Background to this inspection
Updated
29 June 2017
Clock Tower Surgery was established in March 2000 in response to a national and local health care agenda. The contract provided is an Alternative Provider Medical Services (APMS) contract. Clock Tower Surgery is managed by Access Health Care Ltd, part of the wider Devon Doctors group (a social enterprise organisation). It is a GP practice commissioned to provide access to NHS primary care services for approximately 570 homeless and vulnerably housed patients. The vision and aim of the practice was to move patients on to mainstream GP practices once they had stabilised their lives and housing.
There was no practice profile data available regarding the demographics of the practice.
The practice is situated in the city of Exeter and works closely with other mainstream GP practices, health and social care services. The practice moved to the current cross sector hub in April 2016. The practice staff work with and refer to the other services within the hub. These include a homeless outreach team, mental health services, housing support groups, benefit and debt advice, sexual health support organisations, alcohol and drug recovery services and offender management services.
Patients are able to access midwifery, physiotherapy and optician services at the practice.
The practice has two salaried GPs, one of which is female and one is male. The GPs work 10 sessions (one whole time equivalent) and are supported by two practice nurses who cover the week between them. The clinical team are supported by a practice manager, a receptionist and an administrator.
The practice was not a teaching or training practice but accommodated GP trainees to come and observe the assessment and treatment of patients as part of their wider training programme. The practice takes first and third year medical students on a regular basis throughout the academic year for the Peninsula Medical School (PMS). All of the students spend time shadowing the GP’s and nurses and often have some project work in relation to the patient group. Complimentary feedback about the practice and the mentorship of the medical team from both the PMS and the students is often received. Clock Tower Surgery also supported the RD&E Hepatology department Exeter in accommodating some of their second year students.
The practice is contracted to open between 9.15am to 5pm with appointments available from 9.15am until 12.15pm and between 2pm until 5pm. Patients are able to access a drop in clinic between 9.15am and 10.45 all patients arriving at the practice during these times are seen.
Patients are encouraged to access the local walk in centre and out of hours service when the practice is not open.
The practice is registered to provide regulated activities which include:
Treatment of disease, disorder or injury, surgical procedures, maternity and midwifery services and Diagnostic and screening procedures and operate from:
Exeter Co Lab (Previously called Wat Tyler House)
King William Street
Exeter
EX4 6PD
Updated
29 June 2017
Letter from the Chief Inspector of General Practice
We carried out an announced comprehensive inspection at Clock Tower Surgery on 10 May 2017. Overall the practice is rated as outstanding.
Clock Tower Surgery was established in March 2000 in response to a national and local health care agenda. It is a specific GP practice commissioned to provide access to NHS primary care services for approximately 570 homeless and vulnerably housed patients. The vision and aim of the practice was to move patients on to mainstream GP practices once they had stabilised their lives and housing.
Our key findings across all the areas we inspected were as follows:
- Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
- Patients we spoke with said they found it easy to make an appointment with the GP and said there was continuity of care, with drop in appointments and urgent appointments available the same day. An average of 300 patients per month had used the GP drop in service over the last three months (130 for the nurse) and 150 patients had attended booked appointments (45 for the nurse).
- The practice had good facilities and was well equipped to treat patients and meet their needs.
-
There was a clear leadership structure and staff felt supported by local and organisational management. There was an atmosphere of mutual respect and team work amongst the staff group.
-
There were systems in place to monitor and improve quality, identify business risk and systems to manage emergencies.
We saw three areas of outstanding practice:
There was a truly holistic approach to assessing, planning and delivering care and treatment to patients who use services. Staff worked collaboratively with many other providers, both within the hub and externally, to ensure the vulnerable patient group was supported to receive coordinated care which met their needs. Practice staff used opportunistic, innovative and efficient ways to deliver more joined-up care to patients. For example, the practice worked with the Hepatology Department at theRoyal Devon and Exeter (RD&E) Hospitals NHS foundation Trust to provide an outreach drop-in clinic to see patients with viral hepatitis. Since December 2016 the hepatology nurse had completed 12 fibrosis scans (a simple and non-invasive test that can reveal any fibrosis or fatty deposits within the liver) at the practice meaning patients did not need to attend the RD&E hospital.
The involvement of other organisations and the local community was integral to how services were planned and ensured that services met vulnerable patient’s needs. The staff worked as advocates and used innovative approaches to providing integrated person-centred pathways of care that involved other service providers and charities both within the hub where the practice was situated and externally. The aim was to move patients onto mainstream GP services once patients had stabilised their housing and social situations in conjunction with their health needs. As a result, between October 2016 and March 2017 the practice had enabled 123 patients to move on to mainstream services.
Practice staff provided a GP service to patients who had been barred from other services due to the nature of their behaviour. The practice staff used an Acceptable Behaviour Contract where needed to ensure behavioural boundaries were agreed whilst they received treatment. Practice staff had shared this contract with NHS England and other GP practices and given advice when requested of how to manage difficult situations.
The areas where the provider should make improvement are:
Review processes, systems and records for lower level incidents and occurrences.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
People with long term conditions
Updated
29 June 2017
This population group was not rated because of the small numbers of patients in this population group.
-
The practice had found the most effective way of working with patients with long term conditions was by using ‘opportunistic’ screening and reviews and by also using a robust re-call system.
-
The practice nurses had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
-
Longer appointments and home visits were available when needed.
-
When patients attended the practice for the first time they had a named GP who with the support of the nurse carried out health screening checks. Patients were then offered an individualised plan, with structured reviews of their health and medicines whilst they remained registered at the practice.
-
If practice staff were unable to contact a patient through recall, text reminder or a telephone call, one of the clinicians completed a welfare visit to the person’s last known abode or made contact via other involved services.
-
Patients were made aware of the wide range of support sources that were available to them. Social Services and Community Services were also contacted if required by the GPs and the patient.
-
The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional social or health needs.
-
There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.
Families, children and young people
Updated
29 June 2017
This population group was not rated because of the small numbers of patients in this population group.
-
The practice was available for the ‘homeless and vulnerably housed’ so did not encourage families or young children to register but were directed to other mainstream GP practices.
-
If any female patient became pregnant practice staff linked them in and liaised closely with the duty midwife and maternity services.
-
Pregnant patients were added to the practice ‘complex patient’ list for regular discussion at the fortnightly practice meetings. Once the baby was born they were seen by the nursing team for the initial vaccinations before being encouraged and supported to register in a main-stream practice.
-
The practice had a very small number of young patients registered. Depending on their age and housing status these patients were treated as any other patient but offered additional support. For example, housing, benefits and food vouchers through a co-ordinated approach by the practice and other local agencies.
-
The practice had a small number of young patients living at the local YMCA and worked with additional support workers for the care of those patients.
-
Access to contraception advice and support was also available to young patients.
Updated
29 June 2017
This population group was not rated because of the small numbers of patients in this population group.
-
The practice had a small number of older patients. For example, of the 570 patients 66 were between the ages of 55 and 75 and four were above the age of 76. The practice offered proactive, personalised care to meet the needs of the older patients in its population.
-
The GPs at the practice worked with staff in local nursing homes when patients lived there.
-
The practice worked closely with community nursing staff to ensure effective outcomes for patients.
-
Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
-
The practice followed up on older patients discharged from hospital and ensured that any extra social or health needs were addressed.
-
Where older patients had complex needs, the practice shared summary care records with local care and support services.
-
The practice was responsive to the needs of older patients, and offered home visits and rapid access appointments as well as a walk in appointment service to see a GP and/or nurse every day.
Working age people (including those recently retired and students)
Updated
29 June 2017
This population group was not rated because of the small numbers of patients in this population group.
-
The majority of the registered patients were of working age or older, due to their circumstances; however, being homeless or vulnerably housed, they were not able to work due to ill health, substance misuse and social situations.
-
The practice offered five 15 minute ‘walk in’ appointments each morning and often added additional appointments for patients in need in response to fluctuating demand.
-
The practice did not currently offer extended hours as patient demand did not require this.
-
Students located within the city were re-directed to the University to seek advice on an appropriate practice.
-
Practice staff acted as advocates and gave assistance to patients to help them access financial and housing support so they might take the first steps towards having a more stable life.
People experiencing poor mental health (including people with dementia)
Updated
29 June 2017
The practice is rated as outstanding for the care of people experiencing poor mental health (including people with dementia).
-
The practice was situated within a Health, Wellbeing and Community Hub for patients within central Exeter presenting with complex needs. Services include: substance misuse, housing needs (homelessness), offending behaviours, access to primary health care services, access to employment and training, together with access to benefit and debt advice. This provided services under one roof for patients and promoted well co-ordinated care and support for them. Almost all patients attending the practice had received assistance from one or more of these services in conjunction with the practice.
-
Staff knew their patients well enough and had received training and mentorship to detect early signs of mental health relapse and worked closely with patients to keep them safe.
-
The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health.
-
The mental health team were sited within the surgery at Wat Tyler House.
-
The clinical team liaised as required with the mental health team and also met every Wednesday morning with the team and psychiatrist to discuss and review the current caseloads, priorities and update the patient plan on the clinical system.
-
Safeguards were in place to make sure high risk medicines were identified and regularly monitored. The practice held a list of all patients on ‘depot’ medicines (), which included the date when it was last given and next one due. The list was closely monitored by the practice nurse and demonstrated the team was proactive in engaging with patients on this medicine to ensure their safety.
-
Records showed medicines were given as prescribed, which was crucial in stabilising patient’s mental wellbeing so they did not experience unnecessary hospital admission due to mental health crisis. Patients had experienced a discussion about their lifestyle, about their drinking, smoking habits and use of legal highs to help them understand the risks involved with their lifestyle.
-
The practice carried out cervical screening for female patients. Of the 64 eligible patients (25 years plus), 38 smears had been completed (60%) within last 5 years, 11 within the past 12 months. The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations; this was actively promoted by practice staff.
-
The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
-
Shared premises enabled face to face discussions to take place and for responsive support to be available when patients were in crisis.
-
Staff had received training on how to care for patients with mental health needs and dementia.
People whose circumstances may make them vulnerable
Updated
29 June 2017
The practice is rated as outstanding for the care of people whose circumstances may make them vulnerable.
-
The majority of patients at the practice were classed as ‘vulnerable’ either due to their social circumstances (housing situation), health or both. For example, homeless patients, travellers, patients with mental health issues and those with learning difficulties. The aim was to refer patients to a mainstream GP but this only happened when there was evidence that patients were ready and were permanently housed.
-
The dedicated Clock Tower team acted as advocates for patients and worked in partnership with other involved services to ensure that vulnerable patients took priority and were monitored and sign-posted appropriately to receive the best care and support available.
-
The practice was situated within the health and wellbeing community hub which made it easier to signpost directly and avoid unnecessary delays with care plans and duplication of work. This enabled all patients to receive the most effective care pathway for their circumstances.
-
GPs working at the practice had experience in the treatment of substance misuse and took part in shared care prescribing for 70 patients who were part of the RISE service (Recovery and Integration Service). This enabled the GPs to engage and treat vulnerable and hard to reach patients with an aim to reduce drug- related deaths and improve both health and social care outcomes.
-
Staff interviewed knew how to recognise signs of abuse in young patients and adults whose circumstances may make them vulnerable. They 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.
-
Homeless patients could access a GP from the practice without an appointment at the walk in clinic five times a week. They could also be seen by appointment at different times of the day if they preferred. The practice was responsive and saw all patients needing urgent assessment and treatment within minutes of arriving.
-
Staff from the practice had volunteered with the outreach team by providing hot drinks to homeless people in the streets of Exeter and used the opportunity to identify people in need of health care provision.
-
The practice offered 15 minute appointments as standard.