Archived: The Health Centre

Updated 7 October 2016

Kingskerswell and Ipplepen Medical Practice is located in South Devon and has two locations; Kingskerswell Health centre located in the small town of Kingskerswell and Ipplepen Health Centre. The two practices combine training, administration, care and treatment and management processes and have worked together for over 50 years. Survey results, performance data and national data is collected as one provider.

This report relates to Ipplepen Health Centre.

Kingskerswell and Ipplepen Medical Practice has an NHSE general medical services (GMS) contract to provide health services to approximately 10,663 patients. This is divided into 5714 patients atKingskerswell Health Centre and 4949 patients at Ipplepen Health Centre. The practice is open between 8.30am and 6pm Monday to Friday. Extended hours appointments at Ipplepen are offered on  Tuesdays and Thursdays until 7.30pm. In addition, pre-bookable appointments that can be booked up to two weeks in advance. Telephone appointments are also available. Urgent appointments are also available for patients that needed them.

The practice has opted out of providing out-of-hours services to their own patients and refers them to an out of hours provider via the NHS 111 service. This information is displayed on the outside of the practice, on their website, and in the patient information leaflet.

For both locations the mix of patient’s gender (male/female) is almost 50% each. 11.8% of the patients are aged over 75 years old which is higher than the national average of 7.8%. 3.5% of the patients are over the age of 85 which is higher than the national average of 2.3%. There was no data available to us at this time regarding ethnicity of patients but the practice stated that the majority of their patients were white British. The deprivation score was recorded as 8, on a scale of 1-10. One being more deprived and 10 being less deprived.

There are a total of nine GPs working across both practices within this organisation. This equates to just over six whole time equivalent GPs. All GPs are usually based at one practice but work at both sites to cover for holiday and sickness. Nurses work across both locations on a regular basis.

The practice is a teaching practice with good feedback from trainees and the local NHS health education team.

The Ipplepen Health centre practice has an established team of four GPs. There are two male and two female GPs. Three of these GPs are partners who hold managerial and financial responsibility for running the business. The GPs are supported by a practice manager, two nurse practitioners, two practice nurses, three health care assistants and additional administration and reception staff.

We inspected both locations within this organisation. This report relates to the regulatory activities being carried out at:

Ipplepen Health centre

Silver Street

Ipplepen

Devon

TQ12 5QA

Updated 7 October 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kingskerswell and Ipplepen Medical Practice (Ipplepen Health Centre), Devon on Thursday 14 July 2016. Overall the practice is rated as outstanding

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. The practice carried out a thorough analysis of the significant events and arranged for their learning to be shared with other practices and the NHS England quality and safety team. Learning from other practices was also shared with practice staff using the significant event audit learning sharing document.

• Risks to patients were assessed and well managed.
• The practice promoted the SAM (Sepsis Assessment and Management) guidelines giving a checklist and traffic light approach for parents to monitor their children during illness and reinforce their knowledge of when to call for advice from health care staff in the practice or in the hospital.

• There were appropriate arrangements for the efficient management of medicines.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
• Staff held roles within the wider community. For example; one of the GPs was the clinical lead for patient safety and quality for South Devon and Torbay CCG. The IT lead had been appointed by the CCG as their SystmOne, patient record system, Champion.

• Data from Public Health England showed the practice had a higher incidence of patients with long term conditions and dementia. We saw evidence to show that despite this the practice was consistently rated as one of the top practices locally and nationally. For example,Quality and Outcomes Framework (QOF) scores, GP national patient survey, ratings on NHS choices, local surveys, friends and family test results, dispensing service quality scheme and CCG monitoring.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

• The staff often went above and beyond their normal roles to impact on patients within the wider community. For example, one of the GPs had helped set up and volunteered at the local memory café and two others had undertaken a bicycle ride to raise charitable funds for a local hospice which patients benefitted from accessing where their health needs dictated.

• The practice worked jointly with the Teignbridge homeless charity giving out food parcels.

• Relationships with patients was highly valued by all staff and promoted by leaders. We were given examples where staff had worked effectively to build and maintain relationships. For example, patients of a newborn child were sent a letter of congratulations.

• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns. The practice had further developed the complaints process by seeking an independent GP to review patient care following complaints and complete an independent report. The report confirmed effective complaints management and patient care.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

• The practice had a proactive system for identifying carers lead. The practice had identified 4.9% of the practice population as carers. The ongoing support included links to local services and referral to the Devon Carers Network.

• There were failsafe systems in place to ensure patients were offered screening. This had resulted in rates for cervical and bowel cancer screening being higher than CCG and national averages.

• There were good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management. The practice was organised and had effective governance structures in place.
• The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

We saw a number of areas of outstanding practice. These included:

The practice had standardised their use of the computer system (SystmOne) through the development of templates which included care plans, patient leaflets, preferences, protocols, prompts and alerts to improve patient safety and care. For example, the IT lead had developed a frailty template, for use as part of a local frailty project, which had a very positive impact on the practices in the project, by improving the processes and working through a series of prompts to ensure all relevant data is recorded. This template in some instances has been shared nationally as a result of direct requests from other practices. This had resulted in the member of staff receiving a SystmOne (practice computer system) Champion of the Year award (usually given to GPs), primarily for their work in leading a group of nine SystmOne GP practices sharing learning and developing the very best use of the computer system in support of patient care.

Leaders have an inspiring shared purpose and strive to deliver and motivate staff to succeed. The GPs and leadership team had invested in their staff over a long period of time. This had led to a happy, loyal workforce with low staff turnover. Staff were supported both financially and with protected time to develop both personally and professionally in addition to the required updates. For example; the practice manager had started at the practice as a sixth form school leaver. They had started in the administration team and was sponsored to obtain a dispensary qualification, followed by a national vocational qualification (NVQ) in business and administration and level 4 management NVQ. The practice then funded her foundation degree in Management and Leadership prior to promoting her to practice manager. Two additional staff had been supported to obtain NVQ’s in management. One of the practice nurses had been funded to do a prescribing course. Another practice nurse had been funded and supported to do a nursing degree and prescribing qualification. Other staff had been sponsored to become health care assistants and dispensers. Existing partners had worked at the practice as GP trainees. Ex members of staff had been encouraged to develop and pursue promotion and roles outside of the practice. For example, one of the partners now worked for the CCG as chief executive officer. Present staff were also supported to have roles within the wider community. For example, one of the GPs was the Clinical Lead for Patient safety and quality for the local CCG and the IT lead had been appointed by the CCG as their SystmOne Champion, working closely with the chief clinical information officer.

The continuing development of staff skills, roles, competence and knowledge was recognised as integral to ensuring high-quality care. Staff were encouraged to attend advanced training, develop systems, lead pilots and suggest ideas to ensure high quality care and achievement. For example, we saw examples of detailed, multi-layered systems and structures which had good outcomes for patients. These systems were detailed and monitored to ensure the information was effective and in the best interest of patients. For example, including an independent review in the complaints process, development of a quality significant event reporting system, sharing the developed templates and processes with the CCG and promoting the SAM (Sepsis Assessment and Management) guidelines resulting in earlier referrals to paediatrics. Systems, audits and processes were performed with a high level of detail resulting in positive impact for patients and cost savings to the practice and CCG.

There were failsafe systems in place to ensure patients were offered screening and results were followed up as appropriate. As a result, cervical and bowel cancer screening rates were higher than the clinical commissioning group (CCG) and national averages

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 7 October 2016

The practice is rated as outstanding for the care of people with long-term conditions.

• Data from Public Health England showed that 56% of the practice population had a long standing health condition. This is comparable with the national average of 54%.
• Nursing staff 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.
• The practice had employed a nurse practitioner to focus on patients at risk of hospital admission or who were housebound with long term conditions to ensure their conditions were closely monitored.
• There was an annual review process where patients with long term conditions such as diabetes, asthma, COPD (chronic obstructive pulmonary disease), CHD (coronary heart disease) and stroke were called in for review on their birthday month.
• Review invitations were sent four times a year to patients with mental health illnesses, dementia and learning disabilities to help ensure reviews took place.
• Patients with chronic diseases were able to access longer appointments for their reviews.
• All patients with a long term condition had a named GP. The named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care, for those patients with the most complex needs.
• Nationally reported data showed that outcomes for patients with long term conditions were either comparable or better than other practices within the clinical commissioning group (CCG) and nationally. For example, patients with a normal blood sugar level recorded in the last year was 84% compared to the CCG average of 79% and national average of 78%.
• A pharmacist worked at the practice and reviewed cases of polypharmacy (where patients are taking 10 or more medicines) to reduce medicine interactions, improve patient wellbeing and reduce cost.
• Patients in caring roles were identified and offered the opportunity to see a specialist carer’s support worker at the practice or in their home to receive appropriate support and advice.
• The practice worked alongside the CCG in delivering the ‘frailty service’ to the patients of Newton Abbot registered at six practices in the locality. One of the GPs was the clinical lead GP but worked with other practice staff to develop the project.

Updated 7 October 2016

The practice is rated as outstanding 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.
• 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.
• There were regular meetings between the GP surgery and health visitor to discuss action and support for families and children causing concern.
• Patients had access to a full range of contraception services and sexual health screening including chlamydia testing and cervical screening.
• The practice website provided links to information specifically aimed at supporting families, children and young people. This included a variety of behaviour management, parenting and relationship resources.
• The practice promoted the SAM (Sepsis Assessment and Management) guidelines giving a checklist and traffic light approach for parents to monitor their children during illness and reinforce their knowledge of when to call for advice from healthcare in the practice or in the hospital.
• The practice actively participated in promoting Meningitis vaccination for students in secondary and higher education.

Updated 7 October 2016

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

• The practice had a higher than national average of older patients. For example, the practice had 26% of patients over 65 years and 3.5% over 85% compared with the national average of 17% and 2%.
• 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.
• The practice had identified the top 2.3% of older patients who were most at risk of hospital admission and were reviewed at least monthly with the wider primary care team.
• Older patients at risk of hospital admission had care plans where necessary.
• Following patient consent, GPs at the practice shared their electronic medical records with the GP colleague who looked after inpatients at the Newton Abbot Community Hospital.
• Practice staff liaised with the patient and a range of agencies (for example, community hospital staff, carers, social services and the voluntary sector) to effectively manage patients hospital discharge. This coordinated discharge involved complex case management and the patient in ensuring patient safety following their return home.
• Flu, pneumococcal and shingles vaccinations were provided at the practice for older people. Vaccines for older people who had problems getting to the practice or those in local care homes were administered in the community by the GPs and nurses.

Updated 7 October 2016

The practice is rated as outstanding for the care of working-age people (including those recently retired and students).

• The practice offered weekly evening appointments for patients who were unable to attend the practice during normal hours.
• 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. For example, the practice had adjusted appointments schedule to offer evening appointments twice a week.
• The practice was proactive in offering online services as well as a full range of health promotion and screening that reflected the needs for this age group.
• All patients were offered a telephone consultation with a GP or nurse to ensure they got the treatment they needed without spending time waiting for a surgery appointment if this was not necessary.
• The practice had been one of the first in the area to adopt the electronic prescription service. Patients were able to collect their prescription at a pharmacy of their choice, including those more convenient to their work place.
• The practice had a ‘self-service health pod’ which enabled working patients to update their blood pressure, height and weight measurements without the need for an appointment and which was followed up by the GPs and nursing staff if needed. This was particularly helpful for working age females who needed oral contraception medicine reviews.
• The practice used a text communication service for appointment reminders, which all patients said they found helpful.
• The practice nurses offered foreign travel advice and vaccinations in line with current guidance.
• The practice performance in offering and undertaking NHS Health screening was among the best in the locality. For example, data from the national cancer intelligence network showed that the practice was statistically higher for bowel and cervical cancer screening in the last year.

Updated 7 October 2016

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

• The practice had a register which identified patients who had mental illness or mental health problems.
• Data showed that performance for mental health related indicators were all similar to or slightly above the national average. For example, all patients diagnosed with mental illness had been offered the opportunity to have their care reviewed in a face to face meeting in the last 12 months.
• 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 have a good understanding of how to support patients with mental health needs and dementia. The practice had hosted a dementia awareness training session for voluntary groups and staff.
• Patients had access to a self-referral depression and anxiety service (DAS) if they were suffering with anxiety, stress or depression.
• Patients suffering from depression were seen regularly and were proactively followed up if they did not attend appointments to help reduce the impact on other services such as the A&E service.
• The practice has a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• The practice provided a room for a mental health counsellor to use at the Kingskerswell Health Centre.
• The practice encouraged advance care planning for patients with dementia and regularly worked with multi-disciplinary teams in the case management of these patients.
• All patients diagnosed with dementia had been invited to have their care reviewed in a face to face meeting in the last 12 months. The percentage of patients diagnosed with dementia who had had their care reviewed in the last year was 92% compared to a CCG average of 82% and national average of 84%.
• One of the practice GP partners had been actively involved in setting up and running a new Memory Café based at the village hub in Ipplepen, which patients from Kingskerswell could also access. Staff referred patients to the café and one of the GPs also volunteered at the café. GPs also referred patients to the memory team at the local mental health service.

Updated 7 October 2016

The practice is rated as outstanding 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 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.
• The practice scheduled longer appointments for patients having reviews for learning disabilities, mental health issues, and dementia.
• 94% of patients with a learning disability had received an annual health check in the past year and annual visits were provided to a local specialist home for learning disabled.
• 91% of mental health patients had had a face to face review in the last year.
• There was a self-referral service for those patients suffering with anxiety and/or depression.
• A patient lift was provided at Kingskerswell. Disabled parking was available in the practice car park and accessible toilets were provided.
• Chairs in waiting rooms include some with arm rests to assist patients to stand.
• The practice had hearing aid loop systems for the hearing impaired at both sites and all staff had been trained in vision and impaired hearing awareness.
• The practice actively supported the local “one care home – one practice” strategy which aimed to provide continuity to patients and staff in care homes. Feedback from the homes was positive.
• The practice worked effectively with the Teignbridge homeless charity. Receptionists had access to food and toiletries parcels at both health centres which could be collected by anyone the charity referred to the practice. GPs and practice staff had also been given discretion to give these away to anyone they felt would benefit from them. Once issued, a quick phone call to the charity ensured the parcels were replaced promptly.