Keston Medical Practice

Updated 8 November 2016

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.
• Performance for most diabetes related indicators was below the national average.
• Longer appointments and home visits were available when needed.
• All these 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.
• For patients with diabetes the practice provided drop-in clinics, to allow patients to get timely advice regarding controlling their blood sugars, especially when they have had a medication change or been started on insulin.

• With the patient participation group, the practice organised evening seminars about diabetes and pre-diabetes. Longer appointments were available for patients with complex diabetes.

Updated 8 November 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’s uptake for the cervical screening programme was 88%, which was comparable to the national average of 82%.
• 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 8 November 2016

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.
• There was also a schedule of routine home visits by GPs, to provide health and medicine reviews for housebound patients, many of whom were older people.
• The practice initiated a system to improve engagement with staff at nursing homes where they looked after patients, as part of a local improvement scheme. The practice did an audit to assess the impact of the protocol, and found that GP time was being used more effectively, treatment was being provided in a more timely way attendances at hospital accident and emergency (A&E) had reduced. It is generally recognised that A&E attendance should be avoided where possible, and particularly for vulnerable older people, who suffer particularly when moved urgently this stressful and unfamiliar environment. The protocol that the practice designed has now been adopted by the CCG.

Updated 8 November 2016

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.
• Annual ‘flu clinics’ were run on a Saturday, to make it easier for working people to attend.
• 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.
• Patients at the practice were more aware than others locally and nationally of the online services their practice provided.

Updated 8 November 2016

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

• Performance data for most indicators of care for people experiencing poor mental health was in line with national and local averages. However, only 75% of patients diagnosed with dementia had a face-to-face review of their care (compared to 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.
• 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 8 November 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 homeless people, travellers and those with a learning disability.
• The practice offered longer appointments for patients with a learning disability and home visits for annual health checks.
• In 2015/16, 97% of patients with a learning disability had a health check (2015/16 data from the practice, 126 patients on the practice register).
• 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.