Cotswold Medical Practice

Updated 13 October 2016

Cotswold Medical Practice is based in Bourton-on-the-Water, a village and civil parish in Gloucestershire. The practice has been operating from its premises at Moore Health Centre since 1998. The two-storey building has rooms for consulting, treatment and phlebotomy services on the ground floor, with a library and medical records room on the first floor. There is full disabled access, with all treatment rooms on the ground floor. As well as district nurses, the centre is used by community health visitors, mental health nurses and midwives.

Cotswold Medical Practice has around 10,307 registered patients, spread over an area of 300 square miles. The practice has higher than national average patient populations for the 10 to 14 year age group, and from 40 to 85 years and over. The patient populations aged from 0 to nine years, and from 15 to 39 years are all lower than the national average. Cotswold Medical Practice is one of 85 GP practices in the NHS Gloucestershire Clinical Commissioning Group (CCG) area. The practice population is 98% white, with the largest minority ethnic population (around 1.6%) being Asian or Asian British. A measure of deprivation in the local area recorded a score of 9, on a scale of 1-10. A higher score indicates a less deprived area (An area itself is not deprived, it is the circumstances and lifestyles of the people living there that affect its deprivation score. Not everyone living in a deprived area is deprived and not all deprived people live in deprived areas).

Cotswold Medical Practice is the main site located at Moore Health Centre, Moore Road, Bourton-on-the-Water, Cheltenham GL54 2AZ. There is a local branch practice just over six miles away at Bassett Road, Northleach, Cheltenham GL54 3QJ. The branch practice was not inspected during this inspection. This report relates to the main site at Moore Health Centre. Most of the practice patients live within a five mile radius of the main or branch sites, and around 65% of the practice’s patients are seen at the main site.

The practice team consists of eight GP partners (three male, five female) and two GP registrars (qualified doctors with at least two years’ experience who are training in general practice). In addition, six practice nurses, four health care assistants and eight dispensers are employed. The clinicians are supported by a practice manager (who is also a partner in the practice), a deputy practice manager, and a team of medical secretaries and receptionists. The practice has a General Medical Services contract with NHS England (a locally agreed contract negotiated between NHS England and the practice).

Cotswold Medical Practice at Moore Health Centre is open from 8.30am to 6.30pm on Monday, Tuesday and Thursday, and from 8.30am to 5pm on Wednesday. On alternate Fridays, opening times are 8.30am to 5pm, or 8.30am to 6pm.

The branch practice at Bassett Road, Northleach, Cheltenham (GL54 3QJ) is open from 8.30am to 6.30pm on Monday and Wednesday, and from 8.30am to 5pm on Tuesday and Thursday. On alternate Fridays, opening times are 8.30am to 5pm, or 8.30am to 6pm.

Cotswold Medical Practice has a dispensary and a member of the dispensary team is available from 8.30am to 6.30pm on Monday, Tuesday and Thursday, and from 8.30am to 5pm on Wednesday. On alternate Fridays, a member of the dispensary team is available from 8.30am to 5pm, or from 8.30am to 6pm.

A duty doctor is available for both the main and branch sites between 8am and 8.30am, Monday to Friday. GP appointments at both sites are available from 8.30am to 5pm or 6.30pm, depending on that week’s Friday opening times, and can be pre-booked up to four weeks in advance.

Extended hours appointments with a GP and nurse alternate weekly, and are available on either a Monday or Wednesday, between 6.30pm and 8.30pm. All appointments can be pre-booked up to four weeks in advance.

The practice is a Level One research practice, meaning that it has agreed to support or participate in at least two clinical studies per year. For example, one study looked at whether increasing certain inhalers could reduce the worsening of asthma symptoms that would usually require steroids.

The practice has opted out of providing Out Of Hours services to its own patients. Outside of normal practice hours, patients can access NHS 111 and an Out Of Hours GP service. Information about the Out Of Hours service was available on the practice website, and as an answerphone message on the practice phone when the practice was closed.

Updated 13 October 2016

We carried out an announced comprehensive inspection at Cotswold Medical Practice on 2 September 2016. Overall the practice is rated as good, and outstanding for providing responsive services.

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.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in line with current evidence-based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• 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.
• 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 good facilities and was well equipped to treat patients and meet their needs.
• 97% of patients said they could get through easily to the practice by phone compared with the clinical commissioning group (CCG) average of 83% and the national average of 73%.
• The patient participation group (PPG) were well engaged and represented across all age groups, and across a diverse range of professional backgrounds. The PPG suggestions for changes to the practice management team had been acted upon. Also the group had raised awareness about patient services. The practice is participating in a social prescribing scheme to support people who attend their GP surgery but do not necessarily require medical care. Social prescribing supports people with issues such as social isolation and coping with caring responsibilities, to connect to services and groups that can help improve their wellbeing and meet their wider needs.
• Staff had lead roles that improved outcomes for patients such as a care co-ordinator and a carer’s champion.
• 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 and complied with the requirements of the Duty of Candour.
• When there were unintended or unexpected safety incidents, patients received reasonable support, truthful information, a verbal and written apology and were told about any actions to improve processes to prevent the same thing happening again.

We saw three areas of outstanding practice:

• The practice funds and hosts a memory clinic. Following in-house assessments, patients may be referred to clinicians who specialise in memory problems, such as psychologists, geriatricians or dementia specialist nurses. The clinic has been running for four years, with a total of 67 patients referred in the past 12 months.
• The practice rents a room in a local organisation for art therapy sessions. The service is funded by charitable donations raised by the practice and available on referral, for patients who have suffered bereavement, were carers, or were experiencing mental health issues. An average of 25 practice patients per week attend classes and a total of 33 patients have attended classes this year.
• The practice hosts a skin camouflage service for patients who would like to camouflage scarring or a skin condition such as vitiligo. The service is provided by a charity, which is supported by donations from the practice, and is available on referral. The practice has referred 15 of its patients in the past four years, and hosts this service for the county and wider area.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice.

Updated 13 October 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.
• Performance for patients with long-term conditions compared with national averages. For example, 73% of patients with asthma, on the register, had had an asthma review in the preceding 12 months, compared to the national average of 75%. The review included three patient-focused outcomes that act as a further prompt to review treatment.
• 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.
• The practice increased the length of individual appointment times for patients with complex medical conditions from 20 to 30 minutes.
• The practice offered patients the use of technology in their homes, to self-manage long term health conditions.

Updated 13 October 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&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. The practice assessed the capability of young patients using Gillick competencies. These competencies are an accepted means to determine whether a child is mature enough to make decisions for themselves.
• The percentage of women aged 25-64 whose notes record that a cervical screening test had been performed in the preceding 5 years was 81%, consistent with 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.
• The practice hosted a midwifery clinic on one morning per week, and post-natal midwifery home visits.
• The practice provided a room for mothers to breastfeed their children.

Updated 13 October 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 in its population.
• Older patients with complex care needs or those at risk of hospital admissions had personalised care plans which were shared with local organisations to facilitate continuity of care.
• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
• The practice offered a range of services to avoid unplanned hospital admissions for elderly patients, such as in-house collection of blood samples and complex leg ulcer management.
• The practice referred patients to local community health improvement schemes.
• Patients had access at the practice to drop-in clinics from outside agencies such as Cruse Bereavement Care.
• The practice hosted a range of services such as retinal screening, and hearing aid and chiropody clinics, and provided a memory clinic.

Updated 13 October 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 had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
• 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.
• Patients were able to order repeat prescriptions on-line.
• The practice offered text reminders for appointments.
• Patients were able to book and attend appointments throughout the day.
• Telephone appointments were offered where appropriate, as an alternative to face-to-face consultations.
• The practice offered extended opening hours on Monday and Wednesday.

Updated 13 October 2016

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

• 74% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which was below the clinical commissioning group (CCG) average of 86% and the national average of 84%.
• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses whose level of alcohol consumption had been recorded over the course of a year was 94%, which was better than the national average of 90%.
• The practice regularly worked with multi-disciplinary teams in the case management of people 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.
• Patients were referred to a nurse from a local mental health trust who is based at the practice for one day a week.

Updated 13 October 2016

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 those with a learning disability.
• 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 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 was proactive in ensuring that vulnerable patients who did not attend their scheduled appointments were visited by the practice nurse, assessed and if necessary, booked for a same day appointment at the practice.
• The practice hosted a skin camouflage service for patients who would like to camouflage scarring or a skin condition such as vitiligo.