Care Quality Commission

Care Quality Commission

The Care Quality Commission is the independent regulator of health and adult social care in England. It will inspect all GP surgeries by April 2016 and ask:

Are they safe?
Are they effective?
Are they caring ?
Are they responsive to people’s needs?
Are they well led?

The CQC will focus on 6 population groups

Older people
People with long term conditions
Families, children and young people
Working age people (including those recently retired and students)
People whose circumstances make them vulnerable
People experiencing poor mental health (including people with dementia)

Brookroyd Surgery has not yet been inspected, but we are confident of our strong values and performance and look forward to meeting the inspectors.

About our Practice

The Practice was established by Dr J Prior in 1900.In a house originally built for the Minister of Westgate Methodist Chapel.

In 2010 the Practice moved into a new building, Heckmondwike Health Centre. This Health Centre is occupied by two surgeries, Brookroyd Surgery and Undercliffe Surgery and Rowlands Pharmacy.

We are 5 GP Partners with a Practice in Heckmondwike Health Centre.

Our practice area covers all of Heckmondwike. Part of Liversedge, Cleckheaton, Mirfield, Batley and Dewsbury Moor.

We have just under 10,000 Patients on our list.

We believe that we meet and exceed all of the fundamental standards.

We ensure that we provide our patients with safe, effective, compassionate, high-quality care and we encourage improvement.

Our Vision

Is to provide a high quality of care to our patients at all times. Whilst delivering the very best of healthcare and to combine this with good conditions for all who work at the practice.

Our Values

Holistic Care, Openness & Honesty, Decency, Integrity, Professionalism, Respect.

A Safe Practice

The Practice offers a holistic approach to patient care.

We are a diverse skill mix practice with 5 GP’s, 1 Advanced Nurse Practitioner, 1 Minor Ailment Nurse, 4 practice Nurses, 2 Health Care Assistants and 1 Phlebotomist. Our Team are fully integrated.

All staff are appropriately qualified with the right skills and experience.

The practice staff support each other and work well together.

All staff are aware of their responsibilities

The clinical team offer excellent peer support and clinical supervision.

We have well developed, clear and up to date guidance and procedure for all staff to access.

The practice has a GP Safe Guarding Lead and holds regular safeguarding meetings with key staff. All clinical and administrative staff have the appropriate level of safeguarding training appropriate to their role.

The practice has a Significant Event Analysis programme where adverse events, near misses and adverse outcomes are shared with the practice team in a dedicated significant event review meeting. All staff know how to report incidents.

The meeting allows the practice team to discuss the case, learn any lessons and if necessary change procedures or implement remedial activity. Learning is documented and shared with relevant teams. All deaths are discussed as individual case reviews and learning is shared appropriately.

The practice carries out its own Infection Control audits. There is a named infection control Nurse. We ensure that our cleanliness and procedures are of high quality.

Safe systems are in place for prescribing medicines, and ordering and collecting repeat prescriptions.

We have an excellent appointment system allowing designated pre-bookable up to 3 months in advance, along with on-line access and telephone request on the day. We have an open door policy for children that require an appointment at any time, within practice working hours.

Effective

The Practice holds weekly meetings. Clinical and operational items are included on the agendas. All staff have the opportunity to add items to the open agendas. The Clinical Team and the Practice Manger attend monthly regional teaching events.

There is also a monthly general staff meeting. All clinical and non-clinical are able to attend. The agenda is dedicated to discussing change, development, issues/problems arising. Non clinical staff are encouraged to add items for discussion and encouraged to be open and honest.

All our staff have an annual internal appraisal. This is an opportunity for them to be supported by Practice in terms of emotional wellbeing and also to support any learning needs. The GP’s are also annually appraised externally.

We hold monthly MDT (Multi-Disciplinary Team) Meetings. Present are our District Nurses, Community Matron, Palliative care Nurses ,Health Visitor, Clinical Care Coordinator members of our own clinical team and the Practice Manager.

We work closely with Medicines Management. A designated pharmacy technician works in practice one day a week.

We are members of the Cleckheaton & Heckmondwike Cluster. Supporting local commissioning.

All patients registered with the practice, irrespective of population groups, are offered advice and support/signposting with regard to smoking cessation, alcohol consumption, diet and lifestyle advice to help them achieve optimum health and well-being.

We have a robust recall system for long term condition patients that are managed by designated Practice Nurses, to ensure that an efficient system of recall with clinical knowledge is in place.

Each patient has a holistic review of their chronic conditions, taking into account each person’s individual need for their physical, psychological, social, religious and emotional needs. This includes review of their medication.

The housebound are offered reviews with District Nursing staff annually.

Newly registered families are invited for a general health check and for children over the age of 5yrs. They are encouraged to attend as a family and made aware of the GP services available.

We run vaccination programmes for FLU, Travel, Shingles and Pneumococcal.

We offer cervical screening.

We also follow national and local guidance for opportunistically screening patients for dementia, alcohol intake, smoking and high blood pressure.

We have an excellent appointment system allowing designated pre-bookable up to 3 months in advance, along with on-line access and telephone request on the day.

Repeat prescriptions can also be requested on line. The Practice is live on EPS (Electronic Prescription Services) EPS is an NHS funded Service in England. Patients can nominate a Pharmacy of their choice and have their repeat prescriptions sent to a Pharmacy near where they live, work or shop.

We adhere to local guidelines for the prescribing of medicines and referral pathways into hospital.

Our practice is performing well compared to other local practices with no level 2 triggers indicated on the Primary Care web tool. We are an achieving Practice.

Caring

As a practice we ensure that we are sensitive to patient needs. Privacy and dignity is always respected. Our staff respond compassionately to patients concerns, their physical pain or emotional distress.

We offer chaperones for intimate examinations.

We have a hearing loop in reception, a lift, disabled toilets and high seat chairs in the waiting area.

We can arrange interpreting services for non-English speaking patients.

We can arrange sign language interpreting services for our deaf patients.

We offer longer appointments to Learning Disability Patients for their annual health checks.

We have a register of carers and can offer referral to a local service called carers count where they can access the necessary support and advice.

We are a registered Safe Place. Vulnerable patients can come into surgery for our help. All reception staff are trained on how to help the patients appropriately and have access to the relevant contact information for the local support agencies.

We are also a Dementia Friendly Practice.

Responsive to Patient Needs

We have a well-established Patient Group. We meet quarterly in Surgery. We encourage new members.

The practice have developed an action plan based on the practice survey results and suggestions made via friends and family and the patient group.

We also have virtual group members who we contact via email or post depending on their requirements.

Our patients also have access to the following services on site. Supporting care closer to Home. Midwife and Antenatal Care, Child Health including immunisations, Ultrasound, Audiology, Nephrology IAPT (Improving Access to Psychological Therapies)

Rowlands Pharmacy is on site.

We are looking to increase use of our online services. We are encouraging our patients to register so they can book their appointments online and leaving the phone line free for our patients that don’t have internet access. Patients are also encouraged to order their repeat prescriptions.

Patients can register for online access to their medical records. This is for detailed coded access only.

We regularly review complaints and compliments. Complaints are shared openly within the practice. Regular feedback is given in practice to try and optimise the standard of care we provide. We try and learn from our mistakes and always look to improve.

The Practice engages in local schemes to improve patient access. Most recently the Winter Capacity Scheme. Offering weekend appointments.(This service is no longer available in this area)

The Practice experienced difficulty in recruitment in 2015 we were unable to recruit a GP so we responded by employing a Minor Ailments/Injury Nurse.

Focusing on the Six Population Groups

All patients registered with the practice, irrespective of population groups, are offered advice and support/signposting with regard to smoking cessation, alcohol consumption, diet and lifestyle advice to help them achieve optimum health and well-being.

Older Patients

Older People- 65 and over are all actively called

  • Annual flu
  • Single pneumonia
  • Shingles vaccination appropriate cohort.

We have developed an internal patient status alerts using a coloured dot system, this alerts all staff when vaccinations are due. These are linked to purpose built reports. An internal prompt for all staff to offer vaccination appointment when any contact is made the surgery staff.

Nurses  able to refer/signpost to other services including Podiatry, Health Trainers, PALS, Gateway to Care, Clinical Co-Ordinator

NHS Health checks routinely offered up to age of 74 years.

Concerns can be raised easily with District Nurse services either by direct e-referral, discussion or monthly MDT meetings.

Disabled Access;

  • Lifts
  • Toilets
  • Hearing Loop
  • High Seat Chairs in waiting area
  • Sign Language Interpreter

Long Term Condition Patients

We have a robust recall system for long term condition patients that are managed by designated Practice Nurses, to ensure that an efficient system of recall with clinical knowledge is in place.

Each patient has a holistic review of their chronic conditions, taking into account each person’s individual need for their physical, psychological, social, religious and emotional needs. This includes review of their medication.

The housebound are offered reviews with District Nursing staff annually.

Pre-assessment system in place for diabetes. This includes;

  • Phlebotomy
  • Foot check,
  • BMI
  • BP check 2 weeks prior to a review apt

A care plan sent to the home address in advance of the review, giving time to prepare questions, concerns they may have for their review.

Patients under specialist care for diabetes still have a recall for an annual foot check in practice.

COPD reviews proceeded with a spirometry test annually and the facility to undertake diagnostic spirometry is available for asthma and COPD.

Audit work ongoing on monthly basis for any patient prescribed a Short Acting Beta Agonist without a confirmed respiratory disease diagnosis. Invited for further assessment and review with diagnosis coding if appropriate the GP involved in this stage.

Hypertension and vascular disease reviews have a minimum of annual phlebotomy prior to review.

Phlebotomy protocol in place lists all bloods required for all Long-term conditions

Families and young patients

Newly registered families are invited for a general health check and for children over the age of 5yrs. They are encouraged to attend as a family and made aware of the GP services available. They are encouraged to attend as a family and made aware of the GP services aailable.

Contraception services are available for oral medication and signposting to sexual health if requiring alternative methods.

Antenatal and childhood immunisation clinics held weekly.

Cervical screening offered in Practice . In line with Local and National guidance.

We have an open door policy for children that require an appointment at any time, within practice working hours.

Working Age Patients

One the day and pre bookable appointments for GP’s, Nurse Practitioner and Minor ailments/minor injury Nurse

Late night Surgery on Monday’s or offered Tuesday following a bank holiday Monday.

Text messaging booking confirmation and reminder service

Online booking for pre bookable and one the day

Online prescription ordering

Online detailed coded access

Travel Vaccination Advice and vaccination

Student vaccination and advice

Vulnerable Patients:

Learning Disability patients offered annual health check in extended time appointment. They are encouraged to bring a support worker, friend or relative as appropriate.   Concerns resulting from review, are followed up with GP and Learning Disability Team. Gateway to Care involved as appropriate. Patient reviews arranged more regularly as necessary.

Safeguarding node in the clinical tree for all patients as it is recognised that any person may become vulnerable at any time.

Dr Kandimalla Safe Guarding lead. He holds regular meetings with Health Visitor, and Midwife with feedback to the clinical team.

All staff have trained to appropriate level for Safeguarding. Respiratory patients that attend A/E invited routinely to attend follow up apt with Practice Nurse.

Any parent/ guardian who fails to bring a child to Asthma reviews after a third invite, are contacted by telephone to make an appointment to bring the child and advised of the importance of attending for monitoring and review.  Failure to attend following this phone call leads to a safeguarding statement on the clinical node and a letter from the GP stating safeguarding concerns.

Patients with Poor Mental Health and Dementia:

Opportunistic screening using 6CIT memory tool to help with early diagnosis of dementia.

We are a Dementia Friendly Practice . Offering 3 tier system for reviews, this includes pre assessment for general lifestyle, BMI , BP check with Health Care Assistant.

This is followed by Practice Nurse review the same day, concentrating on social circumstances, behaviour, driving information and general health risks. This time  is also used to focus on patient and carer goals with an offer to arrange a further health check for the carer if registered at this practice, and advised to attend own practice to request this review as appropriate .

A further appointment is made with the GP to then discuss medication and compliance along with discussion around Advanced Care Planning. Housebound patients are visited by GP for full assessment.

Patients prescribed Lithium reviewed 3 monthly with blood test, BP, BMI and given a record book with blood results to take to secondary care appointment.

Patients with depression and anxiety are assessed by the clinician then either seen and treated by clinicians or depending on the severity they are advised to self-refer to IAPT service or referred to Community mental health team for further assessment and follow up.  They are also given SPA for mental health number which they can contact in case of crisis.

We are a registered Safe Place. A service for vulnerable patients living in our area.

Well led

The Practice is led by the 5 partners and the Practice Manager.

We maintain staffing levels in line with demand and list size.

We have a multi-skilled non clinical team to support the clinical team. Internal working procedures are regularly reviewed.

Well established MDT team. This includes District Nursing, Palliative Care, Community Matron.  Health Visitor and Care Coordinator. The Care Coordinator is working with our patients that are high risk of an unplanned admission offering a holistic approach to their health and social care needs.

The clinical team offer excellent peer support and clinical supervision. They meet regularly and review and monitor patient services.

We have well developed, clear and up to date guidance and internal working procedures for all staff to access.

The Partners and the Practice Manager meet weekly to discuss current issues and formally review progress on short and long term targets.

The Practice supports all their staff in their development and training. All staff are suitability trained in line with their responsibilities. Nurses attend regular updates as required including cytology & immunisation.

All staff including non-clinical staff have regular training sessions provided for IT ,Fire Safety, Confidentiality, Consent, Conflict resolution, Information Governance, Safeguarding and Basic Life Skills.

The Practice recognises the importance of staff wellbeing.

We have a Buildings Maintenance Manager responsible for all service, maintenance and repair including all annual safety checks and inspections.

A business Continuity Plan is in place to assist with any emergency/major incident.

The Practice Manger is joint chair of the local Practice Managers Group. This working group are actively involved in service development and provides excellent networking across practices.