Haldon House Surgery

Updated 7 August 2017

Haldon House Surgery is situated in the coastal town of Exmouth in East Devon.

The deprivation decile rating for this area is seven (with one being the most deprived and 10 being the least deprived). The practice provides a primary medical service to approximately 5,963 patients of a diverse age group. The 2011 census data showed that majority of the local population identified themselves as being White British. Public health data showed that 12% of the patients are aged over 75 years old which is higher than the local average (CCG) of 10.1% and the national average of 7.8%.

There is a team of four GPs partners, two female and two male; the partners are supported by one salaried GP, and one GP registrar. Some GPs worked part time making the whole time equivalent 3.75 WTE. Partners hold managerial and financial responsibility for running the business. The GP team were supported by a practice manager, assistant practice manager, an IT manager, two practice nurses, two health care assistants, one phlebotomist, one pharmacy adviser and additional administration staff. The practice is a training practice and supported medical students, student nurses, GP registrars and two apprentices.

Patients using the practice also have access to community matrons, nurses and midwives, mental health teams, drug and alcohol support counsellors and long term condition counsellors, general counsellors, district nurses, school nurse and health visitors. The district nursing team are based in the same location. Other health care professionals visit the practice on a regular basis.

The practice is open from 8am to 6pm between Monday and Friday. Extended hours are offered on Tuesdays and Thursdays from 7.15am until 8am and from 6pm until 7.30pm. Outside of these times patients are directed to contact the out of hour’s service via the NHS 111 number.

The practice offers a range of appointment types including face to face same day appointments, telephone consultations and advance appointments (six weeks in advance) as well as online services such as repeat prescriptions.

The practice has a Personal Medical Services (PMS) contract with NHS England.

This report relates to the regulatory activities being carried out at:

Haldon House Surgery

37-41 Imperial Road

Exmouth

Devon

EX8 1DQ

We visited this location during our inspection.

Updated 7 August 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Haldon House Surgery on 11 July 2017. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with 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 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 proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
• The practice had an active patient participation group which had supported the practice in obtaining and acting upon patient feedback, for example in raising patient awareness about the practice website, social media pages and online services available such as appointments and prescriptions.
• The practice nursing team worked with other local practices to visit local care homes to administer flu and shingles vaccinations and carry out annual health checks.
• The practice offered a cryotherapy service (used to treat a variety of benign and malignant tissue damage, medically called lesions), a full contraception service, home blood pressure monitoring, acupuncture, an orthotic service for shoe insoles and support strapping and complex catheter care.

We saw one area of outstanding practice:

The practice supported homeless patients by providing them with a pack containing a sleeping bag, underwear, toothbrush and toothpaste, wet wipes and a map of local services such as food banks to ensure their basic needs were supported.

We identified an area of practice where the provider should make improvements:

The provider should review its procedures following fridge failures in line with Public Health England’s protocol for storing vaccines to ensure prompt action is taken.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 7 August 2017

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

• Practice nurses had lead roles in chronic disease management. For example, a diabetic specialist nurse provided clinics every two months.
• Health care assistants (HCAs) had been trained to provide support on smoking cessation and reduction of alcohol consumption. These areas were also included on new patient questionnaires.
• The practice offered 24hr electro cardiogram testing (ECG). An ECG is a test which measures the electrical activity of your heart to show whether or not it is working normally. The practice also offered 24hr blood pressure recording through offering patients portable blood pressure monitors.
• The practice held QHD (Quality Half Day) meetings quarterly, these involved meeting with the palliative care team to discuss patient care.

• The practice offered an orthotic service for shoe insoles and support strapping.
• Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.
• The percentage of patients with diabetes, on the register, in whom the last blood sugar reading was recorded as being within normal ranges in the preceding 12 months was 90% which was higher than the clinical commissioning group (CCG) average of 81% and the national average of 78%.
• 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.
• 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.

Updated 7 August 2017

The practice is rated as good for the care of families, children and young people.

• The practice had a dedicated children’s area in the waiting room with toys, books, and information on child health set up for parents with babies and young children. A baby changing room was available.
• The practice had a track record of identifying parents with addictive behaviours, for example cases of Munchausen’s syndrome by proxy, and offering appropriate support and safeguarding.
• Child safeguarding was given a high priority at the practice. There was a lead GP and deputy who attended safeguarding and child protection meetings. A coding system was used to identify all family members for ease of any investigations.
• Specialist clinics relevant to this group such as nasal flu vaccinations were offered outside of school time. Clinicians ran early morning, evening clinics and appointments for any patients that could not attend during the usual hours.
• A midwife ran a clinic at the practice once a week, liaising closely with the practice.
• The practice sent personalised congratulations cards to parents on the birth of their babies and new patient forms were enclosed to save them a trip to the surgery. Eight week checks were carried out by a GP and a nurse.

• From the sample of documented 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.
• Immunisation rates were on target for all standard childhood immunisations.
• Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals. The practice had developed a Facebook social media page to help engagement with young people.

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 had emergency processes for acutely ill children and young people and for acute pregnancy complications.

Updated 7 August 2017

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

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns. The practice offered health checks to every patient at risk of unplanned admission to hospital.
• All patients had a named GP and 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.
• The practice co-ordinated the setup of a local federation of practices in order to provide practice nurse visits to patients in nursing and residential care homes, offering vaccinations, blood tests and checks on long term conditions.
• Multi-disciplinary team meetings were held every two weeks to offer support to socially isolated patients or those at risk of unplanned admission to hospital.
• The practice prescribing team checked patient discharge summaries for any changes to patient’s medicine.
• 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. For example, in providing safe care and treatment to patients being admitted to hospital or nursing care homes.
• 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, the practice had trained its nurses in chronic disease management to proactively educate patients about their conditions to reduce risks and improve care.

Updated 7 August 2017

The practice is rated as good 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 were provided in the early mornings and evenings to support working age people.
• The practice offered telephone consultations to patients who preferred this method.
• 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 had an informative website, online services such as appointments and prescriptions, together with a social media Facebook page.
• The practice used a text messaging service (MJOG) to remind patients of their appointments and also obtain alternative methods of feedback for the NHS friends and family survey.

Updated 7 August 2017

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

• The practice carried out advance care planning for patients living with dementia.
• 100% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which was higher than the national average of 87% and the national average of 84%.
• The practice specifically considered the physical health needs of patients with poor mental health and dementia. For example, by providing a room at the practice for a range of mental health counselling support services.
• The practice provided the local depression and anxiety Service (DAS) ‘Talking Health’ clinics, a room two days a week. These counselling sessions were run by a psychological therapist and a psychological wellbeing practitioner who liaised with clinicians in the practice.
• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses whose alcohol consumption has been recorded in the preceding 12 months was 97% which was higher than the CCG average of 90% 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.
• Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.

Updated 7 August 2017

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 supported homeless patients by providing them with a pack containing a sleeping bag, underwear, toothbrush and toothpaste, wet wipes and a map of local services such as food banks to ensure their basic needs were supported.

• The practice kept a register of homeless patients and liaised with other practices with specialist expertise in this area, such as The Clocktower Surgery in Exeter to ensure appropriate treatment was provided.

• 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 offered longer appointments for patients with a learning disability.

• 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 interviewed 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.