Burlington Road Surgery

Updated 4 April 2018

• The name of the registered provider is Burlington Road Surgery. The practice address is 14 Burlington Road, Ipswich, Suffolk, IP1 2EU.
• The practice website is http://www.burlingtonprimarycare.co.uk
• The practice has a Personal Medical Services (PMS) contract with the local Clinical Commissioning Group (CCG).
• The practice is registered to provide diagnostic and screening procedures, family planning, maternity and midwifery services, surgical procedures and treatment of disease, disorder or injury.
• There are approximately 16,600 patients registered at the practice.
• The practice has six GP partners, (four male and two female) and one salaried GP (female). The nursing team includes three advanced nurse practitioners, all of whom are independent nurse prescribers, four practice nurses, two primary care associates and three healthcare assistants. They are supported by a dedicated clinician administration team. The practice manager is supported by three managers who oversee areas such as finance, human resources and information technology. There is also a dedicated prescription team, three medical secretaries and a team of reception staff. A multidisciplinary hub, led by a GP partner operates which facilitates flexible appointment times throughout the day.
• The practice is open between 8am and 6.30pm Monday to Friday. The practice
• has extended hours appointments from 7am to 8am Monday to Friday with GPs, advanced nurse practitioners and healthcare assistants and from 6.30pm to 7pm Monday to Friday with GPs.
• When the practice is closed, Care UK provides the out of hours service and patients are asked to call the NHS 111 service to access this service, or to dial 999 in the event of a life threatening emergency.
• The practice is a training practice, although there was no GP trainee placed at the practice at the time of the inspection. (A GP trainee is a qualified doctor who is training to become a GP).
• According to Public Health England data, the practice has an above average number of patients between the ages of 0-4, and a below average number of patients between the ages of 65 and 85, than the national average. Male and female life expectancy in this area is in line with the England average at 78 years for men and 83 years for women. Income deprivation affecting children is 23%, which is in line with the England average of 20% and above the CCG average of 13%. Income deprivation affecting older people is 21% which the same as the England average and above the CCG average of 13%. Just over 12% of patients are from minority ethnic groups.

Updated 4 April 2018

This practice is rated as Good overall. (Previous inspection report published 6 March 2017 - Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Burlington Road Surgery on 26 February 2018 as part of our regulatory functions.

At this inspection we found:

• The practice had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the practice learned from them and improved their processes.
• The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines. The clinical team met regularly to keep updated, share learning and review patients.
• The practice had developed a number of initiatives to improve the service provided to patients. For example, the General Practitioner Personal Assistant team; a dedicated clinical administration team.
• Clinicians worked in the multidisciplinary hub to ensure that patients were effectively triaged, assessed and directed to the most appropriate clinician with the right skill set, who then undertook further assessment and coordination as appropriate. Flexible appointment times were offered throughout the day.
• The practice had a strong focus on the training, development and support of all staff. Opportunities for learning were scheduled on a daily basis through the work undertaken in the multidisciplinary hub and a GP partner was always available for support and advice. Effective processes were in place for reviewing and developing the work of locum GPs, advanced nurse practitioners and nursing staff.
• The practice’s uptake for cervical screening was 61%, which was below the 80% coverage target for the national screening programme. The practice were aware of this and had taken some actions to improve the uptake. They had a dedicated nurse responsible for improving the uptake of cervical screening of women who were vulnerable due to language barriers, fear of the procedure or other social barriers. 2017/2018 unverified data showed the practice had achieved 70% so far.
• Staff involved and treated people with compassion, kindness, dignity and respect. All staff had received equality and diversity training. The practice were aware of the needs of the patient population and had health information packs available in four different languages.
• Patients generally found the appointment system easy to use and reported they were able to access care at the right time, although some patients reported dissatisfaction with the length of time taken to answer the telephone. The practice monitored feedback from the National GP Patient Survey and had implemented actions in response to the feedback.

• The practice were in the process of establishing a patient population group and were continuing work to identify patient representatives from the minority ethnic groups to ensure the views of these patients were obtained. They had decided to wait until the merger with another local practice had been completed so that there would be one patient participation group.

• Information on the complaints process was available for patients at the practice and on the practice’s website. There was an effective process for responding to, investigating and learning from complaints and responses to patients were timely.
• Staff told us they were happy to work at the practice, received training and support for their role and were encouraged to raise concerns and share their views.
• There was strong leadership; staff had lead roles and responsibilities. Effective governance processes were in place for ensuring that systems were safe and responded to the needs of patients and for monitoring performance.
• There was a strong focus on continuous learning and improvement at all levels of the organisation. The practice was a teaching practice for medical students and a training practice for qualified doctors training to become GPs. The practice offered opportunities for A level students who had been unsuccessful in their medical school application, to work as a healthcare assistant for one year. The practice advised that of the seven staff who have undertaken this opportunity, all of them have since gained entry to medical school.

The areas where the provider should make improvements are:

• Establish the patient participation group.
• Monitor and improve the uptake of cervical screening.

We saw one area of outstanding practice:

• The practice had set up a ‘multidisciplinary hub’ in 2015, where clinicians, including advanced nurse practitioners, primary care associates and GPs worked together in the same room, led by a GP partner, to ensure that patients were effectively triaged, assessed and directed to the most appropriate clinician with the right skill set. Further assessment was undertaken and care was coordinated by one clinician as appropriate to the patient’s needs, with GP oversight. This was for high risk patients but the service had flexibility to meet the needs of all patients with urgent and routine needs, depending on the demand. Flexible appointment times were offered throughout the day. Training was provided to the staff working in the hub opportunistically, based on the cases which presented. An audit on the effectiveness of the hub was completed in November 2015, which demonstrated positive outcomes. Patients who were at high risk were not delayed in needing to attend the accident and emergency department, as they had instant access to a GP for assessment and advice. Patients were subsequently followed up by a clinician in the hub. Six hours of GP training time was made available to supervise clinical and non-clinical practice staff in the practice. Primary care associates received training and mentoring in real time without affecting or compromising patient access. Feedback on the first 100 cases that the primary care associate in the hub had managed, had been obtained from patients, carers, clinicians and care home managers in November 2015. This feedback showed 100% satisfaction with the assessment and management by the primary care associate who worked in the hub and 100% satisfaction with the speed of delivery of medicines. A review of home visit requests showed that following triage, 30% of requests did not need a home visit; 60% of those patients came to the practice for their appointment and 40% had a telephone consultation. This enabled resources to be directed at those with urgent needs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 6 March 2017

The practice is rated as good 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.

• 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). At the time of our inspection the most recent published results for 2014/2015 were 90% of the total number of points available. The exception reporting rate was 7%, which was one percentage point below the CCG average and two percentage points below the national average. We saw that exception reporting across all indicators was generally in line with local and national averages. The practice performance for 2015/2016, which was published and validated following our inspection, was 98% of the total number of points available. The exception reporting rate was 10%, which was also in-line with both CCG and national averages. The performance for asthma related indicators in 2014/2015 was below local and national averages with the practice achieving 61%. This was 33 percentage points below CCG average and 36 percentage points below national average. The practice were able to demonstrate improved parameters and achievement across all QOF indicators for 2015 to 2016. Following our inspection we saw that the practice QOF performance for 2015 to 2016 had improved with the practice performance for the asthma domain increased to 100% across all asthma indicators with exception reporting in-line with local and national averages.

• Longer appointments and home visits were available when needed.
• Patients 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.

Updated 6 March 2017

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. Childhood immunisation rates for the vaccinations given were comparable to CCG/national averages. For example, childhood immunisation rates for the vaccinations given to under two year olds ranged from 61% to 97% which was comparable to the CCG averages of 73% to 95%, and five year olds from 68% to 96% which was comparable to the CCG averages of 71% to 97%.

• 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 74%, which was below the CCG average and the national average of 82%. There was a policy to offer telephone reminders for patients who did not attend for their cervical screening test.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• We saw positive examples of joint working with midwives, health visitors and school nurses.

Updated 6 March 2017

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

• 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.
• The practice worked closely with the multi-disciplinary team, out-of-hours and the nursing team to ensure proactive palliative care planning.
• 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, with the practice achieving 100% across both QOF indicators for 2015/2016.
• The practice looked after patients living in local nursing homes. GPs undertook regular visits and visited patients as and when required. The practice reported providing medical services to 50% of Ipswich care/nursing home beds. The practice had introduced a written service level agreement with each nursing home which set out an agreement and expectation of how the practice and nursing home would function and work together to provide effective care and treatment for patients. For example this detailed what procedures the practice expected the nursing home to have undertaken prior to requesting an annual health review for a patient. In addition to this, the practice undertook extended drug monitoring for each patient to ensure appropriate and effective prescribing of medicines were in place. The practice had an action plan in place for each nursing home with itemised actions and outcomes. For example, we saw that the practice was exploring working closely with the homes to develop a forum.

Updated 6 March 2017

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 reflects the needs for this age group.
• The practice also encouraged its patients to attend national screening programmes for bowel and breast cancer screening. The bowel cancer screening rate for the past 30 months was 57% of the target population, which was slightly below the CCG average of 63% and the national average of 58%. The breast cancer screening rate for the past 36 months was 78% of the target population, which was slightly below the CCG average of 80%, but above the national average of 72%.
• Patients had access to appropriate health assessments and checks. The practice did not undertake the 75+ health checks as they told us they were not satisfied with the outcomes. However the practice had developed and established practice specific multiple registers which linked to the practice admissions avoidance scheme, known as the ‘Burlington Blue folders’. These were overseen by the practice medical secretaries. This used a number of tools and research to identify and ensure effective and responsive care and treatment for older patients. For example, the practice used the Edmonton Frailty score, a tool used for the identification of frail patients before their vulnerability was made evident. GPs ran weekly audits to ensure the effectiveness of medication for patients based on clinical outcomes which were linked to guidelines such as the National Institute for Health and Care Excellence (NICE). Appropriate follow-ups for the outcomes of health assessments and checks were made, where abnormalities or risk factors were identified.

Updated 6 March 2017

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

• The percentage of patients diagnosed with dementia whose care had been reviewed in a face-to-face review in the preceding 12 months (01/04/2014 to 31/03/2015) was 87%; this was above the CCG average of 85% and the national average of 84%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. All staff were dementia friends and were dementia trained.
• The practice carried out advance care planning for patients with dementia.
• The percentage of patients experiencing poor mental health who had a comprehensive, agreed care plan documented in the record in the preceding 12 months (01/04/2014 to 31/03/2015) was 90%. This was above the CCG average of 85% and the national average of 88%. 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 6 March 2017

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 homeless people, travellers and those with a learning disability. The practice worked closely with the local learning disability nurse to case manage patients into the local learning disability pilot scheme.
• 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.
• An information sheet was provided to carers which included contact details on support services including Age UK, Suffolk Mind, Suffolk Well Being, Social Services and the Alzheimer’s Society. The practice facilitated a meeting for carers looking after patients with dementia. An outside speaker attended to give advice and signposting. This was well received with over 28 carers attending the meeting.