Archived: Dunster Surgery

Updated 17 September 2015

Dunster surgery provides primary medical services to approximately 2000 patients living in Dunster and the surrounding area of Exmoor national park in Somerset. The practice provides primary care to seven residential homes and two nursing homes.

The South West UK Census data (2011) shows 98% of the population are recorded as white British. Public Health Somerset’s general practice profile shows that 11.8% of the registered population are aged 0-14 years old, which is much lower than the rest of Somerset at 16.1%. And 15% of the registered population are aged 75 years and over which is much higher than the Somerset average of 10.4%. A higher than England average group of patients aged over 55 is reflected by West Somerset having the longest living population in Europe with over 40% of pensionable age (Office National statistics 2010). The practice population have higher levels of deprivation (22.6%) than the average for Somerset (16.9%).

The surgery is currently in two terraced houses which were converted some time ago. The building is set over two floors with patient services provided on the ground floor. The practice includes a dispensary which 75% of patients use. A purpose built medical centre is currently under construction.

The practice team includes two GP partners (male) and a salaried GP (female); two practice nurses; one healthcare assistant; a home support nurse; a practice manager; dispensary and administration staff. All three GP’s, some of the nursing team and the practice manager work across this practice and Porlock Medical Centre. Dr Kelham began management of Dunster Surgery in 2009 and the two practices share governance and staff and are registered as separate providers with the CQC. Dr Davies became a partner in 2009 and although both GP’s work over both practices they are registered as separate businesses.

The practice also worked with community staff including health visitors, district nurses the community health team for older people and a midwife. The practice worked closely with a local carers support organisation that provide support services within the practice. Age UK were working with the practice to provide support to older people with long term conditions who are isolated.

The practice provides training for trainee doctors and GP Registrars.

The practice had a General Medical Services contract (GMS) with NHS England to deliver general medical services.

The practice has opted out of providing Out Of Hours services to their own patients. Patients can access NHS 111 out of hours and Somerset Doctors Urgent Care provided an Out Of Hours GP service. The practice did provide patients receiving end of life care with GP personal telephone numbers to ensure continuity of care during these times.

Updated 17 September 2015

Letter from the Chief Inspector of General Practice

OUTSTANDING

We carried out an announced comprehensive inspection at Dunster Surgery on 18 May 2015. Overall the practice is rated as outstanding.

Specifically, we found the practice to be outstanding for providing responsive, caring, effective and well led services. It was also outstanding for providing services for older people and people with long term conditions. It was good for providing safe services. It was also good for providing services to the working aged population including those recently retired and students, families, children and young people, people with poor mental health and people whose circumstances make them vulnerable.

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. All opportunities for learning from internal and external incidents were maximised.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. 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 they met people’s needs.
• 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).

• 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.

• The practice had a clear vision which had quality and safety as its top priority. A business plan was in place, was monitored and regularly reviewed 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:

We saw that the practice was responsive to the needs of the local population. For example, the practice had increased the flexibility of access to appointments and could demonstrate the impact of this by reduced use of the Out Of Hours and secondary acute service and very positive patient survey results. The practice had a very good skill mix which included a home support nurse to visit the isolated; those with a high risk of hospital admission and those with a high need for medical care. The practice provided comprehensive screening and regular reviews for patients at risk of developing long term conditions. As well as additional planned medicine and health reviews of patients with long term conditions. The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice; which comprised of a project with Age UK to provide support for isolated patients and tele-consultations and practice visits with patients by specialist hospital consultants. The practice had involved the patient participation group (PPG) in the recruitment of a new GP giving patients the majority on the choice of candidate.

We saw that the practice cared for the population through provision of additional services to enable end of life patients to remain at home. This included funding a night sitter nursing service for the local population; direct contact with a practice GP out of hours and providing additional clinical interventions normally undertaken in a hospital. The practice had reached out to the local community in order to prevent illness by providing an annual flu vaccination clinic which included invitation to local organisations to attend; an annual men’s health evening to promote better health and working with local and national media to promote reading well for self-help. All these were not limited to the practice population. The practice had undertaken a project with Age UK to provide support to isolated patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 17 September 2015

The practice is rated as outstanding for the care of people with long-term conditions. Nursing staff had lead roles in chronic disease management and offered longer appointments, six monthly which included anxiety and depression screening and personal management plans. This was in addition to a structured annual review with a named GP. Housebound patients received an annual home visit from the nurses to carry out a health review.

For those people with the most complex needs, the practice worked closely with relevant health and care professionals to deliver a multidisciplinary package of care. For example the endocrinologist; cardiologist and diabetic specialist nurse attended the practice to carry out joint reviews and education sessions. In addition the nurse run pulmonary rehabilitation clinics.

A significant event had led the practice to lobby for national coding for poor inhaler compliance.

Patients with a high need for medical care; at risk of hospital admission or isolated were referred to the practice home support nurse to provide additional support in their own home. This included referral to multidisciplinary teams and voluntary sector services.

Patients received enhanced end of life care with a night sitter nursing service funded by the practice.

The practice has a high rate of health screening and health promotion. For example, patients with high blood pressure undergo comprehensive yearly checks for diabetes and ECG screening is regularly used in this group of people to diagnose any evolving heart conditions. The practice provided an annual flu event where anyone within the target group from the local population could attend for a flu vaccination and advice or support from a number of agencies.

The GPs had undertaken additional clinical skills, for example minor surgery, so patients did not have a long journey to hospital.

Updated 17 September 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. Immunisation rates were very high for all standard childhood immunisations. Patients told us children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this. Appointments were available outside of school hours and the premises were suitable for children and babies. We saw good examples of joint working with midwives, health visitors and school nurses. As part of a local agreement any young person in the local area could attend the practice and be seen by a GP.

Updated 17 September 2015

The practice is rated as outstanding for the care of older people. Over 75s account for 15% of the practice population. This is higher than the Somerset average of 10% and puts the practice in the top 10% of practices for older populations. 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 caring for people living with dementia and for those who require 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 with a high need for medical care; at risk of hospital admission or isolated were referred to the practice home support nurse to provide additional support in their own home. This included referral to multidisciplinary teams and voluntary sector services. In addition the practice had recently started a project with Age UK to improve lives of isolated older patients and encourage them to maintain active healthy living.

Patients received enhanced end of life care with a night sitter nursing service funded by the practice.

The practice provided an annual flu event where anyone from the local population could attend for a flu vaccination and advice or support from a number of agencies.

Updated 17 September 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. The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs of this age group.

The practice went beyond the expectations of their contract with regards to early screening for diseases. For example diagnostic blood tests for diabetes were used for patients at risk. In conjunction with the local GP federation and patient participation group, the practice ran an annual men’s health event.

Updated 17 September 2015

The practice is rated as good for the care of people experiencing poor mental health (including people living with dementia). All patients experiencing poor mental health had received an annual physical health check which included preventative health screening for heart disease. The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those living with dementia. It carried out advance care planning for patients living with dementia.

The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. It had a system in place to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health. The practice had a close working relationship with the community mental health team. Patients with early signs of memory loss were referred to support services.

GPs had undertaken additional training in caring for patients living with dementia and had worked with the local Psychogeritrician to provide clinics at the practice. We saw the practice was proactive in supporting patients with poor mental health. The practice was the highest user of self-help books in Somerset and one GP had engaged with local and national media to promote the benefits of this therapy.

Updated 17 September 2015

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 those with a learning disability; patients with significant mental ill-health and housebound patients. It offered longer appointments for people with a learning disability and had carried out annual health checks for patients with a learning disability with eight out of nine of these patients receiving a follow up.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. It had told 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.