Archived: Cobtree Medical Practice

Updated 27 July 2017

The Cobtree Medical Practice is a GP practice located in the village of Sutton Valance Kent. It provides care for approximately 2500 patients. The practice is in a rural area.

There are two GP partners and a salaried GP, one male and two female. There are two practice nurses, both female, one being a regular locum nurse.

The age of the population the practice serves is close to the national averages. There are marginally more young people (aged less than 18 years) and slightly more older people (aged over 64 years). Income deprivation and unemployment are low being about half and one sixth of the national figures respectively. About five per cent of the practice’s patients come from the traveller community.

The practice has a general medical services contract with NHS England for delivering primary care services to local communities. The practice offers a full range of primary medical services and is able to dispense medicines to those patients on the practice list who live more than one mile (1.6km) from their nearest pharmacy premises. The practice is not a training practice. The practice hosted student nurse placements as part of the Primary Care Education Network.

The practice is open between 8am and 6.30pm Monday to Friday. There is an evening surgery until 7.45pm on Tuesdays. Appointments are from 9am to 1pm and 2.15pm until 5.30pm.

The surgery building is a converted detached house with consulting and treatment rooms on the ground floor and administrative rooms upstairs.

The practice has opted out of providing out-of-hours services to their own patients. This is provided by Integrated Care 24. There is information, on the practice building and website, for patients on how to access the out of hours service when the practice is closed.

Updated 27 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cobtree Medical Practice on 1 June 2017. Overall the practice is rated as outstanding.

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

• There was an open culture in which all safety concerns raised by staff and patients were highly valued as integral to learning and improvement. The level and quality of incident reporting showed included assessments of harm and near misses, which ensures a comprehensive picture of safety. All opportunities for learning from internal and external incidents were maximised. The practice shared learning from safety incidents with other nearby practices on a regular basis.
• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice.
• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. For example through having a child themed a “fun day” which had doubled the child take up of influenza vaccinations.
• 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 patient participation group (PPG). For example the practice had held a public meeting about a proposed merger of practices with the support of the PPG.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• Feedback from patients about their care was positive and was consistently significantly better than local and national feedback. There was continuity of care, in the most recent GP national survey, 95% patients saw their GP of choice compared to national average of 59%.
• The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result.
• The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. All staff were involved in developing the vision and values for proposed merged practice.
• The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw several areas of outstanding practice including:

• GPs gave a designated mobile contact telephone number to patients who were dying at home and were contactable in the event of a crisis out of surgery hours and at weekends. The same facility was available to the clinical staff the local nursing home for advice on avoiding admission to hospital or end of life care.
• Data showed that patients rated the practice significantly higher, for the caring and the responsive aspects of its services, than all the local and national averages.
• The practice had proactively recruited patients to the patient participation group so that it was truly representative of the practice demographic.
• The practice had mounted an initiative to increase the take up of influenza vaccinations for children aged two, three and four which had had a regional impact.
• The practice had identified patients likely to be at risk of acute kidney injury,had sent them informative leaflets and monitored their welfare.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 27 July 2017

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of patients with long-term conditions.

• Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.
• The practice’s QOF performance for 2015/2016 in diabetes related indicators was similar to the CCG and national averages. For example the percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) is 140/80 mmHg or less was 72% compared with the national and local average of 77%.
• The practice scored 100% of QOF points for asthma, atrial fibrillation, cancer, chronic obstructive pulmonary disease, depression, dementia, heart failure, hypertension and mental health. In all these cases the practice results were higher than the local and national averages.
• 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 needs. GPs identified patients at risk of hospital admission as a priority. The practice had lower than average admission to accident and emergency (A&E) across patients with long term conditions. For example it had had no admissions to A&E for diabetic emergency and had the lowest figure of any practice in the locality.
• There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.
• All these patients had a named GP and there was a system to recall patients for 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.
• There was a patient with a long-term condition who represented this population group on the patient participation group.

Updated 27 July 2017

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of families, children and young people.

• From examples we reviewed we found there were systems 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 accident and emergency (A&E) attendances. When a child did not attend a hospital appointment this triggered an alert to the lead for child safeguarding so that appropriate action could be taken.

• Immunisation rates were 90% or more for all standard childhood immunisations. This was despite the fact that there was a substantial proportion of children from the traveller community who are historically difficult to reach with these services.
• The practice provided support for premature babies and their families following discharge from hospital.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.
• The practice served the needs of boarders at a nearby school, there was a drop in-clinic weekly and access to emergency contraception, for patients registered at the practice and others who were not.
• The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications.
• There was an adolescent patient who represented this population group on the patient participation group.

Updated 27 July 2017

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of older patients.

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

• The practice offered proactive, personalised care to meet the needs of the older patients in its population. The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. Two staff members visited the housebound elderly to administer influenza vaccinations.

• The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.
• The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.
• Where older patients had complex needs, the practice shared summary care records with local care services.

• Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible. For example repeat prescriptions for elderly patients, who had difficulty in attending the practice, were accepted over the telephone.
• The practice offered proactive, personalised care to meet the needs of older patients. It looked after 25 high dependency beds at a local nursing home. Staff there had the GPs telephone number and were able to contact the GP at weekends or out of hours to discuss end of life care or measures to prevent admission to hospital where this was appropriate. All the patients at the home had detailed care plans with an emphasis on avoiding unplanned admission to hospital. There was a nominated GP who held a weekly ward round at the care home.
• Palliative care patients, most of whom fell into this population group, and their families had a designated GPs mobile telephone number and were able to contact the GP at weekends or out of hours to discuss end of life care.
• There was an older patient who represented this population group on the patient participation group.

Updated 27 July 2017

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of working age people (including those recently retired and students).

• The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours.
• 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 provided health checks for new patients and NHS health checks for patients aged 40–74.The practice was the highest achieving for this service across the clinical commissioning group (CCG) with 101%.
• The practice had developed a “one stop shop” for diabetic patients that reduced the number of appointments those patients needed to attend. This impacted particularly on working age patients.
• The evening clinic was staffed by a nurse and GP enabling working age patients to consult with the nurse and go directly to the GP, if necessary, rather than returning for a further appointment.

Updated 27 July 2017

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of patients experiencing poor mental health (including people with dementia).

• The practice carried out advance care planning for patients with dementia. Eighty eight percent of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average. All the staff at the practice were “dementia friends”, so had learned more about the condition and how to help patients and their families manage the condition.
• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
• Performance for mental health related indicators was similar to the CCG and national averages. For example The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have an agreed care plan during the preceding 12 months was 94% compared with the CCG average of 92% and the national average of 89%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
• Patients at risk of dementia were identified and offered an assessment.
• The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.
• The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• There was a patient with a long term mental health condition who represented this population group on the patient participation group.

Updated 27 July 2017

The factors that led to the practice being rated as outstanding over applied to all the population groups, therefore the practice is rated as outstanding for the care of patients 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.
• It had carried out annual health checks for all patients with a learning disability and these patients were offered longer appointments.
• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.
• Staff we spoke with knew how to recognise signs of abuse in children, young people 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.
• There was a nominated GP who held a weekly ward round at the local care home.
• There was a representative from the traveller community on the patient participation group, who had been very active in improving understanding of the needs of that community. The practice responded to these needs by being readily available to see patients without an appointment usually at the beginning or end of sessions.