Archived: St Martins Practice

Updated 29 April 2016

The practice is located in one of the most deprived areas of Leeds. It has a patient list size of approximately 6156 with a higher than national average number of patients who are between the ages of 20 and 59.

The practice had recently had an increase in patient list size due to the recent closure of a local practice but despite this had been able to perform above local and national averages in the majority of areas.

The practice is located in a converted semi detached house located over two floors, the practice have extended the clinical space on the ground floor by adding an annexe building. Clinical services are provided on the ground and first floors.

The practice has a higher than average black and minority ethnic population and also a higher than average percentage of people living in vulnerable circumstances. For example; asylum seekers, learning disabled patients and patients with a history of substance misuse.

The practice has good working relationships with local health, social and third sector services to support provision of care for its patients. They have taken the lead on a number of innovative projects in the area and involved local practices to ensure improvements are realised throughout the community. For example; the Chapeltown Diabetes Service and the Wellbeing Service.

The service is provided by five GP partners (one male and four female) and one female salaried GP. A regular GP locum also worked at the practice. The GPs are supported by three practice nurses, two health care assistants and a well being co-ordinator. The clinical staff are supported by a practice manager, and experienced team of administrative and secretarial staff.

The practice is open from 8.30am to 6pm Monday to Thursday (with the exception of one Thursday each month when the practice closes at lunchtime for training) and on Friday from 8.30am to 12.30pm and 1.30pm to 6pm.

Extended hours are provided from 6pm to 8pm on Tuesday evenings.

When the practice is closed out-of-hours services are provided by Local Care Direct, which can be accessed via the surgery telephone number or by calling the NHS 111 service.

Personal Medical Services (PMS) are provided under a contract with NHS England.

Updated 29 April 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Martins Practice on 24 November 2015. Overall the practice is rated as good for providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

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

• There was an open and transparent approach to safety and an effective system was in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• The practice held a register of the 2% of patients who were vulnerable or housebound and at risk of an unplanned hospital admission. These patients were given same day appointments when contacting the practice and longer appointment times were allocated.
• The practice had a process in place to follow up patients who had attended accident and emergency (A&E) and those patients who had unplanned hospital admission.
• Patients said they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment.
• Patients were positive about access to the service. They said they found it easy to make an appointment, there was continuity of care and urgent appointments were available on the same day as requested.
• Patients registered with the practice had access to a heath trainer. Health trainers help their clients to assess their lifestyles and wellbeing, set goals for improving their health, agree action-plans, and provide practical support and information that will help people to change their behaviour.
• Information about services and how to complain was available and easy to understand.
• There was a clear leadership structure and staff were supported by management.
• The practice held two weekly clinical meetings to ensure information was communicated.
• The provider was aware of and complied with the requirements of the Duty of Candour.

We saw areas of outstanding practice:

• The leadership team in the practice had identified the specific needs of their patient group and proactively established services which were delivered to meet their needs and the needs of the local community.

• The practice had taken the lead on a number of innovative projects. For example; the Chapeltown Diabetes Service. St Martins Practice recruited a specialist nurse and seconded the nurse to work across six other practices in the locality. The specialist nurse provided support to manage more complex diabetes patients and provided training and support to GPs and practice nurses in order to manage these complex cases in the community.

• The practice also approached the CCG with the idea of a wellbeing service. This was aimed at supporting patients and signposting them to other health, social and third sector services as the practice acknowledged that clinicians did not always have adequate time during consultation to provide the best possible information for patients. The practice put together a plan for the role of a wellbeing co-ordinator, presented this to the CCG and were awarded funding. The social prescribing service was then commissioned at CCG level and rolled out to other practices.

• The practice had acknowledged a lower prevalence of some long term conditions such as hypertension and atrial fibrillation. At the time of our inspection the practice was in the process of undertaking work to confirm lower rates of the conditions in the area or improve detection of these conditions.

• The practice had a long history of looking after people with substance misuse and had developed additional services independent of the general practice to support these patients.

• The provider was a hub service for city wide substance misuse service and hosted a support service at the practice for black and minority ethnic (BME) family, friends and relatives affected by the alcohol use of an adult

• The practice was involved in the Leeds North Clinical Commissioning Group (CCG) Serious Untoward Incident (SUI) engagement scheme and had been identified as the highest reporting practice per 100 registered patients in the locality.

• The practice held a local contract to provide medical care to Care in Community (CIC) beds at a local care home. A CIC bed is a bed in a community setting for older people who do not need to be in hospital but cannot be supported at home. There were 20 beds located in the home, enabling patients to avoid hospital admission.

The practice had good links with the local community and had established the Chapeltown Practice Health Champions group. They had taken the lead on arranging activities for patients in the locality such as Zumba classes, coffee mornings and walking groups.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 29 April 2016

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

• All these patients had a named GP and a structured annual review to check that their health and medicines needs were being met. The practice nurses 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.
• Patients who required palliative (end of life) care were provided with support and care as needed, in conjunction with other health care professionals.
• The practice had recruited a Diabetic Specialist Nurse to support the increasing diabetic workload and worked collaboratively with local practices to improve care across the Chapeltown area.
• The practice hosted Health Trainer clinics offering support to patients and supporting them to make lifestyle changes.
• The practice initiated the Wellbeing service which directs patients to other third sector services to support general health and social wellbeing.
• The practice was involved in the Better for Me Project, working alongside Leeds Community Healthcare to offer rapid home visits from services such as occupational therapists and community matrons.

Updated 29 April 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 who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances.
• Patients and staff told us children and young people were treated in an age-appropriate way and were recognised as individuals. There were policies in place to support this.
• Appointments were available outside of school hours and the premises were suitable for children and babies. All children who required an urgent appointment were seen on the same day as requested.
• The practice worked with midwives, health visitors and school nurses to support the needs of this population group. For example, ante-natal, post-natal and child health surveillance clinics.
• Sexual health and contraceptive and cervical screening services were provided at the practice.
• The practice was a primary care hub for the Leeds substance misuse service, including for young people.
• The practice hosted other services to support this group of patients. For example; couples counselling, Citizens Advice Bureau, Stop Smoking Service and the job retention service.

Updated 29 April 2016

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

• The practice provided proactive, responsive and personalised care to meet the needs of the older people in its population. Home visits and urgent appointments were available for those patients with enhanced needs.
• The practice worked closely with other health and social care professionals, such as the district nursing team, to ensure housebound patients received the care they needed.
• The practice held a local contract to provide medical care to Care in Community (CIC) beds at a local care home. A CIC bed is a bed in a community setting for older people who do not need to be in hospital but cannot be supported at home. There were 20 beds located in the home, enabling patients to avoid hospital admission.
• The practice supported the practice health champions to host fortnightly events at the practice for all patients to attend, this included activities such as gardening and light exercise which supported older people with social needs.

Updated 29 April 2016

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

• The needs of these patients 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 extended hours from 6pm to 8pm on Tuesday evenings.
• The practice offered online services as well as a full range of health promotion and screening that reflected the needs for this age group. For example, cervical screening, bowel screening and NHS health checks for patients between the ages of 40 and 74.
• The practice offered a travel vaccination clinic.

Updated 29 April 2016

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

• The practice regularly worked with multidisciplinary teams in the case management of people in this population group, for example the local mental health team. Patients and/or their carer were given information on how to access various support groups and voluntary organisations, such as Carers Leeds.
• The practice carried out mental health reviews which included physical health and lifestyle checks.
• Staff within the practice had received Dementia Friends training. This gave them a greater understanding of how to support patients with dementia and their carers.
• The practice carried out dementia screening on patients at risk of developing this condition.

Updated 29 April 2016

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 and regularly worked with multidisciplinary teams in the case management of this population group.
• Information was provided on how to access various local support groups and voluntary organisations.
• Longer appointments were available for patients as needed.
• Staff knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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 had lead GPs for substance misuse; mental health & dementia; learning disabilities; wellbeing.
• The practice worked with a range of services and hosted sessions to support patients. For example; Citizens Advice Bureau; where patients could access confidential advice; a job retention support worker from Leeds Mind who worked with patients experiencing work stress or recovering from mental health problems.
• The provider was a hub service for city wide substance misuse service and hosted a support service at the practice for black and minority ethnic (BME) family, friends and relatives affected by the alcohol use of an adult
• The practice also approached the CCG with the idea of a wellbeing service. This was aimed at supporting patients and signposting them to other health, social and third sector services as the practice acknowledged that clinicians did not always have adequate time during consultation to provide the best possible information for patients. The practice put together a plan for the role of a wellbeing co-ordinator, presented this to the CCG and were awarded funding to support the initiative.