Archived: Hatherleigh Medical Centre

Updated 6 April 2018

Hatherleigh Medical Practice provides personal medical services to people living in Hatherleigh and the surrounding areas. The practice provides services to a primarily older population and is situated in a rural location where many patient families are involved in farming. The village of Hatherleigh also serves a number of commuters, who work in the large towns with major hospitals approximately 30 miles from the practice. Hatherleigh practice provide a service to approximately 3875 patients.

The mix of patient’s gender (male/female) is approximately 50% each. 16.5% of the patients are aged over 75 years old which is higher than the national average of 9.9%. 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 practice area deprivation score was recorded as 5, on a scale of 1to10. One being more deprived.

The practice is a partnership run by the Lead GP and the practice manager / lead nurse practitioner prescriber. For purposes of this report the partners will be referred to as leadership team or partners. They took over Hatherleigh Medical practice as the registered providers in October 2015. The partners have a second GP practice registered separately with the Care Quality Commission (CQC) approximately 10 miles from the Hatherleigh practice and a separately registered care home with CQC for 12 people.

The GP team consists of two GPs (one male and one female) and additional locum GPs whilst a replacement for a salaried GP is completed. The GP works at Hatherleigh five days a week but splits his time between Hatherleigh and Beech House Surgery on Wednesdays and Fridays. The practice manager states she works at the practice two days a week but does additional work off site.

A practice nurse now works 30 hours per week at Hatherleigh Medical Centre. The nurse is supported by a health care assistant who works flexible hours over two days. There are additional dispensary staff, reception staff, administrators and domestic staff.

Hatherleigh Medical Centre website advertises opening times as Monday to Friday from 8.30am until 6pm with a 1pm to 2pm session for lunch when calls are transferred to the out of hours provider to take calls. A patient leaflet found on the reception desk states that the practice is open until 6.30pm but staff stated that telephone calls are transferred to the out of hours provider after 6pm. Contracts with the out of hours provider show cover is provided before 8.30am, at lunch time and after 6pm. The practice run an ‘open surgery’ whereby patients are able to walk in and wait to see a nurse or GP without a pre booked appointment. Times of these clinics are advertised as between 8.30am and 10.30am and between 4pm and 5pm daily. The practice has been routinely offering Saturday morning appointments if they were required since January 2016. These were not advertised in the patient leaflet found at the inspection or on the website at the time of inspection but are offered as patients need them. The provider has subsequently sent an amended leaflet which contains information about Saturday clinics held.

Routine appointments are available daily and bookable up to two weeks in advance or further into the future according to the patient’s wishes. Urgent appointments are made available on the day. Email and telephone consultations also take place.

Hatherleigh Medical Centre offers an on-site dispensing service for registered patients who live more than one mile from their nearest pharmacy. This service is for just over 2100 patients living outside of a one mile radius of Hatherleigh.

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

Hatherleigh Medical Centre

Pipers Meadow

Hatherleigh

EX20 3JT

Updated 6 April 2018

Letter from the Chief Inspector of General Practice

This practice is rated as Inadequate overall. (Inadequate in Safe and well led. Good in effective, caring and responsive.)

Hatherleigh Medical Centre had been inspected in April 2016 where it was rated inadequate due to breaches in regulations 12 (safe care) 17 (Good governance) 18 (staffing) and 19 (Recruitment). We then re inspected in December 2016 and placed the practice into special measures for continued breaches of the same regulations. On the following inspection in February 2017 the practice was rated as good (requires improvement in well led). The practice was taken out of special measures.

We carried out an announced comprehensive inspection at Hatherleigh Medical Centre on Wednesday 31 January 2018. The purposed was to follow up breaches of regulations made in February 2017 and following concerns about the leadership at the practice received in January 2018.

The key questions are rated as:

Are services safe? – Inadequate

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Inadequate

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Inadequate

People with long-term conditions – Inadequate

Families, children and young people – Inadequate

Working age people (including those retired and students – Inadequate

People whose circumstances may make them vulnerable – Inadequate

People experiencing poor mental health (including people with dementia) - Inadequate

At this inspection we found:

• The practice is a partnership run by the Lead GP and the practice manager / lead nurse practitioner prescriber. For purposes of this report the partners will be referred to as leadership team or partners.
• Care and treatment was delivered according to evidence- based guidelines.
• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Clinical staff had been trained to provide patients with effective care and treatment.
• Patients we spoke with said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care now that the locum GPs were more regularly employed.
• The practice ran an open surgery daily between 9am and 10.30am and between 4pm and 5pm whereby patients were able to walk in and wait to see a nurse or GP without a pre booked appointment.
• The practice held a three monthly diabetic outreach clinic where patients with complex diabetes could be reviewed by the visiting diabetic team from the Royal Devon and Exeter Hospital.
• The service offered a ‘Market clinic’ where staff from the practice held an open surgery in the market in Hatherleigh once a year where anybody, including patients not on the practice registered list, could come and have blood pressure, blood glucose and any health queries checked. The practice staff then gave a report to take to the patient’s own practice.

The areas where the provider must make improvements as they are in breach of regulations are to:

• Ensure care and treatment is provided in a safe way to patients.

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements include to ensure:

• Valid insurance certificates are displayed or available in a timely way
• Policies are reviewed to provide current best practice guidance for staff
• All staff receive appropriate support, training and appraisal to carry out their duties.
• Introduce systems to show that employment records demonstrate continued suitable medical defence cover and current registration with professional bodies whilst staff are employed.
• Records for significant events clearly show staff involvement, learning points and actions taken.
• Levels of GP and leadership cover continue to be monitored to adequately facilitate safe, effective and well-led services for patients and staff, considering the geography of the locations coupled with the clinical commitments of the partners and recent change in GP cover.
• Communication with healthcare professionals is maintained during periods of staff shortages
• Systems are in place to ensure any medicines within doctors bags are within expiry date
• Invoices used in the dispensary or practice are for the provider rather than previous provider.
• Staff have opportunities to attend meetings and are supported to give feedback

I am placing this service in special measures. Services placed in special measures will be inspected again within six months. If insufficient improvements have been made such that there remains a rating of inadequate for any population group, key question or overall, we will take action in line with our enforcement procedures to begin the process of preventing the provider from operating the service. This will lead to cancelling their registration or to varying the terms of their registration within six months if they do not improve.

The service will be kept under review and if needed could be escalated to urgent enforcement action. Where necessary, another inspection will be conducted within a further six months, and if there is not enough improvement we will move to close the service by adopting our proposal to remove this location or cancel the provider’s registration.

Special measures will give people who use the service the reassurance that the care they get should improve.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 9 May 2017

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

• A new practice nurse had been employed and was leading the long term condition (LTC) management clinics with support from the GPs.

• Performance for diabetes related indicators were either comparable or slightly better than both the Clinical Commissioning Group and national averages.
• Longer appointments and home visits were available when needed.
• There were systems to review patients with LTCs.
• Patients with LTCs who were prescribed with a number of medicines had their records checked monthly to identify if they needed an invitation to have their health needs reviewed.
• Patients with long term conditions were given a care plan explaining their treatment and care needs.
• The practice held a three monthly diabetic outreach clinic where patients with complex diabetes could be reviewed by a specialist diabetic nurse from the Royal Devon and Exeter Hospital.
• For those patients with the most complex needs, the GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
• The practice participated in the admission avoidance enhanced service and reviewed patient cases at regular intervals.
• Podiatry (feet and ankle) clinics to monitor the health of patients feet were run at the practice and weekly physiotherapy clinics were also held to reduce the need for patients to travel to the nearest hospital.

Updated 9 May 2017

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

• The practice’s uptake for the cervical screening programme was 87% which was better than local and national averages of 82% and 81% respectively.
• The practice offered travelling health advice for young families.
• Contraception advice was offered.
• Patients were offered pre bookable Saturday morning appointments approximately three times a month.
• Email and telephone advice was available, although a policy regarding digital security had not yet been written.
• 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.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• Parents and carers were able to book joint appointments to discuss their needs and those of their children.

Updated 9 May 2017

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

• The practice ran complex care team meetings once a month, with the input of GPs, practice nurses, administrative staff, district nurses, physiotherapists and social workers.

• The practice participated in the admission avoidance enhanced service and reviewed patient cases on regular intervals.

• The practice offered 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.

• There were weekly GP visits to the local care home.

• . GPs carried out reviews of their registered patients in two local community hospitals.

• Podiatry (feet and ankle) clinics to monitor the health of patient’s feet were run at the practice.

• End of life care patients were given the personal telephone number of the GP so they could access support and advice out of hours in addition to the out of hours provider.

Updated 9 May 2017

The practice is rated as good for the care of working age people (including those recently retired)

• DVLA (driver and vehicle licensing agency) assessments were available.

• Extended opening hours offering appointments from 7.00am to 7.30pm and Saturday morning clinics were available and benefitted working patients.
• Patients could access pre bookable Saturday appointments.
• Patients could book appointments and request repeat prescriptions online
• Telephone consultations could be requested by email.
• Family planning advice was provided at an appointment of the patients’ convenience.
• Patients could access email advice and advice over the telephone.

Updated 9 May 2017

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

• 90% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which is better than the local average of 87% and national average of 84%.
• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations, such as local dependency and addiction clinics.
• Staff had received training about how to care for people with mental health needs.
• Performance for mental health related indicators was 94% of the total QOF points available, which was 5% above the CCG and national averages. Where there were exception reported ratings the practice had systems for ensuring patients were referred to support services appropriately.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice carried out advance care planning for patients with dementia.
• 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 had a good understanding of how to support patients with mental health needs and dementia. Feedback from a local nursing home for people with dementia was very positive regarding the knowledge and compassion of the GPs.
• The practice offered blood tests for patients on high risk mental health medicines to save them a journey to the nearest hospital.

Updated 9 May 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 travellers and those with a learning disability.
• All vulnerable patients were offered annual reviews , including assessment of physical health
• There was sign posting to appropriate support services.
• Patients could see the same clinician at the practice , helping with continuity of care
• Patients could access same day urgent appointment.
• All seriously ill patients were discussed amongst the clinicians so that the practice could respond better to their needs
• GPs and practice nurses worked well with complex care teams and social services.
• 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, such as with the community matron.
• 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. Information about safeguarding contacts had recently been added to the locum GP pack.