Archived: Barnsley Road Surgery

Updated 7 November 2017

Barnsley Road Surgery is located in Sheffield. The practice is based in a two storey converted house with an annex. All patient treatment areas are on the ground floor of the building, the first floor is used as office space for staff.

Public Health England data shows the practice has a comparable national average population of patients and the practice catchment area has been identified as one of the first most deprived areas nationally.

The practice provides Primary Medical Services (PMS) under a contract with NHS England for 2780 patients in the NHS Sheffield Clinical Commissioning Group (CCG) area. It also offers a range of enhanced services such as extended hours and childhood vaccination and immunisations.

Barnsley Road Surgery has one male GP and one female salaried GP. There is one female practice nurse and two healthcare assistants. These are supported by a practice manager and a team of experienced reception and administration staff.

The practice is open 9am to 5.45pm Monday to Friday with the exception of Thursdays when the practice closes at 2.30pm. The GP Collaborative provides cover when the practice is closed on a Thursday afternoon. Extended hours are offered on a Thursday morning 6.45am to 8am. Morning and afternoon appointments are offered daily Monday to Friday with the exception of Thursday afternoon when there are no afternoon appointments.

When the practice is closed between 6.30pm and 8am patients are directed to contact the NHS 111 service. The Sheffield GP Collaborative provides cover when the practice is closed between 8am and 6.30pm. For example, at lunchtime. Patients are informed of this when they telephone the practice number.

Updated 7 November 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Barnsley Road Surgery on 14 February 2017. The overall rating for the practice was good with requires improvement in well-led. The full comprehensive report from 14 February 2017 can be found by selecting the ‘all reports’ link for Barnsley Road Surgery on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 4 October 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 14 February 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice is rated good with requires improvement for being well-led.

Our key findings were as follows:

• Some risks to patients were assessed and managed, others required review. For example, the practice could not provide a fire risk assessment and fire safety systems and procedures were not clear. An infection control audit had been completed although an action plan to address the areas identified for improvement had not been developed at the time of the inspection and there were shortfalls in the monitoring of some cleaning schedules.

• A system to track the use of blank prescriptions throughout the practice had been implemented. However, a record was not maintained when blank prescriptions were received into the practice.

• A monitoring log had been implemented to record medical indemnity cover and registration status with the professional bodies for all clinical staff.

• Actions taken after safety alerts were received by the practice had been documented.

• Staff had not received regular appraisal and some staff were overdue training updates. However, training had recently been arranged for staff and all staff had a date planned for an appraisal in October 2017.

• The procedure for monitoring the medical fridge temperatures had been reviewed and updated.

• The access walkway between the main building and the annex had been resurfaced.

• The system for recording verbal complaints had been reviewed and formalised.

The areas where the provider must make improvements are:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

• Arrange for staff to receive regular appraisals as part of the appraisal system.

• Review practice policies to ensure they are current and reflect custom and practice.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Updated 6 April 2017

The practice is rated as good for the care of people with long term conditions.

• The nurse had a lead role in long term condition management and patients at risk of hospital admission were identified as a priority.

• 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 6 April 2017

The practice is rated as good for the care of families, children and young people.

• 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.

• Immunisation rates were high for all standard childhood immunisations. The practice sent all children a birthday card with a reminder to attend for their immunisation. The nurse would telephone anyone who did not attend for their vaccination at the end of the clinic to make a further appointment. Immunisation rates for children under the age of two years ranged from 92% to 98% which was above the national expected coverage of 90%.

• Staff told us that children and young people were treated in an age-appropriate way and were recognised as individuals.

• Data showed 83% of women eligible for a cervical screening test had received one in the previous five years compared 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 and health visitors.

Updated 6 April 2017

The practice is rated as good for the care of older people.

• The practice offered 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.

• The percentage of patients aged 65 or over who received a seasonal flu vaccination was 72%, comparable to the national average of 72%.

Updated 6 April 2017

The practice is rated as good for the care of working-age people (including those recently retired and students).

• 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 offered early morning appointments at the practice on a Thursday 6.45am to 8am and weekend and evening appointments at a local practice through the Sheffield satellite clinical scheme.

• The practice offered online services as well as a range of health promotion and screening that reflects the needs for this age group.

Updated 6 April 2017

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

• Of those patients diagnosed with dementia, 100% had received a face to face review of their care in the last 12 months, which is higher than the national average of 84%. The GP told us patients would be seen opportunistically for this review.
• Of those patients diagnosed with a mental health condition, 100% had a comprehensive care plan reviewed in the last 12 months, which is higher than the national average of 88%.
• The practice regularly worked with multidisciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
• The practice had advised patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• Staff had a good understanding of how to support patients with mental health needs and dementia.
• The practice hosted Improving Access to Psychological Therapies Programme (IAPT), a counselling service to support patients’ needs.

Updated 6 April 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

• 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.