Ludham and Stalham Green Surgeries

Updated 29 March 2017

Ludham and Stalham Green surgeries are situated in the respective villages in Norfolk.

The practice is contracted to provide general medical services to approximately 5,700 registered patients across both sites. Both locations have a dispensary on site and dispense medicines to patients.

According to information taken from Public Health England, the practice population has a smaller percentage of patients aged below 50, and a higher percentage of patient aged 65 and over (considerably higher in the 65 to 74 age brackets), in comparison to the national average for practices in England. Both locations are in rural areas and have a level of deprivation equal to the national average. Income deprivation levels affecting older people and children are slightly higher than the local average but lower than the national average.

The practice clinical team consists of four GP partners, three male and one female. There are three practice nurses and three health care assistants. The clinical team are supported by a practice manager, a clinical data manager, an office manager, eight dispensing staff, one summariser, one secretary, a management assistant and ten receptionists / administrators. There were also two apprentices and the practice employed a cleaner.

The practice is a training practice and had one registrar active at the time of our inspection. There were also apprentices active at the practice.

Both locations of the practice were open from 8.30am to 6pm during weekdays. The Ludham surgery closed at 1pm on Wednesdays only and the Stalham Green surgery closed at 1pm on Thursdays only. Extended hours were offered on Monday between 6.30pm and 8pm at both sites alternately. Out-of-hours care was provided by IC24 via the NHS 111 service. Appointments with GPs or nurses could be booked twelve weeks in advance

Updated 29 March 2017

We carried out an announced comprehensive inspection at Ludham and Stalham Green Surgeries on 10 January 2017. Overall the practice is rated as outstanding.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed. Where relevant, information was also shared with other practices in the area via a practice manager’s forum, upon instigation of the practice manager.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Feedback from patients about their care was positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Data from the National GP Patient Survey published in July 2016 showed that patients rated the practice higher than others for most aspects of care.
• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The provider was aware of and complied with the requirements of the duty of candour.
• There was a clear leadership structure and staff felt well supported by management.

The area where the provider should make an improvement is:

• Ensure that the procedures following uncollected medicines and for dispensing high risk medicines is consistent across both dispensaries.

We saw various elements of outstanding practice:

• There were various means through which the management team had gone the extra mile to support staff and patients. For example, the practice manager had made various visits to staff that had been sick long term. There were arrangements in place for those members of staff that lived alone to ensure they arrived home safely if they were the last to leave the premises. Individual stress assessments had been undertaken with staff, who had also attended a stress management workshop in November 2015. In addition, the practice had been awarded the Royal College of General Practitioners (RCGP) East Anglia Faculty Practice Team Award in October 2016.
• The practice hosted the Alzheimer’s Society Dementia Café on a monthly basis. This was done during practice closure afternoons so that patients making use of this facility would experience the privacy they may wish for or require. 

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Updated 29 March 2017

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

• Nursing and GP staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
• The practice used the information collected for the Quality and Outcomes Framework (QOF) to monitor outcomes for patients (QOF is a system intended to improve the quality of general practice and reward good practice). Data from 2015/2016 showed that performance for diabetes related indicators was 76%, which was below the local average of 93% and national average of 90%. Exception reporting for diabetes related indicators was below local and national averages (exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects).

• Longer appointments and home visits were available when needed.
• Patients with complex needs 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 had implemented a monthly clinic at each site with the secondary care diabetic specialist nurse to help with patients who found it difficult to access hospital, either because of rural transportation issues or because they felt more comfortable in the familiar surroundings of the practice.
• The practice provided in-house D-Dimer testing (a blood test that measures a substance that is released when a blood clot breaks up) and use of a Doppler machine (used to check for deep vein thrombosis) at both sites.

Updated 29 March 2017

The practice is rated as outstanding 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.
• The practice offered a variety of contraceptive methods including implants fitting and removal.
• Childhood immunisation rates for the vaccinations given were in line with, or above CCG and national averages
• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals. The practice offered school readiness checks for children.
• The percentage of women registered at the practice that were screened for cervical cancer adequately in the previous 42 months (if aged 24-49) or 66 months (if aged 50-64) was 73%, which just below the local average of 77% and in line with the national average of 74%.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• The practice offered chlamydia screening and testing kits.
• The practice offered monthly contraceptive implant and removal clinics, including IUD/IUS (coil) insertion and removal and IUCD (Intrauterine Contraceptive Device) emergency fitting.
• We saw positive examples of joint working with midwives, health visitors and school nurses.

Updated 29 March 2017

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

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• The practice provided ward-round style weekly visits to various local care and nursing homes. Each had different care specialities for patients, including elderly people with medication needs and specialist dementia units. Each home had a specific lead GP allocated to ensure continuity of care. These lead GPs acted as the main point of contact for these homes and worked with the care home teams to ensure patients’ needs were met. The GPs also worked with a community pharmacist when conducting patients’ annual medicine reviews.
• The practice nurses visited care homes and housebound patients to offer chronic disease reviews and seasonal immunisations, together with a member of the admin team to support them with record keeping..
• The practice contacted patients after their discharge from hospital to address any concerns and assess if the patient needed GP involvement at that time.
• Nationally reported data showed that outcomes for patients for conditions commonly found in older people, including rheumatoid arthritis and heart failure, were above local and national averages.
• The practice hosted a vaiety of external services to improve access to these for local residents, eradicating the need for them to travel outside the area. For example, physiotherapy, Age UK, wellbeing services, diabetic eye screening and a hearing aid clinic.
• The dispensary offered medicine dosage and carousel services to those requiring this. This enabled and assisted patients taking their medicines where they otherwise may not have been able to.
• Flu clinics were held at the practice but also in local village halls so that patients did not always have to travel to the practice.
• When the practice recruited a recent member of the GP partner team they had considered the needs of the patient population and recruited a GP with an additional qualification in geriatric medicine.

Updated 29 March 2017

The practice is rated as outstanding 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.
• Extended hours were offered on Monday between 6.30pm and 8pm at both sites alternately.
• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group. Including smoking cessation advice.
• The practice provided text message services for patients including reminders for appointments, annual reviews, flu vaccinations and health campaigns. The also used this medium to approach patients for feedback through the Friends and Family Test.
• Practice staff carried out NHS health checks for patients between the ages of 40 and 74 years.

Updated 29 March 2017

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

• The percentage of patients diagnosed with dementia whose care plan had been reviewed in a face-to-face review in the preceding 12 months during 2015/16 was 89%, which was 7% above the local average and 6% above the national average.
• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive care plan documented in the record, in the preceding 12 months, agreed between individuals, their family and/or carers as appropriate was 90%%, which was 2% above the local average and 2% above the national average.
• The practice hosted the Alzheimer’s Society Dementia Café on a monthly basis. This was done during practice closure afternoons so that patients making use of this facility would experience the privacy they may wish for or require. The practice explained that this was very well attended and appreciated by patients. There was an administration team staff member who was dementia champion, to provide further support for, carers of, and patients with dementia. The practice was also a dementia friendly practice.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice carried out advance care planning for patients with dementia.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations, some of which visited the practice on a regular basis.
• Staff had a good understanding of how to support patients with mental health needs and dementia. There were staff in various champion roles, including dementia champion and carers champion.

Updated 29 March 2017

The practice is rated as outstanding 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 had 23 registered patients with a learning disability of whom 17 had received a review. Of the six patients that were due one had left the area, two had declined and three remained requiring a review.
• 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.

• Patients who were carers were identified and signposted to local carers’ groups. The practice’s computer system alerted GPs if a patient was also a carer. The practice had identified 127 patients as carers (approximately 2% of the practice list). There was a member of the administration staff that had been appointed carers champion to enable further and continuous support for carers.
• A management assistant in the practice had attended a specialist course run by a local charity and presented by people with learning disabilities and sensory impairment in order to improve the practice’s accessible information standards. This resulted in easy read versions of key documents and access to order audio and braille versions as required.

• 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.
• Both staff and patients had commented that the practice also went above and beyond the call of duty to support those suffering a bereavement. This was also reflected in the Practice Team Award awarded by the RCGP East Anglia Faculty in 2016.