Winchcombe Medical Centre

Updated 10 November 2016

Winchcombe Medical Centre is a dispensing practice located near to the centre of Winchcombe a small town in the Cotswolds. The practice has a dispensary offering pharmaceutical services to those patients on its practice list who live more than one mile (1.6km) from their nearest pharmacy premises. The practice dispenses medicines for approximately 2,900 patients. The practice has a higher than average patient population in the over 45 years age group and lower than average in the below 45 years age group. The practice is part of the Gloucester Clinical Commissioning Group and has approximately 7,000 patients. The area the practice serves is urban and semi-rural and has relatively low numbers of patients from different cultural backgrounds. The practice area is in the lowest range for deprivation, nationally.

The practice is managed by five GP partners (three female and two male). The practice is supported by one salaried GP, an advanced nurse practitioner (male), three practice nurses, two health care assistants and an administrative team led by the practice manager. The practice has five trained dispensers who dispense medicines for patients under the supervision of the GPs. Winchcombe Medical Centre is a training practice providing placements for GP registrars and medical students.

The practice is open between 8am and 6.30pm Monday to Friday. Appointments are available between 8.20am and 11.50am every morning and 3pm to 5.50pm every afternoon. Telephone appointments are also available to book. Extended hours appointments are offered 7.30am to 11am on every third Saturday. In addition to pre-bookable appointments that could be booked up to six weeks in advance, urgent appointments were available for patients that needed them.

When the practice is closed patients are advised, via the practice website and an answerphone message, to ring the NHS 111 service for advice and guidance. Out of hours service is provided by South Western Ambulance Service NHS Foundation Trust (SWASFT).

The practice has a General Medical services contract to deliver health care services. This contract acts as the basis for arrangements between the NHS England and providers of general medical services in England.

Winchcombe Medical Centre is registered to provide services from the following location:

Greet Road,

Cheltenham ,

Gloucestershire,

GL54 5GZ.

This inspection is part of the CQC comprehensive inspection programme and is the first inspection of Winchcombe Medical Centre .

Updated 10 November 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Winchcombe Medical Centre on 25 August 2016. Overall the practice is rated as outstanding.

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.
• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example delivering health awareness advice in local schools and working mens clubs.
• The practice had initiated dometic violence training for staff. In order that a single patients best interest was always at the heart of an individuals care, in instances of domestic violence, the practice ensured wherever possible, that the abused patient and their spouse were consulted with by different GP’s, in order that confidence and confidentiality was maintained.
• Feedback from patients about their care was consistently positive.
• 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, the practice improved quality of care and improved outcomes for patients by working collaboratively with other stakeholders to reduce hospital admissions of frail elderly patients.
• The practice were proactive in identifying patients with atrial fibrillation (AF), resulting in a greater number of patients being effectively managed to prevent them having a stroke.
• 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.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• 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.
• The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw two areas of outstanding practice including:

• The practice had identified patients at risk of hospital admission and worked with the community team, for example the rapid response team to prevent hospital admissions. To reduce hospital referrals the practice recognised the expertise of the GPs within the practice and initiated an in house referral system. Data showed that this approach had resulted in the practice having lower than average, referral and admission rates compared to local practices with a similar demography.

• The practice had delivered, in collaboration with the PPG health awareness sessions on men’s health, at the local working men’s club and teenage health at the local secondary school. This had provided the opportunity to deliver health education advice to hard to access cohorts of the population, who were unlikely to attend the practice for health advice.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 10 November 2016

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 patients at risk of hospital admission were identified as a priority. Collaborative working with community teams and improved utilisation of in house expertise had resulted in elective admissions being 5% lower and emergency admissions being 10% lower than local practices with similar demographics.

• Performance for diabetes related indicators was better than local and national averages. The percentage of patients with diabetes, on the register, in whom the last blood test was within the target range in the preceding 12 months (2014 to 2015) was 83% compared to a local average of 80% and a national average of 78%.
• The practice had recognised that due to the distance from the practice where diabetes education sessions were being held, diabetics who would benefit from these were not able to attend. Following discussions with the local dieticians the practice gained agreement for the sessions to be held at the practice. During the first six sessions 30 patients had benefitted from these courses.
• The practice was aware that diabetic patients who had been transferred from tablets to injections often lacked confidence to adjust the amount of insulin given until the desired clinical effect, determined by their nurse or GP, was achieved. To support patients, the practice nurse telephoned the patient daily to support them until they felt confident to continue this on their own.
• In response to the National Review of Asthma Deaths the practice identified and reviewed all patients who were over using inhalers and at risk. This approach had led to a decrease in the number of patients over using inhalers from 11% to 8%. Auditing of this has continued, with the objective of further improvement.
• Data had highlighted the practice as having a low diagnosis rate and a low testing rate for coeliac disease (a disease which leads to difficulty in digesting food). A process to improve this had raised detection rates to nearly twice the national average, from 1/1000 to 5/1000 which was significantly higher than national average of 3/1000. Diagnosed patients were invited for annual reviews and templates were rewritten for the computer system to improve the quality of these reviews.
• The practice had participated in the chronic obstructive pulmonary disease (a chronic lung condition) winter pressures programme. The programme offered additional appointments to review these patients during the winter period, when exacerbations and hospital admissions were more likely.
• Longer appointments and home visits were available when needed.
• All these patients had a named GP and 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 10 November 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.
• Health awareness days were held annually at the local secondary school. Working with the patient participation group (PPG) the practice ensured these days were relevant to teenage health.
• The practice’s uptake for the cervical screening programme was 82%, compared to the local average of 84% and the national average of 82%.
• 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.

Updated 10 November 2016

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

• 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 recognised that some of their patients who lived in rural areas were unable to collect their medicines from the practice. In response to this the practice employed a delivery driver for this purpose. The practice also held a list of volunteer drivers who assisted these patients getting to hospital and practice appointments.
• The practice provided medical services to a large local nursing home. To ensure high quality care a GP visited the home four times a week and the advanced nurse practitioner on one day a week.
• The practice participated in the Gloucestershire social prescribing scheme which provided non-medical support for older patients.
• The practice were proactive in identifying patients with atrial fibrillation (AF), resulting in a greater number of patients being effectively managed to prevent them having a stroke.
• Collaborative working with community teams and improved utilisation of in house expertise had resulted in elective admissions being 5% lower and emergency admissions being 10% lower than local practices with similar demographics.

Updated 10 November 2016

The practice is rated as outstanding 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.
• Telephone appointments were available as well as extended hours appointments held monthly on a Saturday morning for both the GP and nurse.
• 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.
• In collaboration with the PPG the practice had delivered a health advice session on men’s health at the local working men’s club. This had provided access to patients who were unlikely to attend the practice for health advice.

Updated 10 November 2016

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

• 90% of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the last 12 months, which was better than the local average of 86% and the national average of 84%.
• The percentage of patients with a serious mental illness who had a comprehensive, agreed care plan documented in the record, in the preceding 12 months (2014 to 2015) was 94% compared to a local average of 93% and a national average of 88%.
• 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 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 had a good understanding of how to support patients with mental health needs and dementia.
• To support patients experiencing poor mental health the practice hosted counselling and primary mental health care co-ordinator clinics. Staff had been updated in this area by an education session from a consultant psychiatrist at the practice and an update of care pathways by the local elderly mental health consultant. The practice in collaboration with the patient participation group (PPG) had recently run an information session entitled “Mind Matters” for patients, which led to patients having a greater understanding to manage their condition.

Updated 10 November 2016

The practice is rated as good for the care of people who 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 offered longer appointments for patients with a learning disability. The practice recognised that trust and rapport for these patients was very important and ensured they saw the same nurse each time they visited. This had resulted in patients being willing to accept the care they needed.

• The practice had undertaken training in identifying and supporting those at risk of domestic violence.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients. For examplethe practice improved quality of care and improved outcomes for patients by working collaboratively with other stakeholders to reduce hospital admissions 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.