Ward Practice

Updated 23 July 2018

Ward Practice, also known as Honiton Surgery, is a GP practice which provides its services to approximately 17,000 patients.

The practice is situated in the Devon town of Honiton and is made up of two separate practices which merged in 2016.

The practice is open Monday to Friday between 8.30am and 6.30pm. Outside of these hours patients are directed to the local NHS 111 out of hours provider as part of a local agreement. Out of hours information is displayed outside of the practice, within our newsletter, website and within the patient information leaflet. Extended hours are offered but not freely advertised on the website or in the patient newsletter. Patients were advised to speak with a receptionist about these. We were told these were between 7.30am and 8am on Monday, Wednesday and Thursdays and from 6.30pm until 8pm and sometimes 8.30pm on Tuesdays and Wednesdays.

Routine appointments can be made for nurses up to six months in advance and for GPs up to two months in advance. Urgent appointments are available on the same day and can be booked by receptionists, however there is a trigger point where the practice move to a total telephone triage system where patients speak with a GP first. There is a system to ensure patients falling within certain criteria would automatically see a GP. For example, children under the age of five years old.

The practice population is in the eighth decile for deprivation. In a score of one to ten, the lower the decile the more deprived an area is. There is a practice age distribution of male and female patients equivalent to national average figures. Average life expectancy for the area is similar to national figures with males living to an average age of 81 years and females living to an average of 85 years.

There is a team of 15 GPs (ten female and five male). Of the 15 GPs, 11 are GP partners, holding financial and managerial responsibility of the practice. Together they provide a whole time equivalent (WTE) of nine GPs. The team of GPs are supported by nine registered nurses, one

Assistant practitioner and ten health care assistants. The clinical team are supported by a practice manager and a team of over 30 administration and reception staff and a team of five cleaning staff.

The practice is a teaching practice for medical students and is also a Royal College of GPs (RCGPs) research practice.

The GPs provide medical support to five care homes and two homes for patients with learning disabilities. The practice is registered to provide regulated activities which include:

Treatment of disease, disorder or injury, surgical procedures, maternity and midwifery services and Diagnostic and screening procedures and operate from the main site of:

Honiton Surgery

Marlpits Road

Honiton

Devon

EX14 2NY

Updated 23 July 2018

This service is rated as Good overall.

We undertook a comprehensive inspection of Ward Practice in August 2017 under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The practice was rated as Requires Improvement for providing well led services.

We undertook a follow up inspection on Wednesday 16 May 2018 to check that action had been taken to comply with legal requirements. The full comprehensive report on the August 2017 inspection can be found by selecting the ‘all reports’ link for Ward Practice on our website at www.cqc.org.uk.

At this inspection the key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

At this inspection we found:

• An overall improvement in the systems and processes used to ensure good governance in accordance with the fundamental standards of care, particularly in regard of record keeping, recruitment, staff training, risk management and staff development.
• Continued reporting and management of significant events with a more detailed recording system to further evidence learning and actions taken.
• A more comprehensive system for the identification of patients who were also carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 11 September 2017

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

• Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.

• The practice held vascular clinics which encompassed primary and secondary prevention of cardiovascular disease (hypertension, hyperlipidaemia), asthma and chronic obstructive pulmonary disease (COPD). COPD is a chronic lung disease.
• Each chronic disease clinic was supported by a lead GP to provide advice if required.
• The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.
• There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.
• All these patients had a named GP and there was a system to recall patients for 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 held educational meetings for GPs and nurses. For example, woman's health update (including contraception), asthma and COPD update. The clinical team learned from case based discussions at the weekly clinical meetings (discussing complex or challenging cases advice/support), clinical audit and review, and from the twice yearly whole team significant event analysis meetings.
• Clinical staff worked with specialist teams from the local acute NHS in the management of long term conditions including diabetes. Twice yearly virtual clinics were held which provided practice staff with guidance on more complex diabetic care and provided opportunities for education.
• Patients could access additional support and advice through the practice website linking to local and national self-help forums and support groups. There were also links to other NHS websites such as patient code.uk and health information on the national website NHS choices.
• The practice considered health promotion as an important aspect of care and actively signposted patients to weight management, alcohol reduction, smoking cessation support and exercise programs.
• Practice staff and members of the patient participation group (PPG) had held educational events with different themes. For examples men's health, women's health, and mental health so patients had a better knowledge of health conditions and services available for help.
• Quarterly palliative care meetings were held with hospice care team and community nurses to discuss patients on the palliative care register and highlight any patients where increasing intervention was necessary. In addition, a white board was maintained to highlight patients receiving end of life care. This was updated by GPs and hospice nurses.

Updated 11 September 2017

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

• There were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young patients who had a high number of accident and emergency (A&E) attendances.
• Post-natal checks and eight week baby checks were offered in line with immunisation programmes.
• Patients told us, on the day of inspection, that children and young patients were treated in an age-appropriate way and were recognised as individuals.

Appointments were available outside of school hours and the premises were suitable for children and babies.

• The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.
• The practice had emergency processes for acutely ill children and young patients and for acute pregnancy complications.

• The practice promoted the use of a leaflet and provided an app called HANDi which provided advice, support and guidance for common childhood illnesses. For example, what to do if a child has a temperature and guidance of when to contact a GP, call NHS 111 or 999.

Updated 11 September 2017

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

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
• The practice offered proactive, personalised care to meet the needs of the older patients in its population.
• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
• The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.
• The practice had a system for identifying patient at risk of falling. These patients were then referred to the local falls team nurse who visited and assessed the patient at their home. The GPs then worked with a local rehabilitation team to address the risk factors.
• The GPs provided medical input and were able to admit patients to the local community hospital’s medical ward. This enabled older or patients at the end of life to be looked after closer to home, with the continuity of care from the community rehabilitation team.
• The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.
• Where older patients had complex needs, the practice shared summary care records with local care services.
• Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible.
• The GPs provided a personal medical service to 181 patients across seven care homes. Each care home had been allocated with a named GP for continuity of care.

Updated 11 September 2017

The practice is rated as good for the care of working age patients (including those recently retired and students).

• The needs of these populations 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, extended appointments were available in the morning on Mondays, Wednesdays and Thursdays and late evening appointments on Tuesdays and Wednesdays for working patients.
• Telephone appointments, triage appointments and face to face appointments were available.
• 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.

Updated 11 September 2017

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

• The practice carried out advance care planning for patients living with dementia. Practice staff were offered dementia awareness training at clinical meetings.
• 87% of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average of 85%.
• The practice specifically considered the physical health needs of patients with poor mental health and dementia.
• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
• The practice was situated next to a mental health service. GPs regularly worked with these multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
• Patients at risk of dementia were identified and offered an assessment.
• The practice had updated their website to ensure information was available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations. GPs also referred patients to local voluntary services and supported patients to self-refer to services including Recovery and Integration Service (RISE) which was a Devon-wide adult substance misuse service, working with people with alcohol and drug problems.
• The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.

Updated 11 September 2017

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

• The practice held a register of patients living in vulnerable circumstances including those with a learning disability. One of the GPs led the care for patients with learning disabilities.
• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
• The practice offered longer appointments for patients who needed them.
• The practice regularly worked with other health care professionals, for example, the learning disabilities nurse in the case management of vulnerable patients.
• The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.
• Staff interviewed knew how to recognise signs of abuse in children, young patients and adults whose circumstances may make them vulnerable. They 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.