Yarm Medical Practice

Updated 17 December 2015

Yarm Medical Practice is located in a residential area of Yarm. There are 13188 patients on the practice list and the majority of patients are of white British background. There are a higher proportion of older patients on the patient list compared to the practice average across England. The practice is training and teaching practice having up to four registrars at any one time. There are seven GP partners’ four GP partners (female), and three GPs (male). There are three nurse practitioners, three practice nurses, two health care assistants and a phlebotomist (all female). There is a practice manager, reception, secretarial and other administration staff.

The practice is open 8am to 6pm, Monday to Friday. The practice provides extended hours on Tuesday evening until 8pm and on Saturday mornings between 8am and 11.30am. Extended hours appointments are by appointment only. Patients requiring a GP outside of normal working hours are advised to contact the GP out of hour’s service provided by Northern doctors via the NHS 111 service. The practice has a General Medical Service (GMS) contract.

Updated 17 December 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 21 October 2015. Overall the practice is rated as outstanding.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

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.

• There was a holistic approach to assessing, planning and delivering care and treatment to people who used the services.The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice.

• Staff actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking, peer review and accreditation were proactively pursued.

• The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high-quality care.

• Patients said they were treated with compassion, dignity and respect and staff went the extra mile when patients required extra support.

• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they were meeting the needs of their patients.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients, staff and from the Patient Participation Group (PPG).

• The practice had good facilities and was well equipped to treat patients and meet their needs. The building was designed to meet the needs of patients. The Patient Participation Group (PPG) was actively involved in the design of the building.

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

• The practice had a clear vision which had quality and safety as its top priority. A business plan was in place, monitored and regularly reviewed with all staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

• There was a high level of constructive engagement with staff and a high level of staff satisfaction.Staff were proud of the organisation as a place to work and spoke highly of the culture. Staff at all levels were actively encouraged to raise concerns and ideas.

• The leadership across the practice drove continuous improvement and staff were accountable for delivering change. There was a clear practice approach to seeking out and embedding new ways of providing care and treatment.

We saw several areas of outstanding practice including:

• The practice carried out annual Inflammatory Bowel Disease (IBD) testing. The term IBD is a group of inflammatory conditions of the colon and small intestine. One of the GPs was the IBD Clinical Champion for the CCG area and involved with the Gastroenterology team at the local acute hospital, to assess the possibility of using near patient testing to assess for IBD in primary care. The practice was the only GP practice in the country to do this and if the research is fruitful, this model may be rolled out to primary care nationwide.

• The practice worked collaboratively with the lead GP from a neighbouring practice to develop best practice mental health care plans which were then used for the care of patients across both practices. These plans advised clinicians on what they should be monitoring, questions they should ask patients about their condition and when they should refer patients to a consultant or acute care. We saw data that indicated the number of patients accessing mental health out patient’s services had decreased since the care plan had been put in place.

• The practice used a screening tool to reduce polypharmacy and the prescribing of medicines that may cause side effects in older people. We saw that there was a reduction in admissions of older people to acute services from the previous year.

• The practice, in collaboration with a neighbouring practice had developed Clinical Standards for the care delivered in the care homes they visited. The Standards set out what care the patient and staff in the homes should expect and how they would monitor their effectiveness.

• The practice developed a range of templates and guidance for staff in the management of patients not included in Quality Outcome Framework (QOF). Examples of these were the care of patients suffering from coeliac disease.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 17 December 2015

The practice is rated as outstanding for the care of people with long-term conditions. Nursing staff had lead roles in chronic disease 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 that their health and medication needs were being met. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care. One of the GPs with palliative care training had contributed to the current pro-forma used across the Northern Region for End of Life Care. The practice consequently had low admission and prevalence rates compared with the locality for such conditions such as asthma, chronic heart disease, stroke and diabetes.

Updated 17 December 2015

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 relatively high for all standard childhood immunisations. Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals. We saw evidence to confirm this. Appointments were available outside of school hours and the premises were suitable for children and babies. The practice held a baby clinic weekly. The Health visitor also held clinics at the same time in a nearby local authority building We saw good examples of joint working with midwives, health visitors and school nurses. The health visitor attended the monthly multidisciplinary meetings. We saw there was a weekly well women drop in clinic which provided contraceptive advice including the fitting of intrauterine devices and contraceptive implants. Two of the nurse practitioners were completing their training to enable them to insert implants.

Updated 17 December 2015

The practice is rated as outstanding for the care of older people. The practice had introduced a number of initiatives to improve the care of older people. They had identified an increasing number of older people and organised care to better meet their needs. Due to the additional number of older people the practice had recruited an additional full-time nurse practitioner to improve capacity.

The practice, with neighbouring practices had initiated a system to address polypharmacy in older people. The practice also used a tool to calculate Anti-Cholinergic Burden Score for each patient over 75. This alerted clinicians to the use of inappropriate medicines for this age group. The Anticholinergic Cognitive Burden Scale alerted clinicians to medicines that should be avoided which may worsen pre-existing conditions such as dementia. The practice was able to demonstrate that this intervention had led to a reduction in the prescribing of certain medicines and the associated side effects.

The practice provided regular ward round visits to the local care homes as part of a scheme initiated by the CCG. We saw that the GPs were visiting the care homes over and above this; often several times a week. The practice had initiated named GPs going into each care home in their area for the past ten years. In addition to this, the practice worked with a neighbouring practice to devise a Care Home Quality Standard. Measurable outcomes had been agreed to monitor the effectiveness of the agreed quality standards. For example reviewing the percentage of patients who had had a multi-disciplinary follow up assessment after admission within eight weeks. The document also stated what patients and staff in the care home should expect and promoted the best interests of the patient.

The practice had systematically implemented emergency health care plans, avoiding admission plans and do not attempt resuscitation (DNAR) to reduce burdensome interventions and unnecessary admission to acute care. We saw the information was evidence based and provided guidance to clinical staff. An example of this was when to refer patients for further investigations. We saw evidence of reduced inappropriate admission to acute care for this patient group. The practice also worked collaboratively with community matrons who managed patients in their own homes.The community matrons and district nurses who visited patients met monthly with the GP partners to review patients. In addition to this the nurse practitioners and HCAs visit patients in their own homes to provide chronic disease management and immunisations such as shingles, flu and pneumonia.

Updated 17 December 2015

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. The practice participated in healthy heart and lung checks for patients aged 40 to 70 years. All new patients are offered a Health check on registering. The practice provides a travel clinic and offered Yellow Fever vaccines to patients both registered and not registered. 

Updated 17 December 2015

The practice is rated as outstanding for the care of people experiencing poor mental health (including people with dementia). There were 91 patients on the mental health register, all had been offered a review and 39 patients who were assessed as suitable had had an individual care plan developed specific to their needs. We saw the practice had developed their own detailed care plans for specific mental health conditions and this included advice, guidance and what help and support was available locally for each condition. There was a marked decrease of patients accessing mental health outpatient services this year. Patients experiencing poor mental health had an annual physical health check and regular reviews. The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. The practice also hosted a drop in service for those patients with alcohol problems.

The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. The on call GP was always available to speak with patients in crisis. The practice liaised with the Samaritans organisation to update patient information making this available to patient. There was a system in place to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health.

During the year the practice had invited patients with anxiety and depression to see a mental health worker. The aim was to provide patients with a review of their symptoms and help with self-management plans and signposting to appropriate agencies. The practice had a low admission rate for patients with mental health problems into secondary care.

Staff had received training on how to care for patients with mental health needs and dementia. There were numerous educational sessions held in the practice including those from a Psychiatric Consultant. We saw the staff were in the process of becoming dementia friends. They supported dementia patients from new diagnosis through the different stages of the disease.

Updated 17 December 2015

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 such as those with a learning disability. It had carried out annual health checks for people with a learning disability and 65 % of these patients had accepted the invitation. It offered longer appointments for people with a learning disability. We saw the practice staff had recently undergone training to improve the management of those patients with learning disabilities.

The practice regularly worked with multi-disciplinary teams and the community matron in the case management of vulnerable people. It had told 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 practice produced an easy read and Braille version of the practice leaflet and a hearing loop had been installed in the building. One of the patients with sight loss was currently reviewing the large print patient leaflet and information in Braille to ensure it met the needs of visually impaired patients. There was disability access throughout the building.