Evidence of quality of care provided by Holes Lane Surgery in specified patient populations
As a surgery we aim to offer an excellent standard of clinical and personal care to all of our patients. Below are examples of how we aim to achieve this goal for the population groups set out in the CQC pre-inspection documentation.
We have a designated GP as the clinical lead for the care of patients aged 75 and older. This GP is responsible for overseeing the care plans for this age group. Our Care plans were sent out to over 600 patients in 2015. This included a summary of our services, how to access these services, opening times and also information regarding extended access, out of hours and appropriate A+E use.
We encourage all of our patients aged 65 and over to have their annual flu vaccine and to have had their pneumococcal and shingles vaccination.
Home visits are provided for the housebound by GPs, and also our attached Community Matron, District Nurses and Practice Nurses for - Chronic disease and Dementia reviews , Blood testing , Influenza vaccinations and other injections , and BP monitoring.
Our Community Matron sees our most vulnerable patients to provide advice, support and prescriptions if needed to prevent unnecessary hospital admissions.
Long Term Conditions
At the surgery we encourage all of our patients with a known chronic disease to attend for a review at least on an annual basis. We have a specific member of the senior admin team who is responsible for arranging recall appointments and home visits for those with chronic diseases identified on QoF register. We use month of birth recall. There is a designated GP responsible for each different chronic disease area. The doctors work closely with our nurses who have worked hard to develop skills in providing care in specific chronic disease areas. We have two monthly clinic meeting for all clinical staffs, offering opportunity to review clinical care we provide and how to improve patients experience and journey. It provides opportunity for training update in various chronic disease areas, practice development activities such as discussing, developing and agreeing on new practice protocols and pathways for clinic care e.g. for hypertension.
We also have quarterly QoF meetings with the nurses to evaluate the care with provide and discuss any area of care that needs reviewing.
Any urgent issues are also addressed during our monthly partners meeting or weekly meeting and actions cascaded as appropriate.
We have used IT to improve the care we provide to our patients with chronic disease. We have created our own templates to allow for efficient and effective patient reviews and ensure accurate clinical coding and recall system. The templates follow the various clinical pathways we have developed in the surgery, based on national guidelines, to improve and standardise the care we provide. These pathways are reviewed at a specified time or earlier if new clinical evidence emerges. We have templates and pathways for hypertension, diabetes, atrial fibrillation and heart failure, and are in the process of creating one for all chronic diseases.
We also have a robust recall and monitoring protocol for patients on disease modifying drugs, Novel oral anticoagulant and warfarin. These ensure that medications are prescribed safely and patients are not missed should they be discharged from hospital, for example following missed outpatient appointment.
Care for specific chronic disease areas:
Heart failure: One of our partners is a GPwSI in Cardiology. We provide a community heart failure services for our patients and patients from four other practices in our Cluster. This is a pilot project for Warrington Health Plus. We have established close working relationship with the Cardiology Team at Warrington General Hospital to facilitate this and provide the necessary clinical governance.
Diabetes: We have redesigned our diabetes care pathway using mapping process to improve patients’ journey and quality of care. We have a simplified and robust process, where all their chronic conditions are reviewed in a single clinic at least annually. Newly diagnosed patients are offered the opportunity to attend diabetes education programmes. All patients are encouraged to attend for retinal and foot check programmes. Our 2 specialist chronic disease nurses have now taken on the lead for diabetes with a supervising GP.
COPD and Asthma: Patients with COPD and / or asthma are offered annual reviews; spirometry is performed by the nursing staff on site.
We aim to provide Asthma action plans as suggested by Asthma uk to help patients manage their Asthma. This is incorporated on our Asthma template.
IHD / Hypertension: Patients are offered annual review. 12 lead ECGs, hand held Alive cor ECG, 24 hour ambulatory ECG and home blood pressure monitoring are available at the surgery
Patients with several long-term conditions have one single all-inclusive review to avoid multiple surgery visits.
We have 4 – 6 weekly Gold Standard Framework meetings to discuss all our patients with a suspected or confirmed cancer diagnosis. All the GPs attend with the Community Matron, District Nurses and usually our Macmillan Nurse. This allows us to update the Palliative care register, and for everyone to be aware of those who are approaching end of life, and those experiencing difficulties. We have also created a formulary of all palliative drugs on our computer system that enable standard prescriptions to be generated for each patient as required. Therefore simplifying prescription of these drugs and reducing risk of error and inconvenience that an incorrect prescription could cause to patients, and their families.
In addition the surgery has enrolled in a local initiative through which we have identified a group of patients thought to be at higher risk of unplanned admission to hospital, and have devised individual care plans for these patients to help to try and avoid unplanned admissions. These plans are regularly reviewed. These patients have a copy of their care plan and have been given a priority number to call in case they need to get through to the surgery.
When any patient with a chronic disease is reviewed the clinicians try to ensure that opportunities are taken to promote lifestyle improvements, including quit smoking programmes, exercise and diet programmes and encouraged to attend for an annual flu vaccination.
We work closely with District Nursing Team to facilitate the care of our patients with chronic disease. They visit our practice daily to review a designated communication book and action as appropriate such as annual blood test or blood pressure. They also take this opportunity to discuss any concern that me have regarding care of patient.
Families, Children and Young People
We provide extensive family planning services at the surgery, including implant and coil insertion. We have a designated community midwife at the surgery with whom we work closely. We also perform antenatal and post natal checks at a designated weekly clinic.
Baby checks and child development checks are carried out at the surgery, following written invitations to attend.
We encourage families with young children to receive all of the childhood immunisations as recommended. We have a designated GP (and deputy) for safeguarding and child protection issues. We work closely with child protection services to provide accurate and up to date reports on children and families involved and to ensure that conference information is placed in the appropriate records so that clinicians are aware of developments.
We encourage all women in the appropriate age range to attend for cervical smears as per the national programme.
We offer urgent & emergency appointments for children SAME DAY if needed.
Working Age People
We offer an extended access to our patients which, is run at Bath Street, through Warrington Health Plus. This is running 6.30 to 8 pm Monday to Friday and 8-8 Saturday and Sunday morning. We have half of our GPs start their surgery at 08:30 and others at 09:00 to improve access for this patient group.
We offer telephone appointments to improve our access for working people to book an appointment.
We offer an online booking service, and patients can use the telephone system to book, check or cancel routine appointments. Patients can e-mail the surgery with prescription requests. The surgery also provides electronic prescribing services.
We also have our own website which provides information regarding the surgery and advice regarding some common self-limiting conditions.
We have a GP assigned as clinical lead for people with learning difficulties. All staff (including the reception team) are trained to tailor and personalise care for this group of patients. For example, we ensure that they are seen promptly on arrival to reduce any anxiety and any preferred method of communication is set as an alert in patient’s record.
We maintain a list of patients known to have learning difficulties; this is highlighted on their notes and taken in to consideration on each clinical contact. We work closely with our colleagues at the 5 Boroughs Partnership learning disability team. Our health facilitator Rachel helps our patients with learning disabilities attend their annual health checks offered by our surgery. This might mean encouraging these patients to attend or even bringing them in herself. This is particularly helpful when patients require a blood test or any intervention such as cervical smear. Staffs at 5 Boroughs now recommend our practice to any new patient that comes into their care that lives within our practice boundary. For annual reviews, this is done on their month of birth by a designated staff that contacts patient (and care), and coordinate their review with LD team at 5 Boroughs. We offer a coordinated 30minutes appointment with a nurse and another 20minutes appointment with a GP to develop a comprehensive plan with patient (and carers) and any issues raised are addressed either by the GP or LD team.
We have also taken over the health care needs of Sandy Lane, which is a specialist centre for caring for the resident clients with learning disabilities. Although there are 9 or 10 closer practices, the staffs feel we provide a helpful, respectful and responsive service to their clients.
We are a designated place of safety, as identified on our front door. We are a safe place for anyone to come and sit in our waiting room if they are feeling unsafe or distressed.
We have recently sought and agreed a named social worker and link worker to come to our practice to help meet our patients social and well-being needs. Introducing our Social Care colleagues to our surgery is part of the wider plan we have to integrate and collaborate with our cluster services.
We keep a list of the housebound population to ensure they have chronic disease and general medical reviews as appropriate. We also have a list of carers and offer support to them.
People Experiencing Poor Mental Health (Including People with Dementia)
The surgery has a designated clinical lead for the area of mental health. We actively promote an annual physical and mental health review in our patients with dementia and serious mental health diagnosis. We keep an accurate register for these, which are regularly reviewed and updated. We perform mental health assessments as part of the annual review in patients with chronic diseases. All clinical staff is also encouraged to do these reviews opportunistically when possible, to minimise disruption and any distress to patients. We have accepted shared care agreements prescribing memory enhancing drugs to assist our patients and colleagues at Hollins Park memory clinic.
All clinic letters from Mental Health Team are reviewed and coded within 24 hours, and any medication change is made immediately with notification patient (and carers if applicable).
We offer our patients with anxiety and depression access to the IAPT team for C.B.T by showing them their website with all its resources and crisis numbers and the dedicated phone number where they can self-refer for help.
Care Quality Commission
The Care Quality Commission (CQC) are the independent regulator of health and adult social care in England.
The CQC make sure health and social care services provide people with safe, effective, compassionate, high-quality care and encourage them to improve.
They monitor, inspect and regulate services to make sure they meet fundamental standards of quality and safety and publish what is found, including performance ratings to help people choose care.
Our GP Practice has recently undergone a CQC inspection and the results are now freely available on the CQC Website. You can access the report below