and is in a converted two storey house. The building is owned and partly maintained by a private landlord. The practice provides NHS primary medical services to approximately 1600 patients through a General Medical Services (GMS) contract (a GMS contract is the contract between general practices and NHS England for delivering primary care services to local communities) with the local Clinical Commissioning Group (CCG).

The practice provides a range of enhanced services including, child and travel vaccines. It is registered with the Care Quality Commission to carry on the regulated activities of maternity and midwifery services, family planning services, treatment of disease, disorder or injury and diagnostic and screening procedures.

There is one GP (female) who does nine sessions per week and the practice nurse (female) works two sessions per week. The practice manager works 24 hours per week and there are a variety of administration and reception staff working 50 Hours per week.

The premises do not have step free access or an accessible toilet but do have baby changing facilities.

The practice is open from;

• Monday: 8:30am – 6:30pm
• Tuesday: 8:30am – 6:30pm
• Wednesday: 8:30am – 1:00pm
• Thursday: 8:30am – 6:30pm
• Friday: 8:30am – 6:30pm

Appointments were from;

• Monday: 9:00am – 11:00pm and 4:00pm to 6:00pm
• Tuesday: 9:00am – 12:00pm and 4:00pm to 6:00pm
• Wednesday: 9:00am – 11:00am
• Thursday: 9:00am – 12:00pm and 4:00pm to 6:00pm
• Friday: 9:00am – 11:00pm and 4:00pm to 6:00pm

Extended hours appointments were 07:30am to 08:00am with the nurse on a Wednesday and 6:30pm and 7:00pm on a Thursday with the GP. The practice also provides telephone consultations and home visits which are carried out between morning and evening surgery. Out of hour’s including weekends are covered by the local out of hour’s service provider and the 111 service.

The practice working age population is 64% aged between 25 to 64. The practice population is 64 % white British with Indian being the next largest group at 11%. The average male and female life expectancy for the practice is 81 years for males (compared to 81 years within the CCG and 79 years nationally), and 84 (compared to 84 years within the CCG and 83 years nationally) years for females. Information published by Public Health England rates the level of deprivation within the practice population group as seven on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

Updated 27 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Su Su Thwe on 19 January 2017. Overall the practice is rated as requires improvement.

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. However, reviews, investigations and learning's were not thorough enough.
• Although risks to patients who used services were assessed, the systems and processes to address these risks were not in all instances implemented well enough to ensure patients were kept safe, specifically in relation to fire risk assessments, fire drills and training for staff, no health and safety and legionella risk assessments, gas certificate and fixed wire testing.
• Data showed patient outcomes were low compared to the national average. Although some audits had been carried out, we saw no evidence that audits were driving improvements to patient outcomes.
• Patients said they were treated with compassion, dignity and respect, and they were involved in their care and decisions about their treatment.
• Patients commented that the premises needed updating and there was poor disabled access.

• Information about services and how to complain was available and easy to understand.

• 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.

• Staff did not always feel supported by management. The practice 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.

• The practice had a number of policies and procedures to govern activity, but not all were being followed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 27 April 2017

The provider was rated as requires improvement for safe, caring and well-led. The issues identified as requiring improvement overall affected all patients including this population group.

• Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

• The percentage of patients with diabetes, on the register, in whom the last IFCCHbA1c

  is 64 mmol/mol or less in the preceding 12 months was 77% which was comparable to the national average of 78%.

• 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 27 April 2017

The provider was rated as requires improvement for safe, caring and well-led. The issues identified as requiring improvement overall affected all patients 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.

• The practice’s uptake for the cervical screening programme was 83%, which was comparable to the national average of 81%.

• 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.

Updated 27 April 2017

The provider was rated as requires improvement for safe, caring and well-led. The issues identified as requiring improvement overall affected all patients including this population group.

• 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.

• Nationally reported data showed that outcomes for patients for conditions commonly found in older people were above average.

• The percentage of patients diagnosed with dementia whose care plan has been reviewed in a face-to-face review in the preceding 12 months was 100% which was higher than the national average of 84% (this was for eight patients’).

Updated 27 April 2017

The provider was rated as requires improvement for safe, caring and well-led. The issues identified as requiring improvement overall affected all patients 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.

• 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.

• Online appointment booking and prescription requests were available.

• Telephone consultations with clinicians were available to meet the needs of this population group.

• Patients aged 40–74 had access to appropriate health assessments and checks that were followed up where abnormalities or risk factors were identified.

• The practice offered extended hours surgery twice a week.

Updated 27 April 2017

The provider was rated as requires improvement for safe, caring and well-led. The issues identified as requiring improvement overall affected all patients including this population group.

• The percentage of patients with Schizophrenia, bipolar disorder and other psychoses whose alcohol consumption had been recorded in the last 12 months was 86% which was comparable to the national average of 89%.

• 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.

Updated 27 April 2017

The provider was rated as requires improvement for safe, caring and well-led. The issues identified as requiring improvement overall affected all patients including this population group.   

• 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 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.