Archived: Castle Place Practice

Updated 28 September 2017

Castle Place Practice was inspected on Monday 21 August 2017. This was a focused inspection.

Castle Place Practice covers an area of 100 sq. miles, consisting of town and rural areas. There are 15,318 patients on the practice list and the majority of patients are of white British background. All of the patients have a named GP and linked administrative staff. There is much a higher proportion of older adults on the patient list compared with other practices in the area. A third of the patient population are children and young people. The total patient population falls within the mid-range of social deprivation, but there is very high deprivation in one area of Tiverton.

The practice is managed by seven GP partners (four male and three female).They are supported by six female salaried GPs. The practice uses the same GP locums for continuity wherever possible. There are five female practice nurses and two female HCAs (health care assistants). All the nurses specialise in certain areas of chronic disease and long term conditions management.

The practice is open 8:30 am to 6:30 pm Monday to Friday. Extended opening hours are available every day with a combination of GP, nurse and HCA early morning and late evening appointments listed on the practice website: Early morning appointments are on Monday, Tuesday, Wednesday and Friday mornings (7:30 until 8am) and late evening appointments are on Monday and Thursdays (6:30pm until 7:30pm).

Opening hours of the practice are in line with local agreements with the clinical commissioning group. Patients requiring a GP outside of normal working hours are advised to contact the out of hours service provided by Devon Doctors. The practice has opted out of providing out-of-hours services to their own patients and referred them to another out of hour’s service.

The practice has shared responsibility for monitoring in patients at the community hospital in Tiverton. The GPs provide shared cover for the urgent care centre based at Tiverton Hospital. The practice covers alternate weeks with another practice between 8am to 6.30 pm and 6.30pm to 10pm each night during weekdays.

Castle Place Practice provides regulated activities from Castle Place Practice, Kennedy Way, Tiverton. We visited this location during our inspection.

Updated 28 September 2017

Letter from the Chief Inspector of General Practice

This announced focused inspection was carried out on 21 August 2017 to confirm that the practice had made improvements to meet the recommended actions in our previous comprehensive inspection on 14 January 2016. In January 2016 the overall rating for the practice was Good. The full comprehensive report for the January 2016 inspection can be found by selecting the ‘all reports’ link for Castle Place Practice on our website at www.cqc.org.uk.

Overall the practice is rated as Good

Our key findings were as follows:

• Systems had been set up to schedule audits and monitor these to provide assurance of embedded shared learning and improvement so that patients experience high quality care and treatment. Examples seen included audits looking at appropriate appointments and effective management of prescriptions.

• The practice had clearly defined and embedded systems to obtain patient consent in a consistent way. Governance had been strengthened and monitoring results demonstrated consent was consistently obtained and followed national guidelines.

• Succession planning and implementation of GP recruitment and retention was effective, within the context of the national shortage of GPs.

• Implementation of a nationally recognised on line training source for all staff providing assurance of adherence and internal rewards in recognition of completion of modules.

• Wider engagement across the health and social care sector within Tiverton and surrounding areas to utilise resources effectively and improve patient experience.For example, the practice led a working group with all the community pharmacists and GPs in the area to agree a consistent approach across Tiverton.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 12 April 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. We saw several examples where the team had provided a flexible person centred service which resulted in health improvement, effective management and improved quality of life for patients. For example, the practice had negotiated alternative treatments normally prescribed and monitored by secondary care services for a patient, with weekly appointments to administer this medicine. This had resulted in improvement of the patient’s diabetes control, which had significantly reduced the frequency of unplanned admissions to hospital and their need to access out of hours services for support.

• Heath promotion was strongly advocated through rehabilitation aimed at enabling patients to achieve the best quality of life possible. For example, the practice team was instrumental in developing the pulmonary care group run at the community hospital and continued to provide expertise and support with this. Patients experienced continuity of care as a result.

• Longer appointments and home visits were available when needed.

• All these patients had a named GP and a structured reviews that were tailored 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 12 April 2016

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

• GPs were accredited family doctors and experts in family medicine. They demonstrated that good communication with young people and children was at the core of the service. There was a child friendly atmosphere with children’s area in the waiting room.

• The practice held children specific equipment on site, for example, to check a childs blood saturation levels in the event of an emergency situation, such as an asthmatic attack.

• 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. For example 84.9% to 99.0% and five year olds from 91.8% to 98.0%, which were in line with the CCG and national averages.

• The percentage of patients diagnosed with asthma, on the register, who had an asthma review in the last 12 months was The percentage 71.35% and comparable with the national average of 75.35%.

• 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. For example, the practice was embracing new technology to engage with young patients through email, online booking and use of social networking sites.

• The practice performance for the cervical screening programme was 80.8%, which was higher than the CCG average of 77.0% and the national average of 74.3%.

• Appointments were available outside of school hours and the premises were suitable for children and babies. For example, after school flu vaccination clinics were held to target school age children and young people.

• We saw positive examples of joint working with midwives, health visitors and school nurses.

Updated 12 April 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. For example, the practice used frailty scoring to identify any patients who could be at risk of falling and put measures in place to reduce this. These included referring older patients to mobility rehabilitation services through the physiotherapy department at the community hospital.

• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

• GPs had shared responsibility for managing the health needs of patients during their inpatient stay at Tiverton Community Hospital. Patients experienced continuity of care because of this and responsive discharge planning and support was put in place.

• All patient had a named GP who supported them in whatever setting they lived, whether it was at home or at an adult social care service.

Updated 12 April 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. For example, repeat prescriptions could be ordered online and the electronic prescribing system allowed the practice to send this to the most convenient pharmacy for the patient anywhere in the country.

• 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. Extended hours were available four mornings and two evenings a week with patients able to choose to see a GP, nurse or healthcare assistant.

• Private services such as a travel clinic and heavy goods vehicle medicals were provided. The practice was a registered yellow fever centre, which meant patients had access to services locally rather than having to travel to Exeter for this.

• Health checks were available for working age patients and opportunistic screening of blood pressure, cholesterol and diabetes were done at routine appointments for early detection of any long term conditions.

Updated 12 April 2016

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

• 91.14% of patients diagnosed with dementia who had had their care reviewed in a face to face meeting in the last 12 months, which was higher than the national average of 84.01%.

• 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 aimed to provide services close to home and was facilitating this. For example, it provided accommodation for the depression and anxiety service (DAS) in Tiverton to be based there free of charge for two days a week so that patients could benefit from a locally provided service.

• 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.

Updated 12 April 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 patients, travellers and those with a learning disability.

• The practice offered longer appointments for patients with a learning disability and demonstrated flexibility and a person centred approach in the way care plans were delivered for patients. We saw several examples where patients’ health had improved through a tailored approach and resulted in a reduction of use of the out of hours service and unplanned hospital admissions.

• The practice regularly worked with multi-disciplinary teams in the case management of vulnerable patients.

• Reasonable adjustments were in place to ensure that patients with communication needs were fully involved in decisions about their care and treatment. For example, information throughout the building and used in consultations was accessible in specific different languages and other formats such as easy read (documents using pictures and simple words to explain something).

• 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.