Buckland Surgery

Updated 24 December 2015

Buckland Surgery was inspected on Tuesday 20 October 2015. This was a comprehensive inspection.

The main practice is situated in the Devon town of Newton Abbot and provides a primary medical service to approximately 3,000 patients of a diverse age group. The catchment area for Buckland shows a nationally average deprivation demographic but practice data showed that the majority of patients lived in the area where the practice was located, which had a high number of social housing and higher than average deprivation rate.

The GP was a sole provider and held managerial and financial responsibility for running the practice. She was supported by a practice manager and three salaried GPs. There were two male and two female GPs at the practice. The team were supported by a practice nurse, health care assistant and additional administration staff. Patients also had access to community nurses and health visitors who are based at the practice. Other health care professionals visit the practice on a regular basis. For example community nurses and midwives.

The practice is open from Monday to Friday – 8am to 6pm. Evening pre-bookable appointments are available on a Monday from 6.30pm and on Friday mornings from 7.30am. Outside of these times patients are directed to contact the out of hours service (Devon Doctors) by using the NHS 111 number.

The practice offered a range of appointment types including book on the day, telephone consultations and advance appointments bookable up to four weeks in advance.

Updated 24 December 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Buckland Surgery on Wednesday 20 October 2015. Overall the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There was a systematic approach to use all opportunities for learning from internal and external incidents.

• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the practice were part of the one GP one care home scheme in the locality and had seen a reduction in hospital admissions.

• Feedback from patients was overwhelmingly positive. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment and were given sufficient time when making these decisions. Information was provided to help patients understand the care available to them.

• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet people’s needs. For example, the practice worked with housing associations, food banks, domestic violence teams and drug and alcohol services.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the newly formed Patient Participation Group (PPG).
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Information about how to complain was available and easy to understand. Complaints were used to improve the service provided.

• The practice had clear leadership and a clear vision which had quality and safety as its top priority. A business plan was in place and discussed with all staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

We saw several areas of outstanding practice including:

• The practice had flexibility of access to appointments. Access included a flexible boundary philosophy to support patients until they had registered at a new practice, for example, patients with unstable home environments or those between addresses. The practice offered extended appointment times regularly and if patients attended on the wrong day or at the wrong time they would be seen anyway. If a patient missed attending an appointment the practice telephoned the patient or organised a home visit.

• The practice had responded to the needs of homeless patients and those in financial hardship and worked with the Teignbridge Housing Association Team and referred patients to food banks. The practice also held a supply of dried food stuffs to hand to patients in need before they were referred to the food bank organisation.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 24 December 2015

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.

All these patients had a named GP and a structured annual review to check that their health and medicine 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, so that patient needs were communicated and met using an integrated and coordinated approach.

Patients were able to access urgent and same day appointments and were encouraged to book 20 minute appointments to discuss long term conditions. Staff had used their judgement toalter the length of appointments as appropriate.

Patients were invited for six monthly reviews with the GP to discuss their medicines and had access to nurse led chronic disease management clinics. The data for the practice showed that uptake for reviews was good.

The practice were effective in the management of diabetes and had developed a system to review patients with pre-diabetes or multiple risk factors for chronic disease annually, using the recall system. The clinical team met with the dietician, diabetic consultant and diabetic specialist nurse twice a year to discuss complex patients and agree a multidisciplinary plan with the patient.

The practice provided proactive management for potential health crises, for example patients with chronic obstructive pulmonary disease (COPD) had home action plans to assist them to recognise any deterioration in their condition and provide information on how to access help. The practice also maintained information for health care professionals on the out-of-hours system to ensure timely and appropriate care for these patients when the surgery was closed.

All clinical staff were encouraged to screen for depression in patients with long term conditions. Patients with complex co-morbidities or palliative care needs were also discussed at the monthly MDT meeting.

Updated 24 December 2015

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 or those that did not attend for appointments. Practice staff worked closely with health visitors who were based at the practice and found this useful when discussing safeguarding concerns or families of concern.

Children were offered appointments to fit with school times and had access to immunisation programmes.

The practice held midwife led antenatal care at the practice and had areas if mothers wished to feed their baby in private. The practice held regular postnatal clinics.

A full range of contraception services and sexual health screening, including cervical screening and chlamydia screening was available at the practice.

Updated 24 December 2015

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

Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example, in dementia and end of life care.

It was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs.

Patients over the age of 75 had a named GP and those receiving regular medicines were seen for bi-annual face-to-face reviews with the GP. Being a small practice the staff knew patients well, were familiar with their family situations, those with social isolation, and those who were carers. This meant that staff could recognise that something may be wrong at an earlier stage.

The practice participated in the NHS Frailty scheme. There were systems in place to identify the top 2% of the practice population who were judged to be most at risk. These patients were made known to staff and placed on the ‘blue bed’ frailty scheme. GPs held monthly reviews of the identified patients to proactively co-ordinate their care, perform medicine reviews and dementia reviews. Systems were in place to ensure they had prompt access to treatment, regular updates of care plans and treatment escalation plans, which were then shared with out of hours providers.

The practice were also part of a local ‘one care home one GP’ scheme. Two GPs provided a primary medical service to two care homes in Newton Abbot. The GPs made monthly visits to the care homes. The GPs also carried out six weekly (or more frequent if necessary) reviews with the patient, staff and patients family to discuss treatment and care plans. Feedback from the care home managers demonstrated that this provided continuity of care, palliative care and developed strong relationships with the residents, managers and staff. Feedback from the CCG, patients and family members was also positive.

Practice staff discussed ‘admission care avoidance’ with the multidisciplinary (MDT) community team each month to help maintain patient independence and enable patients to remain at home, rather than be admitted to hospital. The MDT team were also able to refer patients to other health and social care services. A member of the local Kingscare voluntary service also attends to assist with befriending or to offer ways to reduce social isolation.

Patients admitted to hospital were identified and the named GP informed to contact/visit them following discharge. Patients needing end of life care had been managed in a coordinated way with the palliative care nurse and community team which meant patient wishes for end of life care could be planned.

Updated 24 December 2015

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.

Pre booked appointments were available a month in advance and on the same day. There were evening appointments every Monday and early appointments every Friday morning.

Patients were offered a choice of either face to face appointments or telephone consultations if more convenient. Patients were able to access a text reminder service for appointments and order their medicine on line if they chose. Patients could also request prescriptions to be sent to a pharmacy of their choice.

Practice nurses offered travel advice and vaccinations.

The practice offered NHS health checks to patients aged 40-70, smoking cessation clinics and provided dietary advice to patients.

Updated 24 December 2015

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

The practice were flexible with appointments for patients with mental health needs and those with dementia and encouraged longer appointments or telephone consultations if needed. As the staff were familiar with patients they had been able to recognise early signs or behaviours when patients were not so well or where they missed appointments. The practice said if patients attended on the wrong day or at the wrong time they would be seen anyway. Patients who failed to attend had been telephoned and offered a follow up appointment or seen at home. Where there had been concerns about a patient’s capacity to attend for appointments, or understand their care and treatment, communication with relevant parties had taken place

The practice held a register of patients with poor mental health and contacted patients listed with depression within a month of diagnosis. The practice had higher rates of dementia diagnosis compared to the local clinical commissioning group (CCG) national average. For example the practice dementia diagnosis rate was 100% which was 11% above CCG and 6.6% above national average. Further data showed that 93.18% of these patients had received a health care review compared to the CCG rate of 83.82%.

Data showed that the practice managed annual physical health checks and medicine reviews for patients with mental illness well. There was an attitude of ‘seizing the moment’ to attend to the patient’s needs when they were in the practice rather than asking them to rebook for further tests or consultations. Patients appreciated this. The practice worked well with the crisis resolution team and offered in house counselling.

Updated 24 December 2015

The practice is rated as outstanding for the care of people who circumstances may make them vulnerable.

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.

The practice held a register of patients living in vulnerable circumstances including those who were frequently in and out of prison, those with a learning disability, domestic violence patients, patients with drug and alcohol addictions, the frail elderly, the homeless, patients with mental health issues, and those complex health problems. The practice operated a flexible boundary philosophy to support patients until they had registered at a new practice. For example, patients with unstable home environments or those between addresses. Special notes were made on the computer system to facilitate this – for example whether patients had n consent for communications through a third party.

These patients had a named GP and were reviewed regularly, discussed at the monthly MDT meetings and managed with a primary care team approach across the community including the voluntary sector. Using this combined approach enabled the GPs to refer vulnerable, isolated patients to the living well scheme where they could access further help and support.

The practice worked with the Teignbridge Housing Association Team and had referred patients to food banks. The practice also held a supply of dried foodstuffs at the practice, to hand to patients in need before they were referred to the food bank organisation.

The practice referred patients with drug and alcohol issues to RISE (Recovery and Integration Service) a service for adults in Devon.

Translation phone services were used to accommodate language needs if requested.

The practice had a learning disability register and ran annual health checks for this population. The practice had performed 68% of the health care checks for these patients so far this year with the remaining patients booked in.