Ashburton Surgery

Updated 21 November 2017

Ashburton surgery is situated in a rural town on the edge of Dartmoor national park and provides a primary medical service to approximately 6311 patients of a diverse age group. The practice is a dispensing practice. (A dispensing practice enables patients who live remotely from a community pharmacy to receive their medicines directly from the practice.)

The practice is a training practice for doctors who are training to become GPs, training for medical students is provided, and the practice is a research centre.

The practice population is in the seventh decile for deprivation. In a score of one to ten the lower the decile the more deprived an area is. Average life expectancy for the area is similar to national figures with males living to an average age of 80 years and females living to an average of 84 years.

There are five GP partners, two male and three female. The team is supported by a practice manager, nurse practitioner, three practice nurses, two phlebotomists, an assistant practitioner and additional reception, administration and dispensary staff.

Patients using the practice also had access to other health care professionals, including mental health teams either at the practice or in the community.

These include community nurses, midwives, mental health teams and counsellors.

The practice is open to patients between Monday and Friday 8.30am until 6.00pm, which is in line with local contract agreements. Patients could access pre-booked consultations or on the day appointments and could request telephone consultations. The practice is also open until 8pm either on a Tuesday, Wednesday or Thursday. Outside of opening times patients were directed to contact the Devon doctors out of hours service by using the NHS 111 number.

Patients are able to book their face to face or telephone appointments using the website so that services can be accessed outside normal working hours. The practice used text messages extensively for appointment reminders.

The practice operates from:

1 Eastern Road

Ashburton

Devon

TQ13 7AP

Updated 21 November 2017

Letter from the Chief Inspector of General Practice

This inspection of Ashburton Surgery was an announced focused inspection carried out on 12 October 2017 following information of concern provided by patients and also to confirm that the practice had carried out their plan to meet the areas requiring improvement that we identified in our previous inspection on 9 February 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The overall rating for the practice at the announced comprehensive inspection in February 2016 was good. The full comprehensive report on the February 2016 inspection can be found by selecting the ‘all reports’ link for Ashburton Surgery on our website at www.cqc.org.uk.

At this inspection in October 2017 we looked at the Safe, Effective and Responsive domains.

Overall the practice is still rated as good overall.

The information received from patients included information about clinical care and care of patients with mental illness. We also looked at the areas requiring improvement set at the last inspection in February 2016 relating to record keeping for complaints and significant event processes. We also looked at the areas requiring improvement regarding the assessment of dispensary staff competencies and management of expiry dates on dispensary medicines.

Our key findings this inspection in October 2017 at were as follows:

• There continued to be an open and transparent approach to safety and a system in place for reporting and recording significant events. Significant event records continued to be clear but had been further improved to reflect more of the detail of discussion, action and learning that had taken place.
• Information about services and how to complain was available. The practice continued to maintain a complaints register and reviewed this regularly. Further improvements had been made to the annual complaints review register to reflect the outcome and learning that had taken place.
• Patients we spoke with said the care and service provided was excellent and found the staff professional, caring and attentive.
• Procedures and processes had been reviewed in the dispensary, which reflect national guidelines.
• Further systems to monitor safety and quality assurance in the dispensary had been introduced by the practice.
• The practice continued to use the information collected for the Quality and Outcomes Framework (QOF) and performance against national screening programmes. Mental health indicators between 2015 and 2016 were higher than local and national averages. Patients with mental illness were cared for in a sensitive, effective and responsive way. Systems were in place to monitor the physical and mental healthcare needs of this population group. Staff worked effectively with external healthcare professionals and referred patients to other services in a timely way.
• Records kept relating to patients were contemporaneous and contained detailed information of clinical action or treatment made and included a thorough assessment of the patients concerns and management plan.
• The practice was actively participating in research projects
• Since the last inspection, the practice had promoted the online services at the practice and had achieved a high number of patients signing up to online services For example, 39.8% of patients had signed up to online services.

We saw one area of outstanding practice:

• Practice staff encouraged seeking out and embedding new ways of providing care and treatment. For example, staff wanted to respond to a measles outbreak in the local community but acknowledging practice childhood immunisation rates were lower than national averages due to the alternative lifestyles of significant numbers of parents in the locality. Practice staff, in accordance with NHS E guidance, had targeted patients over the ages of 16 to receive an MMR (measles, mumps and rubella) vaccination to boost immunity in the community. The practice had so far immunised 319 patients (with two vaccines each).

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 10 March 2016

The practice is rated as good 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. These patients had a structured annual review to check that their health and medicine 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. Patients’ needs were communicated and met using an integrated and coordinated approach. Patients with long term conditions told us they had confidence in the care and treatment they received from the GPs and nursing staff.

Patients were able to access urgent and same day appointments and were able to book 20 minute appointments to discuss long term conditions. All of the eight patients we spoke with on the morning of our inspection told us they had made their appointments that day.

The practice had a thorough recall system for reviewing patients with long term conditions. Patients told us that this system worked well and that longer appointments were available. The practice had also recently expanded the skills in their team through the recruitment of a pharmacist to further improve the management of patients with a chronic disease.

The practice was effective in the management of diabetes and had developed a system to review patients with pre-diabetes or multiple risk factors for chronic disease annually, using the recall system.

The practice providedproactive management for potential health crises, for example, patients with chronic obstructive pulmonary disease (COPD) had home action plans/rescue packs to assist them to recognise any deterioration in their condition. Staff also provided information on how to access help. The practice maintained information for health care professionals on the out-of-hours system to ensure timely and appropriate care for these patients when the practice was closed.

All clinical staff were encouraged to screen for depression in patients with long term conditions. Patients with complex co-morbidities or palliative care needs were also discussed at the monthly MDT meeting.

Practice staff referred patients to the lower limb therapy service at the community hospital where complex wounds were dressed. This saved patients travelling to the acute hospital.

Updated 10 March 2016

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&Eattendances or those that did not attend for appointments.Practice staff worked closely with health visitors who visit the practice regularly and found this useful when discussing safeguarding concerns or families of concern.

The practice was conscious that the childhood immunisation uptake of 70% was lower than national averages due to the alternative lifestyles of significant numbers of parents in this locality. We saw many initiatives provided to attract more parents. For example, flexible appointments, promotion of benefits advertised on social media sites and offering opportunistic immunisations.

The practice held midwife led antenatal care at the practice and had areas if mothers wished to feed their baby in private.

A full range of contraception services and sexual health screening, including cervical screening and chlamydia screening was available at the practice.

Updated 10 March 2016

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

The practice offered proactive, personalised care to meet the needs of the older people and had a range of enhanced services. For example, in dementia and end of life care.

The practice were responsive to the needs of older people, and offered home visits and rapid access appointments for those with complex needs.

All patients receiving regular medicines were seen for regular reviews. The practice was a small practice and the staff knew patients well, and were familiar with their family situations, those who were socially isolated, and those who were carers. This enabled staff to recognise that something may be wrong at an earlier stage.

The practice participated in the unplanned admissions enhanced service. Systems were in place to identify the top two percent of the practice population who were judged to be most at risk. Patients were made known to staff and placed on a ‘blue bed’ frailty scheme. GPs held monthly reviews of these patients with a multi-agency team and voluntary organisation to proactively co-ordinate their care, perform medicine reviews and dementia reviews. Systems were in place to ensure patients had prompt access to treatment,regular updates of care plans and treatment escalation plans, which were then shared with out of hours providers.

GPs at the practice made weekly visits to a local care home. This provided continuity of care, and developed strong relationships with the residents, managers and staff. Feedback from the Clinical Commissioning Group, patients and family members was also positive.

Practice staff formally discussed ‘admission avoidance’ with the multidisciplinary (MDT) community team each month to help maintain patient independence and enabled patients to remain at home, rather than be admitted to hospital. The MDT team were also able to refer patients to other health and social care services. A member of the local voluntary service also attended these meetings to assist with befriending or to offer ways to reduce social isolation.

Patients admitted to hospital were identified and the named GP was informed to review them following their discharge. Patients needing end of life care were managed in a coordinated way with the palliative care nurse and community team which meant patient wishes for end of life care could be planned. Feedback from patients whose relatives had received palliative care informed us that the service had been supportive, sensitive and caring.

Updated 10 March 2016

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 has adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

Pre booked appointments were available three months in advance and appointments were also abavialable on the day. There were evening appointments on alternate Tuesday and Wednesday evenings.

Patients were offered a choice of either face to face appointments or telephone consultations if more convenient. Patients were able to access a text reminder service for appointments and order their medicine online if they chose. Patients could also request prescriptions to be sent to a pharmacy of their choice.

Practice nurses offered travel advice and vaccinations and patients were able to complete their initial travel forms online.

The practice offered NHS health checks to patients aged 40-70, smoking cessation clinics and provided dietary advice to patients.

Updated 21 November 2017

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

• Between 2015 and 2016 all QOF (Quality Outcomes Framework) indicators for mental health were higher than the local Clinical commissioning Group were higher than local and national averages. For example, 100% of patients with schizophrenia, bipolar affective disorder and other psychoses had received a comprehensive, agreed care plan documented in the record. This was higher than the local average of 86% and national average of 89%.
• There were 22 patients on the mental health register. Exception reporting in the last year was for two of these patients.
• The practice was flexible with appointments for patients with mental health needs and those with dementia and offered longer appointments or telephone consultations if needed.
• Staff were familiar with patients and were able to recognise behaviours when patients were not so well or where they missed appointments.
• Where patients attended on the wrong day or at the wrong time they were fitted in for review if possible. Patients who failed to attend routine appointments, were unwell or had not been seen for a period of time were proactively chased and offered a follow up appointment or seen at home.
• Where there were concerns about a patient’s capacity to attend for appointments, or understand their care and treatment, communication with relevant parties took place.
• Data showed that the practice managed annual physical health checks and medicine reviews for patients with mental illness well.
• There was an attitude of proactively attending to the patient’s needs when they were in the practice rather than asking them to rebook for further tests or consultations. Patients appreciated this. The practice worked well with the crisis resolution team and offered in house counselling.

Updated 10 March 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

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 contactrelevant agencies in normal working hours and out of hours.

Those patients identified as vulnerable were highlighted as such on the clinical system. These patients might include those who are living in vulnerable circumstances including those with a learning disability, domestic violence patients, patients with drug and alcohol addictions, the frail elderly, homeless, patients with mental health issues, and those with complex health problems. The practice supported patients until they had registered at a new practice.

Patients identified on the Unplanned Admissions service or by health care professionals or notifications were reviewed regularly, discussed at the monthly MDT meetings and managed with a primary care team and voluntary sector approach.

The practice referred patients with drug and alcohol issues to RISE (Recovery and Integration Service) a recovery orientated drug and alcohol service delivered across Devon.

Translation phone services were used to accommodate language needs if requested.

The practice had a learning disability register and offered annual health checks for this population with a specialist learning disability nurse.