Appletree Medical Practice

Updated 4 July 2016

Appletree Medical Practice is situated in the village of Duffield in Derbyshire, about five miles north of Derby and on the edge of the Peak District National Park. The main surgery also referred to as the Duffield Surgery is located at 47a Town Street, Duffield, Belper, Derbyshire, DE56 4GG and the branch surgery is located at 10 The Town, Little Eaton, Derby, DE21 5DH.

As part of this inspection we visited the Duffield surgery which is based in a purpose built premises with an attached pharmacy. The practice provides primary medical services to approximately 11,000 patients through a general medical services contract (GMS). Approximately 56% of the practice population are aged 50 years and over, with approximately 150 patients in residential or nursing homes in the local area.

The level of deprivation within the practice population is significantly below the national average. The practice is in the tenth and least deprived decile meaning that it has a higher proportion of people living there who are affluent when compared to most areas.

The clinical team comprises of six GPs partners (four female and two male), and a nursing team which includes an advanced nurse practitioner, a specialist nurse, three practice nurses, a treatment room nurse and a healthcare assistant.

The clinical team is supported by a full time practice manager and a team of medical secretaries, data assistants, team leaders, reception and administrative staff.

Appletree medical practice is a training practice for GP specialist registrars (fully qualified doctors who already have experience of hospital medicines but have decided to specialise in general practice). The practice also hosts final year medical students attached to the University of Nottingham medical school and student nurses.

A community nursing team is also based at the Duffield surgery. This includes district nurses and the community matron. Practice staff worked in collaboration with the attached care coordinator and advanced care practitioner employed by the Derbyshire Community health service NHS Foundation Trust (DCHS).

The practice has opted out of providing out-of-hours services to its own patients. This service is provided by Derbyshire Health United (DHU) and is accessed via 111.

Updated 4 July 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Appletree Medical Practice on 18 April 2016. Overall the practice is rated as good. Specifically, we found the practice to be good for providing safe, effective, caring and well-led services. It was outstanding for providing responsive services.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

• Risks to patients were assessed and well managed overall.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

• The practice used clinical audit to drive quality improvement within the practice

• Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. We found many positive examples to demonstrate how patient’s choices and preferences were valued and acted on.

• The practice worked closely with four other GP practices (Belper five sublocality), Derbyshire Community health service NHS Foundation Trust (DCHS) and the local community in planning how services were provided to ensure they met patients’ needs.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group (PPG).

• The practice had good facilities and was well equipped to treat patients and meet their needs.

• The practice actively reviewed complaints and how they were managed and responded to, and made improvements as a result.

• The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

• The practice had strong and visible clinical and managerial leadership and governance arrangements.

• Staff were committed to improving the services for patients and the wider community; and volunteered to pilot new ideas and innovations before they were rolled out across the local area

We saw areas of outstanding practice:

• The practice worked in collaboration with four local practices on a project to drive improvement in care for older people and reduce emergency admissions from care homes. This had resulted in an 8% reduction in emergency admissions in the preceding 12 months.

• The practice staff and PPG had engaged with patients aged 17 to 24 and with students (also referred to as community ambassadors) from the local school. The PPG had student representation at their meetings for the past three years.

• The commitment by practice staff, allied health professionals and empowerment of the PPG to offer: a range of compassionate and additional services to support carers and people at risk of social isolation was outstanding. For example, The PPG facilitated a bi-monthly carers’ forum which enabled carers to seek peer support, form friendships and be empowered with information relating to their caring role and people they cared for. This forum has been running since November 2011 and attendance averaged 15 to 20 people. In addition, a tea party had been held for older people at risk of isolation and with multiple health needs in February 2016. The practice planned to continue offering this service to patients.

The areas where the provider should make improvement are:

• Ensure a protocol is in place for following up children who do not attend hospital appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 4 July 2016

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

• Each GP had a lead role for the overall monitoring of specific long term conditions and were supported by the nurses in chronic disease management. For example, the nurses facilitated a range of clinics for conditions such as asthma, diabetes and chronic obstructive pulmonary disease (COPD); and patients were encouraged to understand and self-manage their conditions in line with agreed care plans.

• An anti-coagulation service was offered for patients prescribed warfarin (a drug used in the prevention of blood clot formation which requires regular blood tests).

• Patients at risk of hospital admission were identified as a priority and systems were in place to follow-up their care post hospital discharge.

• 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.

• The practice used telehealth monitoring devices to aid in the diagnosis of hypertension for patients with high blood pressure.

• Longer appointments and home visits were available when needed.

Updated 4 July 2016

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 at risk of abuse. This included practice staff engaging with midwives, health visitors and school nurses in regular safeguarding meetings. There was no protocol in place to ensure staff followed up children who did not attend hospital appointments.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

• Families were allocated the same named GP for continuity of care.

• Immunisation rates for all standard childhood immunisations were comparable to the local average and school age vaccination clinics were held after school or on a Saturday morning.

• Appointments were available outside of school hours and children presenting with urgent medical needs were seen on the same day.

• The premises were suitable for children and babies.

• The practice had engaged students from the local sixth form secondary school and a number of students had attended the patient participation group meetings for the past three years.

Updated 4 July 2016

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

• The practice staff prioritised the care needs of older people including residents living in six care homes they supported. The practice had taken a lead role in piloting the locally commissioned care home enhanced service which included providing regular and planned “ward rounds” for the residents and having a nominated GP with lead responsibility for each of the care homes to ensure continuity of care.

• The practice was part of the Belper five (group of five local GP practices) integrated community care pilot project which included working in partnership with Derbyshire community health service NHS foundation Trust to address the challenges relating to the care provision of older people. For example, the practice’s advance nurse practitioner and CCG employed advanced care practitioner specifically focused on the management of frail and elderly patients. As a result of this project hospital admissions and accident and emergency presentations had reduced.

• Regular multi-disciplinary meetings were held to discuss the care needs of older people and the practice was responsive to their needs. This included use of care plans to ensure co-ordinated care and signposting

• Home visits and urgent appointments were offered for those with enhanced needs.

• A tea party had been facilitated in February 2016 for older people at risk of isolation and with multiple health needs and eight patients had attended.

• All patients, including those aged 75 and over had a named GP but were free to consult with any of the GPs.

• The practice had a high success rate in administering flu vaccines to this age group with an 80% uptake, including 157 done during home visits.

Updated 4 July 2016

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 was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group. For example, the practice’s uptake for the cervical screening programme was 89%, which was marginally above the local average of 84% and the national average of 82%.

• A range of appointment types were offered to these patients and this included telephone consultations and extended opening hours on a Saturday morning between 8am and 11am. This enabled more flexibility for patients wishing to access appointments outside of standard working hours.

• The practice used social media such as twitter and facebook to communicate with this population group as well as a text messaging service.

Updated 4 July 2016

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

• Staff had a good understanding of how to support patients with mental health needs and dementia. This included working with multi-disciplinary teams in the case management of these patients and carrying out advance care planning for patients with dementia.

• Published data showed:

• 93% of patients with a mental health condition had a documented care plan in the last 12 months which was in line with the CCG average of 92% and the national average of 88%.

• 86% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months which was in line with the CCG average of 85% and the national average of 84%.

• The practice staff told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

• Patients with symptoms of anxiety or depression were referred or directed to counselling clinics hosted at the practice.

• 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.

Updated 4 July 2016

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

• The practice and supporting its carers. For example, “Friends of Carers” (volunteers from the PPG) facilitated a bi-monthly carers' forum at the Duffield surgery. The forum empowered carers to share their experiences, form new friendships and learn more about facilities available to them.

• The practice was one of five GP practices within the local area that hosted a carers' clinic run by Derbyshire Carers Association. The clinics were held on the first Thursday of every month and carers did not have to be a patient with the practice to benefit from the service.

• The practice provided care to a residential care home for young adults with challenging behaviour including severe autism and learning disabilities.

• A comprehensive yearly health check was offered to these residents and other patients with a learning disability. A total of 93% of eligible patients with a learning disability had received an annual health check. Easy read information using pictures and simple language was used in invitation letters and explanations about their care.

• The practice was a member of the Derbyshire safe place scheme, providing a safe haven for patients with learning disabilities who felt unwell, confused or threatened whilst out in the local community.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients and longer appointments were offered.

• 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.

• The premises were user friendly for patients with a range of disabilities including patients using wheel chairs and hard of hearing.