Archived: Cordley Street Surgery

Updated 24 August 2016

Cordley Street Surgery established in 2003 is a branch surgery registered with CQC to provide primary medical services under the provider organisation Great Bridge Partnership for Health. Collectively there are approximately 7,400 patients of various ages registered and cared for at Great Bridge Partnership for Health, and the branch in Cordley Street. Sai surgery and Cordley street have a shared list of patients therefore the data provided is shared across the two sites.

Services to patients are provided under a General Medical Services (GMS) contract with NHS England. The practice has expanded its contractual obligations to provide enhanced services to patients. An enhanced service is above the contractual requirement of the practice and is commissioned to improve the range of services available to patients.

Cordley Street Surgery is overseen by two directors who were not based at this location. The clinical team includes a salaried GP, consultant nurse, an advanced nurse practitioner and a practice nurse. The GP, consultant nurse, advanced nurse practitioner and practice manager form the management team and are supported by administration and reception staff.

The practice is open and appointments are available between 8am to 8pm on Mondays, 8am to 6.30pm on Tuesdays, Wednesdays, 8am to 8.30pm on Thursdays and 8am to 6.30pm on Fridays, 9.30am to 5pm on Saturdays. When the practice is closed during the out of hours period patients are directed to the ‘walk in centre’ or 111 out of hours service.

Updated 24 August 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cordley Street Surgery on 29 April 2016. Great Bridge Partnerships for Health, Sai Surgery was also visited as part of the same inspection as both locations share the same patient list, although Cordley Street is a branch surgery. This report therefore reflects the service delivered from both locations.

Overall the practice is rated as requires improvement.

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 in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• The practice had a programme of clinical audits.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• The majority of patients said they were treated with compassion, dignity and respect.
• The practice had not taken action to address the areas of low satisfaction from the national patient survey.
• Information about services and how to complain was available and easy to understand. Improvements were made as a result of complaints and concerns.
• Patients said it was difficult to make an appointment with a named GP, which affected continuity of care, however urgent appointments were available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Staff felt supported by management. The practice had an active patient participation group (PPG) and acted on feedback provided from the PPG.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider must make improvements are:

• The provider must have effective systems to enable them to assess and monitor the quality of the service by; actively seeking and act on views of people who use the service, about their experience and quality of the care and treatment delivered in order to improve the quality of the service.

• The provider must ensure care and treatment provided to patients is appropriate, meets their needs and reflects their preferences by ensuring care plans are sufficiently detailed and updated following changes in their circumstances actively seek and act on views of people who use the service, about their experience and quality of the care and treatment delivered.

The areas where the provider should make improvements are:

• The provider should take more proactive steps to promote bowel and breast screening in the practice.

• The provider should investigate the reasons for high exception reporting in mental health indicators and take more proactive steps to ensure patients are recalled and monitored

• The provider should put systems in place to monitor improvement following the installation of additional telephone lines.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 24 August 2016

The practice is rated as requires improvement for the care of people with long-term conditions. This is because the practice is rated as requires improvement for providing effective caring and well led services. These ratings affect all population groups.

• Nursing staff had lead roles in chronic disease management, for example, diabetes and respiratory disease.

• Longer appointments and home visits were available when needed.

• All these patients had an annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the practice worked with relevant health and care professionals to deliver a multidisciplinary package of care.

• Performance indicators showed that outcomes for patients with long term conditions was in line with CCG and national averages.

• Not all these patients had a named GP, and the personalised care plans were not detailed. However the advanced nurse practitioner had commenced a review of all care plans.

Updated 24 August 2016

The practice is rated as requires improvement for the care of families, children and young people. This is because the practice is rated as requires improvement for providing effective, caring and well led services. These ratings affect all population groups.

• There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk.

• 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, and we saw evidence to confirm this.

• The practice’s uptake for the cervical screening programme was 80%, which was comparable to the national average of 81%.

• Appointments were available outside of school hours and the premises were suitable for children and babies.

Updated 24 August 2016

The practice is rated as requires improvement for the care of older people. This is because the practice is rated as requires improvement for providing effective, caring and well led services. These ratings affect all population groups.

• The practice offered proactive, personalised care to meet the needs of the older people in its population. All older patients had a named GP. 

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs but care plans were not being updated following a change in circumstances

• The premises were accessible to patients with mobility difficulties.

• Nationally reported data showed that outcomes for patients for conditions commonly found in older people was in line with local and national averages. For example, Performance for diabetes related indicators was 91% compared to the CCG average of 84% and the national average of 88%.

• National screening data for breast and bowel cancer was below local and national averages.

Updated 24 August 2016

The practice is rated as requires improvement for the care of working-age people (including those recently retired and students).This is because the practice is rated as requires improvement for providing effective, caring and well led services. These ratings affect all population groups.

• 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 and flexible. .

• The practice was proactive in offering online services.  Screening rates in respect of breast and bowel cancer were below the CCG and national averages and more proactive steps were needed to encourage increased uptake.  

Updated 24 August 2016

The practice is rated as requires improvement for the care of people experiencing poor mental health (including people with dementia). This is because the practice is rated as requires improvement for providing effective, caring and well led services. These ratings affect all population groups

• 79% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was comparable to the national average of 84%.

• Performance for mental health related indicators was 100% compared to the CC average of 89% and the national average of 83%. However the exception rates for these indicators ranged between 24% and 50%, compared to the CCG and national average of 3% and 21% and the practice staff were unable to explain the reasons for this.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

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

• Staff understand of how to support patients with dementia.

Updated 24 August 2016

The practice is rated as requires improvement for the care of people whose circumstances may make them vulnerable. This is because the practice is rated as requires improvement for providing effective, caring and well led services. These ratings affect all population groups.

• 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.