The Misbourne Practice

Updated 14 December 2016

The Misbourne Practice is a GP teaching practice based across two sites in an area of south-east Buckinghamshire known as The Chalfonts. The Chalfonts lie between High Wycombe and Rickmansworth and includes Chalfont St Peter which is one of the largest villages in the UK with nearly 13,000 residents. The Misbourne Practice is one of the practices within Chiltern Clinical Commissioning Group (CCG) and provides general medical services to approximately 12,100 registered patients. A CCG is a group of general practices that work together to plan and design local health services in England. They do this by 'commissioning' or buying health and care services alongside NHS England.

Services are provided from two sites:

• The Misbourne Surgery, Church Lane, Chalfont St Peter, Buckinghamshire SL9 9RR.

• St Giles Surgery, Townfield Lane, Chalfont St Giles, Buckinghamshire HP8 4QG.

According to data from the Office for National Statistics, The Chalfonts has a population with high levels of affluence, low incidence of substance misuse and severe mental health problems and low levels of deprivation.

Ethnicity based on demographics collected in the 2011 census shows the population of The Chalfonts and the surrounding area is predominantly White British with 4.8% of the population composed of people with an Asian background.

The practice population has a higher proportion of patients aged 45-84 and a lower proportion of patients aged 20-39 compared to the national average. The prevalence of patients with a long standing health condition is 56% compared to the local CCG average of 52% and national average of 54%.

The Misbourne Practice also provides primary care GP services for six nursing and residential homes (approximately 60 patients) and 90 residents based at the National Epilepsy Society located in a neighboring village.

The practice comprises of eight GP Partners (three female and five male) who are supported by a female salaried GP. The Misbourne Practice is a teaching practice for medical students and has recently become a training practice and will support GP Registrars from 2017. GP Registrars are qualified doctors who undertake additional training to gain experience and higher qualifications in general practice and family medicine.

The all-female nursing team consists of one nurse prescriber, three practice nurses and a health care assistant who also performs phlebotomy duties.

The practice manager is supported by a deputy practice manager and a team of reception, administrative and secretarial staff who undertake the day to day management and running of The Misbourne Practice.

Both The Misbourne Practice in Chalfont St Peter and the branch surgery in Chalfont St Giles are open between 8.30am and 6pm Monday to Friday (appointments between 8.30am and 5.30pm). A GP was on site at both the Chalfont St Peter and Chalfont St Giles practices and provided an emergency telephone service between the hours of 8am and 8.30am and 6pm and 6.30pm. Each week extended hours for pre-bookable appointments are available at both surgeries, every Thursday and Friday morning between 7.10am and 8am, every Tuesday and Thursday evening between 6.30pm and 7.10pm, most Saturday mornings and occasional Sunday morning and Sunday afternoons.

The practice has opted out of providing the out-of-hours service. This service is provided by the out-of-hours service accessed via the NHS 111 service. Advice on how to access the out-of-hours service is clearly displayed on the practice website, on both practices door and over the telephone when the surgery is closed.

Updated 14 December 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Misbourne Practice in Chalfont St Peter, Buckinghamshire on 28 October 2016. 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 an effective system in place for reporting and recording significant events.

• 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.

• 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.

• There was an effective system to assess, manage and mitigate risks across the two sites the practice delivered clinical services from. For example, there was a standard operating procedure, protocol and risk assessment for the practice’s use of liquid nitrogen.

• An understanding of the clinical performance and patient satisfaction of the practice was maintained. The practice had proactively improved QOF performance and implemented actions to review and improve already high levels of patient satisfaction.

• Feedback from patients relating to access to services and the quality of care was significantly higher when compared with local and national averages. This was corroborated by written and verbal feedback collected during the inspection.

• 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, with the National Epilepsy Society and other practices within the local GP Federation.

• 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 was regularly reviewed and discussed with staff.

The areas where the provider should make improvement are:

• Ensure an action plan for dementia care plans with a view to increase the number of yearly reviewed care plans is monitored through the practice meetings.

• Promote and display information to alert patients that translation services were available.
• Ensure extended hours appointments details are advertised on the practice website and displayed in the premises.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 14 December 2016

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

• The number of patients registered at The Misbourne Practice with a long-standing health condition was higher than local and national averages. For example, 56% of patients had a long-standing health condition, this was higher than the local CCG average (52%) and national average (54%).

• GP’s, nurses and the health care assistant had additional training and lead roles in chronic disease management. In September 2016, the practice commenced diabetes care planning.

• Performance for diabetes related indicators showed The Misbourne Practice had achieved 97% of targets which was similar when compared to the CCG average (95%) and higher when compared to the national average (90%).

• Performance for Chronic Obstructive Pulmonary Disease (known as COPD, a collection of lung diseases including chronic bronchitis and emphysema) indicators showed the practice had achieved 100% of targets which was similar when compared to the CCG average (99%) and higher when compared to the national average (96%).
• Longer appointments and home visits were available when needed.

Updated 14 December 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 in line with local averages and higher than national averages for all standard childhood immunisations.

• Four of the five nurses had additional Safeguarding training, the remaining nurse was completing this training (Safeguarding Children level three) during the inspection.

• 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’s uptake for the cervical screening programme was 83%, which was similar when compared to the CCG average (84%) and the national average (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 14 December 2016

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

• The practice offered proactive, personalised care to meet the needs of the older people in its population. Older people at risk of isolation within a rural community were identified and discussed at meetings including multi-disciplinary meetings to address any additional support required.

• The Misbourne Practice was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs. The practice identified if patients were also carers; information about support groups was available in the waiting areas.
• Nationally reported data showed that outcomes for patients for conditions commonly found in older patients were higher when compared with local and national averages. For example, The Misbourne Practice performance for osteoporosis (osteoporosis is a condition that weakens bones, making them fragile and more likely to break) indicators was higher than both the local and national averages. The practice had achieved 100% of targets which was higher when compared to the CCG average (96%) and the national average (88%).

Updated 14 December 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.

• Services were flexible, provide choice and ensure continuity of care for example, telephone consultations were available for patients that chose to use this service.

• There were a range of appointments including early morning, evening and weekend appointments. These appointments were specifically for patients not able to attend outside normal working hours but there was no restrictions to other patients accessing these appointments.
• Phlebotomy services, an in-house allergy clinic and dermatoscopy services are available at the practice which meant patients did not have to attend hospitals for testing.

Updated 14 December 2016

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

• 94% of people experiencing poor mental health had a comprehensive care plan documented in their record, in the preceding 12 months, agreed between individuals, their family and/or carers as appropriate. This was similar when compared to the CCG average (92%) and higher than the national average (89%).

• 79% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was lower when compared to the local CCG average (85%) and the national average (84%).

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

• The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
• Staff had a good understanding of how to support patients with mental health needs and dementia. All staff at The Misbourne Practice had additional training in recognising and supporting people with dementia.

Updated 14 December 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 homeless people, travellers, those with caring commitments and those with a learning disability.

• We saw 113 patients on the Learning Disabilities register, 94 of those were residents at the National Epilepsy Society. These patients had regular Care Management Plans completed at the Society and these plans sent to the practice, viewed by a GP and scanned onto the computer system. One of the GPs was the practice lead for Learning Disabilities and negotiations with the National Epilepsy Society were strengthening.

• The practice offered longer appointments (double appointments, 20 minutes in length) for patients with a learning disability.

• In October 2016, the practice patient population list was 12,092. The practice had identified 296 patients, who were also a carer; this amounted to 2.4% of the practice list. The practice had recently held a carers awareness event. This event provided carers with information including the various avenues of support available to them and also provided the in-house care co-ordinator to ensure the computer system was up to date and accurately recorded patients caring responsibilities.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients.
• 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.