Thank's Sharon, Celebrating 20 Years of Outstanding Service

Thank you Sharon.

This week we are celebrating the 20th birthday of the practice, and 20 years since our wonderful secretary, Sharon, joined the surgery team.

Sharon has been instrumental in the success of the practice. She is happy to turn her hand to anything and has, in the past, supervised the reception team as well as her performing her administrative and secretarial roles. Sharon is incredibly helpful to our patients and to all of the team here at St Wulfstan. In fact, she is kind and caring to everyone she meets. She really is the most wonderful colleague and friend to all of us and we are so lucky to have her!

So, congratulations Sharon on 20 incredible years – we don’t know what we would do without you.

Join a Great Team: Part-Time Receptionist Vacancy

Receptionist Vacancy

Our Reception Team is Incredible! We pride ourselves on offering a fast, friendly, efficient service.

According to the 2001 GP Patient Survey:

  • 98% of patients found it easy to get through to us via telephone (national average was 68%)

  • 97% of patients found our receptionists helpful (national average 89%)

  • 96% of patient were satisfied with the appointment times we had available (national average 67%)

We are currently looking for a Part-Time Receptionist to join our team for 16 hours per week - so get in touch!

Click to find out more details or apply.

Applications close 4th August 2021.

10 Minute Shake Up Games for Kids!

The NHS have teamed up with with Disney, Pixar and Marvel to create some games which you can play at home, inspired by some of the kids favourite characters! Why not give them a try and keep the kids more active throughout the Summer holidays.

According to Public Health England it is recommended that “children take at least 60 minutes of moderate to vigorous physical activity every day. Even before the effects of Covid-19, less than half of children were meeting this and in the last 15 months, since the pandemic began, we've seen rates fall further. This, in combination with the decline in physical activity during the summer months, means it is more important than ever that we help keep kids active during the holidays.”

You can even order your own free Shake Up Pack to help you get going.

Sleep Hygiene: How to Sleep Better... 😴💤🛌

This is the second article from Ludmila, our Health & Wellbeing Coach on sleep. You can read the first here.

If you want to find out how you can sleep better, please read on…


Sleep Hygiene

 

Work on your sleep throughout the day so it can happen for you throughout the night.

Sleep is something that needs adjusting, like a clock that does not keep the time so well. The brain needs information from the outside to trigger the release of sleep and wake hormones every day in the right amount. If we do not keep up with the correct cues for sleep, the system gradually gets out of sync. Worse even, if we fail to work on our sleep patterns, we never feel refreshed in the morning and the body must function in a depleted state of energy. Over the years, this can lead to increased ageing and susceptibility to the development of chronic diseases. A good night of sleep every night is a basic need and nobody can function well in the day without it though for some people the number of hours needed for rest may be less than average. But even for those who can function well on less sleep, regularity is still a must.

 

Sleep and mental health. 

Sleep and mental health go hand in hand and people who suffer with insomnia are 10 times more likely to develop mood disorders. Sleep disturbance is a strong risk factor for the development of major depression and patients are less likely to respond to treatment for depression if they have chronic sleep problems. Addressing sleep as a priority may be the first step towards improved health and wellbeing. It can seem difficult to improve sleep as if it is something out of our control, but by following the steps listed below it is possible to start making gradual improvements until a new night-time routine is established.  

 

Good sleep happens with routine – mornings are not for catching up on missed sleep.

Waking up at the same time every day is a simple trick that many people miss out on. We tend to think that if we are sleep deprived, we ought to catch up on sleep by staying in bed and getting up later the next morning or on weekends for many who work long hours during the week. However, by creating this contrast between weekdays and weekends, we actually promote sleep dysregulation and risk insomnia becoming a long-term problem. Even if it makes us tired, it is much better to keep to the same wake up time and get up as a routine every day. To catch up on sleep, try instead to go to bed half hour earlier over the course of a few days. If you cannot afford going to bed earlier, keeping to a regular sleep routine, however many hours you can manage, is an important factor. Even if you did not get a nice rest, you should get up at the usual time. Working on a bedtime routine which helps the brain to wind down is a big help to set up a regular sleep pattern. There are countless free apps which provide guided meditation for free. Setting 5 minutes aside for a quick but regular meditation practice in bed is a simple and yet transformative practice to achieve better sleep.

 

The contrast between light & dark/ day & night helps the brain to switch sleep on and off.  

To promote sleep at night, the best strategy is to get exposure to sun light outdoors as early as possible. When the weather is overcast, we can maximise the effect by prolonging the exposure. But even if time is limited, a brief exposure to natural light first thing in the morning will still be helpful.   

Viewing bright light suppresses sleep whilst total darkness promotes sleep. Avoiding light at night, especially avoiding light from electronic devices such as phones and computers is very important for the brain to switch on the sleep hormone melatonin. However, that is not the whole story. The amplitude is also a factor. Natural sunlight exposure during the day and avoidance of artificial light at night is a strong predictor of an ideal night of sleep. The brain looks for the contrast between bright and dark and the bigger the contrast between day and night, the stronger our drive to sleep at night. You will notice that from days out in the country or holidays abroad when you stayed outdoors for long. There is a guaranteed good night of sleep at the end of days like that. Not just because you moved about and were active, though that counts as well, but especially because you were out receiving natural light through your eyes most of the day. Of course, we cannot always spend most of our time outside during the day but getting some exposure first thing in the morning and perhaps again at lunch time or at the time of sunset is an extremely powerful aid to sleep.  

 

There is a reward system in the brain for viewing light early in the day (dawn) and then again at the time the sun is setting (dusk). The configuration of light, combining different spectrums of blues and yellows at the beginning and end of each day is very informative for the brain. Those moments send signals to our internal clocks and promote synchronicity with our environment. If we dedicate some time to do that every day, sleep becomes like clockwork.  On the other hand, there is a punishment system in the brain for when we expose our eyes to bright light in the evenings. Human brains were not designed to see bright light after sunset and if we expose our eyes to bright or artificial light other than a candle or fireplace after dark, we are sabotaging the quality of our own sleep, depriving ourselves and impairing our ability to recharge and repair our bodies.

 

Bed for sleeping, not for browsing. 

About 130 years ago, we used to sleep around 9 hours on average. These days, the average is 6.5 hours and that is thanks to electricity. The issues around light exposure at night are not just about 'blue light' from screens and computer. Blue light does have the strongest effect in suppressing the sleep hormone melatonin, but it is not the only frequency that can affect us. Ideally, we should set an early finish with phones, laptops, computers, and screens 3 hours before bedtime. If browsing the phone in bed is a habit hard to break, it is much better to do it in the morning. But the best is to leave the phone charging downstairs or away from the bedroom. Bed should not be associated with screen activities. Avoiding screen related activities in bed helps the brain to create patterns that associate bed with sleep. For the same reason, staying in bed for too long whilst trying to fall asleep when not tired may not be helpful. Instead, getting up early the next day will set the brain on a mission to make an early appointment with bedtime for the next time.  

  

The more you move during the day, the more you sleep during the night.

Exercising early is good to help with sleep later but vigorous exercise in the evening is likely to release the wrong chemical signals and keep you awake beyond the point you should. Although exercise is good to promote sleep, timing is also important for that matter.  Ending exercising up to 3 hours before bed is a good cut off point to prevent triggering alertness at the wrong time. 

  

The less you sleep, the more you want to eat.

Another problem that comes from bad sleep is the tendency to eat more junk foods. When we manage to fall asleep, it means the body can relax and let go. When we cannot sleep, the body interprets that as a need to stay alert and restless. Skipping on relaxation at night informs the body of some danger or threat we need to prepare for (even if that is not the case).  Because of old mechanisms of survival hardwired into our brains, sleeping less is interpreted by the brain as pressure to move more (as in running away or running after something we need). This pressure can sometimes be translated in the body as stress and anxiety.  For that reason, our brains will seek to find quick energy supplies to keep up with the anticipation for increased demands (including energy demands for a quick escape or physical engagement). We then develop an increased appetite for salty, fatty and sugary foods – all the main ingredients of junk high calorie foods. 

 

These mechanisms are old and they have been with us for thousands of years, even though, in modern day life, we hardly ever need to run away from things to survive. We are much more likely to eat all the extra energy and just accumulate more weight because of bad sleeping habits.  The take home message is: if you do not sleep well, your body interprets that as a signal for physical engagement and need for sugar. Moreover, if you do not sleep well and do not exercise the next day, you can see you will be left with the inevitable consequences of gaining extra weight. 

 

The right time for caffeine (coffee, black or green tea).  

Caffeine is a powerful aid in staying awake and it is no wonder coffee is so commonly taken first thing in the morning everywhere in the world. But to continue to take caffeinated drinks throughout the day is a mistake when you wish for a good night of sleep. Caffeine has a chemical that occupies the receptors for adenosine. Adenosine is the breakdown product of energy. The more tired you get, the more adenosine you accumulate through the day. Nothing gets rid of adenosine except for sleep. However, although caffeine cannot eliminate adenosine, it can block its signals. So by drinking caffeine, we can remain awake but not because we are not tired. We remain awake and build up sleep deprivation. As soon as the caffeine wears out, we need more to avoid crashing.

 

Some people are particularly fast in processing caffeine and they can drink coffee and go to sleep without any difficulty. For them, caffeine does not occupy the receptors for adenosine because these receptors are slightly different. That is down to genetics, but for most people, caffeine interferes with sleep. If you are not sure, experiment and check for yourself: are you building up an energy deficit and masking it with caffeine every day? Or are you managing to sleep and restore your energy waking up refreshed every morning? If you are rested, you can take it or leave it when it comes to coffee. Caffeine is not the villain and you don't need to eliminate it from your life, but if you are dependent on it to function, you may benefit from changing how you use it.  For most people, caffeinated drinks are best taken in the first part of the day, ideally up until noon. In the afternoon, non-caffeinated drinks such as water and herbal teas will be more helpful to allow the body to build up its adenosine stores and let the brain gradually wind down in preparation for sleep later. If you work with your body, you will have better results. Sometimes all that is missing is that we notice some signals given out by the body day by day but missed out as we simply did not know their meanings. Try and find out whether you are missing out on any clues your body has been offering.  

 

Remember that if you decrease your intake of caffeine and especially if you withdraw from caffeine completely it will take a few days for the body to adjust. Stay with it until you reach the other side and work on as many other aspects of sleep as you can. In a couple of weeks, you can look back at your experience and see if there was something there you were meant to learn.

 

By LUDMILA ENTICOTT

By LUDMILA ENTICOTT

Sleep: So Much More Than Rest... 😴💤🛌

Welcome to our latest article from Ludmila, our Primary Care Network Health & Wellbeing Coach.

Please read on. And come back next week for our post on specific things you can do to improve your sleep.


Sleep: so much more than rest

-        When we sleep, we lose weight.

-        When we sleep, we fight infections.

-        When we sleep, we repair structures.

-        When we sleep, we rejuvenate.

-        When we sleep, we consolidate learning.

Are you getting enough sleep at night to fully function in the daytime? What else could you be missing out on?

How is sleep regulated?

The main hormone associated with sleep is called melatonin. Melatonin production in the brain is stimulated by darkness and suppressed by light. That is the reason behind the advice to avoid light exposure from screens such as phones and computers at night. The threshold to suppress melatonin has been estimated to be as low as 30 lux, which is well below normal fluorescent light of about 300-400 lux. The light picked up by our eyes informs the brain of how much melatonin to produce. Exposure to light at night will therefore suppress our ability to produce melatonin. With suppressed melatonin, we suppress sleep. With suppressed sleep, we may be missing out on a lot more than rest.

What else happens when we sleep?

The sleep hormone melatonin controls a whole load of other functions in the body. As the brain gets off to sleep and skeletal muscles remain still, the body switches to a completely different mode of action that allows for other parts of the system to boost. Some systems increase their activities whilst the brain and the muscles decrease the demand for energy. The brain is incredibly power hungry, and it consumes a lot of the available energy generated in the daytime to maintain cognitive and social activities. At night, during sleep, there is a shift in activity and even weight loss is promoted throughout the night – that is if you get a good night of sleep and respect your circadian rhythms.  As we stop eating whilst we sleep, fat cells should come to the rescue and provide much of the energy necessary for running the system overnight. This is especially so when we stop eating early enough in the evening to allow a few hours before we go to bed. Not everyone manages to rely on their fat reserves to make it through the night though and this is one of the reasons why people might sometimes wake up in the middle of the night struggling to fall back asleep. When our fat cells are not flexible enough and we rely on constant food intake for energy, we train our bodies not to rely on stored fat and the result could be a rush of adrenaline late at night. When blood sugar falls below a certain level, adrenaline is released with an alert to the system of low energy to make it through the night. Adrenaline will trigger the release of emergency reserves of sugar stored in the liver but at the cost of stress to the system and inability to relax back into sleep. 

Our natural daily rhythm – why is it important?

An energetic switch from brain to immune system also happens at night. During the day, and in health, the immune system works more in surveying mode which is cheaper and allows for the brain to be prioritised with energy during waking hours.  At night, or when we fight infections or disease, the immune system behaves differently taking up more energy to increase its functions. The immune system gets on with a lot of housekeeping in preparation for the next day. It not only protects us from invading viruses, bacteria, and other microbes but also promotes repair and rebuilding of structures that get damaged through wear and tear or injury. The switch from day to night, brain to immune function, food to fat is part of what we call circadian rhythm. Our bodies follow hormonal signals that keep this switch regularly aligned with the changes between light and darkness. A regular sleep pattern means we allow the body to attend to many maintenance functions that require night-time hormones and a resting brain for the work to be carried through.

Sleep and disease – how do they connect?

Sometimes the immune system might take over daytime activities and literally put us in bed. A good example of that is when we fall ill with the flu. Chemical reactions happen faster in higher temperatures, so we develop a fever to accelerate these reactions in the fight against infection.  As the brain gives way to the immune system to defend the body, we develop what is known as 'sickness behaviour'. We literally become withdrawn and tend to stay in bed. When the fight is over and the inflammation starts to abate, the energetic drain is alleviated, and we regain the interest in social life and engagement with other complex cognitive activities. It is possible to notice how the need for sleep increases if the body is busy defending or repairing parts of the system.

When we disregard our needs for regular sleep, especially over prolonged periods, the whole system is impacted and desynchronised. It is no coincidence that, when health first starts to decrease, sleep problems tend to show up first. Soon, if unaddressed, these problems can progress towards inflammatory states that can lead to diseases, chronic pain and fatigue further down the line. Inflammatory chemicals increase in response to short or disturbed sleep. Ongoing states of low-grade inflammation are linked with increased risk of cardiovascular, neurodegenerative, auto-immune diseases, diabetes and chronic pain conditions. 

So making an effort to keep to a regular sleep routine and respecting the time limit for exposure to light may be a worthy habit to maintain. As always, our bodies are highly dynamic and sophisticated systems that interconnect and self-adjust with a precision we are yet to appreciate. It pays to invest in a healthy lifestyle and to consider how or choices today may impact our lives tomorrow.


Come back next week for specific tips on improving your sleep…

By LUDMILA ENTICOTT

By LUDMILA ENTICOTT

A Wonderful Patient Story...

At St Wulfstan Surgery we are always keen to hear great patient stories. And this one is particularly inspiring. Thank you Teresa for writing this article, and well done! Your amazing journey is summed up by the before and after photo above. Thank you for letting us be part of that journey!


My journey started at st Wulfstan Surgery in 2007 after being diagnosed with arthralgia of multiple joints in 1981. I had numerous hospital appointments and admissions in hospital for treatment of my painful joints.  In between, I studied at Warwickshire college and did my NVQ in business administration.

I won an award at college for my courage and bravery as I was poorly but determined to pass my qualifications.


When I joined St Wulfstan Surgery in 2007 I was very poorly, needed 24-hour care and was using an electric wheelchair. My joints had become so painful that I couldn’t walk and my asthma hit a turn for the worse. I developed swallowing problems and I had reoccurring chest infections due to aspirating and food going in to my lungs. I had to have a supra pubic catheter fitted due to fluid retention and incontinence and my kidney test results were not good. I had restricted opening of my mouth which caused me lots of pain and affected my speech and eating. After my jaw surgery, I had to have regular steroid injections in my jaw joints at the hospital.

Dr Viswa and team of GPs and nurses at the surgery have given me outstanding care and attention and looked at different treatments. They provided me a care plan to keep me from being admitted to hospital all the time always being there to support me and my family putting things in place to help my day to day quality of life.

 

Some days used to be very hard battling with this extreme pain, not being able to move, having to have help washing, dressing, feeding, not being able to sit up as my muscles got weak, not being able to stand as my leg muscles got weak. Later I was diagnosed with fibromyalgia which affected me mentally and I found it hard to cope.  Dr Viswa and the team was always there to talk to and help me get through this illness.  But the most important thing was my determination and self help!

 

In 2018 I found some inner strength with my treatment and pain under control. I started to gain some mobility. I remember going to see Dr Viswa for an appointment and she had a surprise seeing me walk into her consulting room on a walking frame.  I gradually progressed to being able to swallow better with using special thickener to put in my puréed food and fluids and gaining some strength. Also my asthma had settled as I was not getting as many chest infections and not aspirating so frequently.

 

Here I am today, coping with my illness with a manual wheelchair as back up and taking a new step everyday.  I am waiting for a hip replacement as I have osteoarthritis in my right hip but I keep my determination going. 

 

On the 9th June 2021, I walked down the aisle to marry my best friend in the world ‘Dave’. Dave has seen me through my journey as he was my wheelchair engineer and friend.  We got together in 2019. It was a day he will never forget, after coming annually to service my wheelchair, he was not expecting me to greet him at the door, standing

By Teresa


If you have a story you would like to share, who not email us!

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Local COVID-19 Vaccination Update

The Southam Clinic COVID-19 vaccination programme has continued at pace.

It is now possible for adults from the age of 18 upwards to book their vaccine if they have not done so already.

To book please call the Southam Clinic COVID-19 Vaccination Booking line on 01926 962719.

It is also possible to book vaccinations outside of Southam by visiting the dedicated NHS vaccine booking page.

👇👇Want to stay up-to date? Why not register for our weekly newsletter by registering towards the bottom of this page… 👇👇

Welcome Carole - Our Frailty Nurse Practitioner! 👩‍⚕️👩‍⚕️

A warm welcome to the latest member of our team!

Carole is an experienced Registered Nurse whose career has spanned over 42 years to date. 

She has worked in both hospital and community settings and has cared for patients with a wide range of health conditions.  In her previous role, she was working as a nurse consultant in cancer at Oncology Unit, South Warwickshire NHS Foundation Trust.     

Caring for patients with long term health conditions has equipped Carole with the skills and knowledge to undertake her current role as a Frailty Nurse Practitioner.  In this role, she is working within our local nursing and residential care homes.  Together with the GP’s and pharmacists, she will be working with the residents, carers/relatives and home staff to optimise the residents health, plan for future health events and support them when their health needs changes.  She will also support the care home staff with training and development.  She will play an important role in care home multidisciplinary team meetings at St Wulfstan Surgery. 

A big, warm welcome to Carole!

My Bowel Cancer Story - Why Screening Is So Important 💩💩

This little kit could save your life.

Bowel Cancer screening has been introduced to try and identify bowel cancer early, so early that you may not even have yet developed any symptoms of bowel cancer. And the sooner cancer is diagnosed, the better the chances are of having a successful treatment.

We asked Clive Challinor if he wanted to share his story having recently been diagnosed with bowel cancer, even before any symptoms actually developed. Please read his article below. Thanks Clive!


I have been asked by my GP to put together my thoughts and honest feelings about a very important decision in my life and it is still going on today. Like most people, we get up in the morning, get dressed, pick your lunch, kiss the misses and kids and head off to work. Come home, kiss the family, do some DIY, have your evening meal, sort the kids then retire to bed ready to start again on the circle of life without a thought for things that can change your life.

Back in February I received a BOWEL TESTING KIT. I looked at it and like most people put it on the work surface to read later thinking ‘why have they sent me this, I have no symptoms, no pain, no discomfort, no bleeding.’ That’s WHY in-fact it took me about 2-3 weeks to make the decision to open it up and read it and work out the best way of using the poo stick. I finally did it and sent it off at the end of February thinking at least thats done.

I carried on with my life until one day I received a letter. ‘Please can you attend on the 5th march 2021 Warwick hospital ENDOSCOPY UNIT for a COLONOSCOPY examination’. I replied and attended my routine appointment. This took about 2 hours in total. At the end of my appointment I was in bits. See I was coming up to 63 years young, having lost my father some 30 odd years earlier with lung and brain cancer at about the same age.

WHAT NOW.... I have cancer, Christ what about my work, my family, my daughters and my grandson, I have not seen him yet. PANIC oh sh*t, I felt so alone just lying on the bed after the biggest event of my life. Then, after getting dressed and a few more tears I met Alison, my COLORECTAL NURSE, who said ‘you are not alone, we are all here to help you. All of us.’

This is now a journey of blood tests, scans, operations and chemotherapy and lots of doctors appointments and hopefully full recovery. So on the 13th April I checked into Warwick hospital 7.30 am 23 hour ward following a covid test 3 days before. I was sent upstairs after another check to meet my surgical team and got on with it. At 1530 i came round feeling rather groggy, but the nurses and doctors were fantastic, making me very welcome and comfy. I left the hospital on Saturday evening and returned home. About 2 weeks later my surgeon rang to tell me it was a success and that on further examination, they had found a small hernia and also removed 18 lymph nodes, with 1 being cancerous. Hence I needed chemo.

PLEASE DON’T IGNORE THE TEST get it done. I have and I am glad I did it.

Thank you for reading this, now for my next stage...
— Clive Challinor

The screening test is sent every 2 years to those aged between 60 and 74 years. If you're 75 or over, you can ask for a kit every 2 years by phoning the free bowel cancer screening helpline on 0800 707 60 60.

For more details on screening, please visit the NHS bowel cancer screening page.

A Few Words from Mina, our Clinical Pharmacist... 💊💊

By Mina Hunjan, Clinical Pharmacist

By Mina Hunjan, Clinical Pharmacist

A few words from Mina about her new role at St Wulfstan Surgery…

My name is Mina and I'm one of the Clinical Pharmacists at St Wulfstan’s surgery.  I form part of the multi-disciplinary team looking after Care Home residents. 

 

I've always worked with Care Homes and in my last role, I helped support them through the pandemic.  I have to say that in such challenging times, the dedication and care shown by the carers was so inspiring. I'm sure we are all grateful for their efforts and thankful that Care Homes are becoming more accessible once again.  

 

The part of my job I enjoy the most is helping the residents understand their medicines and supporting carers and families during medication reviews.  To do this effectively, I spend time at the surgery checking their electronic records for medication lists and dosage, their indications, searching for any interactions and their recent investigations.  Then I arrange visits to Care Homes to discuss resident's medications to find out what they take, their medicine likes and dislikes and if it's working!  When we talk together, it is a great opportunity to hear the resident's ideas, concerns and expectations of their medicines and get the whole picture. Carers and patient’s families are also invited to give their views, meaning we can optimise resident's medicines in a holistic way and sharing the decision-making process. 

 

At the surgery, we meet in a multidisciplinary team which is led by Dr Viswa, in order to further discuss and optimise our Care Plan. This keeps the health, safety, wellbeing and most importantly of all, the wishes of our residents at the heart of Medicine Reviews and ongoing Care Planning. 

 

Working together like this is hugely satisfying and a great way to look after our most vulnerable patients. 

🤧 It's Hay Fever Season Again! 🤧

The sunshine has arrived - hooray! But for those of us with hay fever it can be bittersweet.

Hay fever is an allergic reaction to pollen and the symptoms occur or worsen in the Spring and Summer when pollen counts are higher. This can result in sneezing, coughing, a runny or blocked nose, itchy or watery eyes and an itchy throat.

 

We often get calls about hay fever at this time of year, but recent changes mean that most treatments for hay fever can now be purchased over the counter at your local pharmacy, meaning your pharmacist is often best placed to help.

 

The treatment of hay fever normally consists of antihistamine tablets, antihistamine eye drops and steroid nasal sprays. If required you can use a combination.

Anti-histamine tablets/syrup

There are several different types available from your pharmacy. If you try one which doesn’t help, then it is worth trying an alternative, unfortunately this often involves some degree of trial and error. Some anti-histamine’s such as Piriton (chlorphenamine maleate) can make you feel drowsy, so there are non-drowsy preparations available, such as cetirizine.

If, despite trying different anti-histamines, your symptoms persist then consider adding in eye drops, or a nasal steroid spray, or both.

Anti-histamine Eye Drops

These can be purchased from the pharmacy and work well where itchy and runny eyes are more problematic. The drug is called sodium cromoglicate.

Nasal Steroid Spray

These can work very effectively helping control your symptoms of hay fever and can be used in conjunction with the above treatments. Nasal steroid sprays can take days or weeks to reach their fullest effect so they are worth persevering with.

What Next?

If the above treatments, when used in combination, have failed to solve the problem, and you have given them a reasonable period of time to work, then please give us a call to discuss further.