Cambrian Surgery

Updated 25 October 2016

Cambrian Surgery is located in Oswestry, Shropshire. It is part of the NHS Shropshire Clinical Commissioning Group. Cambrian Surgery is registered with the Care Quality Commission as a partnership provider. The provider holds a General Medical Services contract with NHS England. At the time of our inspection, 13,087 patients were registered at the practice. The practice, in line with the local Clinical Commissioning Group (CCG), has a higher proportion of patients aged 65 years and over when compared with the practice average across England. For example, the percentage of patients aged 65 and above at the practice is 22%; the local CCG practice average is 24% and the national practice average, 17%.

The practice is in a modern three storey purpose built building, completed in 2011, of which the practice occupies approximately 30%. The practice treatment areas and consulting rooms are on the ground and first floor. There is a lift available and an automatic door at the practice entrance. The practice has 11 consulting rooms, six nurse/treatment rooms, a minor operations room and a phlebotomy room. There is an on-site pharmacy. The practice is a training practice taking medical students from Birmingham University and Staffordshire University. As well as providing the contracted range of primary medical services, the practice provides additional services including:

• Minor surgery

• Venepuncture (blood sample taking)

• NHS Health Checks

The practice is open each weekday from 7.30am to 6.30pm with extended hours by appointment only on a Monday between 6.30pm and 8pm, on bank holiday Mondays the extended hour’s provision changes to a Tuesday. During these times telephone lines and the reception desk are staffed and remain open. The practice has opted out of providing cover to patients outside of normal working hours. Shropdoc provides the out-of-hours services.

Within the practice there are a number of key leadership roles including medical, nursing and administration and support. Staff at the practice work a variety of full and part time hours. Staffing at the practice includes:

• Six GP partners (5 male and 1 female) and a managing partner.

• One salaried female GP.

• Two regular locum GPs (male and female).

• One Advanced Nurse Practitioner.

• Five practice nurses.

• Two female healthcare assistants and a healthcare assistant/phlebotomist (a person who takes blood).

• Two pharmacists (who job share).

• A human resources and governance manager.

• A finance manager.

• A contract performance manager.

• Two reception/administration operational managers.

• 16 reception/administration staff.

• A Community and Care Coordinator.

Updated 25 October 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cambrian Surgery on 11 May 2016. After the comprehensive inspection, the practice was rated as good overall with requires improvement in providing safe services. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Cambrian Surgery on our website at www.cqc.org.uk. We undertook a focussed follow up inspection on 3 October 2016 to check that improvements had been made. The practice is rated as good for providing safe services and rated good overall.

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, recording and the learning from significant events.
• The provider was aware of and complied with the requirements of the duty of candour.
• Risks to patients were assessed and well-managed and full clinical audits completed.
• For patients on high-risk medicines and those requiring regular medicine reviews, these had been undertaken and systems were in place for medicine review monitoring.
• Formal system for recording and monitoring medicines that on an ad hoc basis maybe taken by GPs to home visits was in place.
• An audit about the identification of carers had been conducted and the numbers of carers on the practice register had increased.
• General health and safety risk assessments had been completed, this included fire risk assessments, maintenance records and Legionella.
• The practice ensured their recruitment arrangements included Disclosure and Barring Service (DBS) checks were completed for staff who had contact with potentially vulnerable patients including locum GP staff and references were recorded.
• Staff who provide a chaperone service were in receipt of chaperone training and had a Disclosure and Barring Service (DBS) check completed.
• Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment. Training included a documented induction system and safeguarding adults and children to the appropriate levels as well as basic life support.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 22 June 2016

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

• Patients at the highest risk to unplanned hospital admissions were identified and care plans had been implemented to meet their health and care needs.
• 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 medicines needs were being met. For people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
• Nursing staff had lead roles in chronic disease management and had undertaken additional training.
• A practice nurse with specialist diabetic nurse training supported diabetes patients with dietary advice, referred patients to a structured education program, foot screening service and retinal screening service when they were first diagnosed. The practice nurse had completed training on the initiation of insulin in diabetes and was able to give advice and support with respect to self-injection techniques.
• The practice had a pre-diabetes register offering patients lifestyle advice and monitoring and set up systems to review all the blood glucose test results ordered throughout the practice to ensure that all elevated results were acted upon. The practice aim was to reduce the number of patients who progress to diabetes. The practice population of diabetics was now between 4% and 5% from what had been a base line level of 2%.

Updated 22 June 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 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, and we saw evidence to confirm this.

• The practice provided support to a children’s hospice.

• The practice’s uptake for the cervical screening programme was 79% which was slightly lower but comparable with the CCG average of 83% and national average of 82%.

• The practice was young person-friendly and offered condoms, pregnancy testing and Chlamydia testing for all aged 15-24.

Updated 22 June 2016

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

• There were 2,862 patients over the age of 65 (list size 12,927), 127 patients, approximately 1% of the registered patients, were living in local care homes. The practice GPs completed the Care Homes Advanced Scheme II (CHAS2) care plans. This is a local initiative supported by the Shropshire Clinical Commissioning Group that allows and empowers the practice to dedicate more time and resources looking after their frail patients. All patients had a care plans and 100% of these had been reviewed within six months. The practice allocated an on the day appointment, for those able to attend the practice, for patients from care homes to see a GP if required.

• The practice offered proactive, personalised care to meet the needs of the older people in its population.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

• A partner visited a nursing home for a clinical session each week and reviews as many patients as needed. The GP provided and coordinated care with other agencies such as, occupational therapy, dieticians, community physiotherapists and pharmacists. This was said to be a clinical challenge at times as many patients had complex medical needs such as; step down beds from the local hospitals, admissions for palliative care, and urgent respite admissions via social services.

• The practice employed two part-time care coordinators who reviewed care plans, reviewed hospital admissions and provided further support coordinating with other organisations such as district nurses, physiotherapists and charity and other voluntary organisations.

Updated 22 June 2016

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

• The practice offered appointments outside of core working hours starting at 7.30am and offered extended hours two evenings a week,

• The practice provided online services to enable patients to book appointments, order repeat medicines and access some parts of their health records online.

• Health promotion and screening services reflected the health needs of this group.

• The practice was in the process of recruiting a prescribing pharmacist and a nurse prescriber to meet the needs of patients.

Updated 22 June 2016

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

• Performance for poor mental health indicators was in line with national averages. For example, 84% of patients with severe poor mental health had a recent comprehensive care plan in place compared with the CCG average of 89% and national average of 88%. Clinical exception reporting was however was higher at 36% when compared with the CCG average of 12% and national average of 13%. Clinical exception rates allow practices not to be penalised, where, for example, patients do not attend for a review, or where a medicine cannot be prescribed due to side effects. Generally lower rates indicate more patients had received the treatment or medicine. The practice was aware of these figures and had plans in place to address this.

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

• 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.

• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 22 June 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 including known vulnerable adults, those who were housebound and 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.

• 2% of the practices’ frail and complex patients (220 patients) who may be at risk of unplanned hospital admissions had been identified by the practice and a register and care plans for these patients were maintained.

• The practice provided primary care service support to a local Learning Disabilities college.