Bovey Tracey and Chudleigh Practice

Updated 11 May 2018

Bovey Tracey and Chudleigh Practice is a GP practice based over two sites which provide services under a Personal Medical Service (PMS) contract for approximately 14,600 patients. The main practice is situated in the rural town of Bovey Tracey with a smaller branch surgery situated in the smaller town of Chudleigh, Devon. Staff work across both practices. The practice cover over 100 square miles which includes Dartmoor national park with minimal public transport links.

The practice population area is in the eighth decile for deprivation. In a score of one to ten, the lower the decile the more deprived an area is. The practice distribution and life expectancy of male and female patients is equivalent to national average figures. However, the practice had a significantly higher than average number of patients aged over 75 and 85 years, (13% of the practice list were over the age of 75 years compared to the national average of 8% and 4% of the patient list were over the age of 85 compared with the national average of 2%). 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 85 years.

There is a team of 13 GPs (seven female and six male). Of the 13 GPs eight were partners and five were salaried GPs. The whole time equivalent of GPs was 10.03 WTE.

The team also includes a practice manager, finance and governance manager, six registered nurses, six health care assistants, and 23 administration and reception staff.

Patients using the practice have access to community staff including community nurses and health visitors who were based at the practice. Patients could also access counsellors, depression and anxiety services, podiatrists, alcohol and drug recovery workers, retinal screening, aortic aneurysm screening and other health care professionals.

The practice is a teaching practice for student nurses, medical students and GP Registrars (doctors training to become a GP).

The GPs provide medical support to residential care homes and nursing homes in the area and have provided weekly ‘ward rounds’ and annual health reviews for these patients.

The practice is registered to provide regulated activities which include:

Treatment of disease, disorder or injury, surgical procedures, family planning, maternity and midwifery services and diagnostic and screening procedures and operate from the location of:

Riverside Surgery

Le Molay

Littry Way

Bovey Tracey

Newton Abbot

Devon

TQ13 9QP

and

Tower House Surgery

Market Way

Chudleigh

Newton Abbot

Devon

TQ13 0HL

We visited both sites during our inspection.

Updated 11 May 2018

Bovey Tracey and Chudleigh Practice are rated as good overall and outstanding in the well led domain. (the previous inspection rating in April 2015 was Good with outstanding in the effective domain)

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? – Outstanding

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection of Bovey Tracey and Chudleigh Practice on Tuesday 20 March 2018 as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen there was a genuinely open culture in which all safety concerns raised by staff and people who use services were used as opportunities for learning and improvement.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

• Patients said the care and treatment they received was very good and added that staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system easy to use and reported that they were able to access care when they needed it, although they added that they had to wait a little longer to see a GP of their choice.

• There was a strong focus on continuous learning and improvement at all levels of the organisation with many examples shared of career development.

• The practice was organised, efficient, had effective governance processes and a culture which was embedded effectively and used to drive and improve the delivery of high-quality person-centred care.

• The involvement of other organisations, voluntary services and the local community were integral to how services were planned. Proactive involvement ensured that services met patient’s needs.

• The practice worked with H.I.T.S. (Homeless in Teignbridge) and held emergency food and toiletry bags at each practice for distribution to those in crisis.

• The practice promoted the ‘Message in a Bottle’ scheme and distributed bottles. This scheme is a mechanism where information relating to frail and vulnerable patients (medical history, allergies and medicines) were stored in a container and kept within the patient’s fridge. All emergency staff were aware to check in the fridge to access this information to ensure the most effective care pathway for the patient.

• The leadership, governance and culture were embedded, established and used to drive and improve the delivery of high-quality person-centred care and were clear, supportive and encouraged creativity.

• The practice had standardised their use of the computer system through the development of templates which included care plans, patient leaflets, preferences, protocols, prompts and alerts to improve patient safety and care.

• There were high levels of staff satisfaction. Staff were proud of the organisation as a place to work and spoke highly of the culture.

• The partners and leadership team were aware of the changes within the community with planned allocation of over 900 homes in the area. The practice staff had begun planning for this increase in patient numbers.

We saw areas of outstanding practice including:

• Leaders had an inspiring shared purpose and strive to deliver high quality services and motivate staff to succeed. The GPs and leadership team had invested in their staff over a long period of time. This had led to a happy, loyal workforce with low staff turnover. The practice welcomed nursing students, medical students and apprentices and had a long history of being a popular GP training practice. Staff were supported both financially and with protected time to develop both personally and professionally in addition to the required updates. For example; reception staff had been supported to develop to senior health care assistants and phlebotomists. Nursing staff had been mentored through non-medical prescribing and one had been supported through nurse practitioner training. This support and motivation had been recognised in 2017 when the employer had won an apprentice training provider award.

• The organised leadership, detailed governance and culture were embedded and recognised as integral to ensuring high-quality care. We saw examples of detailed, multi-layered systems, audits, reviews and governance structures which demonstrated effective and safe outcomes for patients. These systems were detailed and monitored to ensure the information was effective and delivered in the best interest of patients.

• Research was seen as an integral way to generate relevant evidence to help guide general practice and improve patient care. The research team in the practice had successfully recruited many patients and had obtained additional sessional status funding to move research forward in the area. As a result the team had won two awards for outstanding innovation and outstanding team culture award.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 18 June 2015

The practice maintained a register of all patients with long term conditions and had computer prompts to remind staff to book additional screening as required.

The practice had a lead GP and nurse for each clinical area and developed clinical protocols to ensure best practice was followed.

Patients with long term conditions were invited to attend the practice for an annual check. Patients were offered vaccination against flu, shingles, and pneumonia at this appointment. Receptionists had also been trained to identify these patients opportunistically and arrange appointments to meet all their needs in one visit.

The practices offered weekly nurse led clinics for diabetes, cardiovascular disease and hypertension and these clinics were overseen by a specific GP.

The practice referred housebound patients to the community nursing team for follow up of their long term condition.

There were systems in place to identify patients who were carers. The carers were offered health checks.

A GP met with the community nurse to review palliative care patients every four weeks.

GPs contacted patients following bereavement of their relatives to offer support and ensure emotional needs were met.

Patients with long term conditions were able to access support from the Riverside befrienders and Bovey Community Care.

Updated 18 June 2015

Appropriate systems were in place to help safeguard children or young people who may be vulnerable or at risk of abuse. Safeguarding was a standing item on the monthly clinical meeting agenda. All staff knew who the Safeguarding Lead was in the practice. At risk families, children and young people were flagged on the computer system and families were encouraged to register with the same GP.

Receptionists had been given authority to book children in for a face-to-face appointment with a GP without the need for triage for urgent appointments.

The Health Visitors were accommodated in the surgery and had appropriate access to the medical records and direct access to the GPs throughout the day for urgent matters. Ante-natal care was provided by a team of midwives who worked with the practice. A midwife held clinics at the practice, had appropriate access to the patient’s computerised notes and could speak with a GP should the need arise.

The practice offered childhood immunisations and contacted patients and liaised with the health visitor regarding non-attenders. The practice offered walk-in flu vaccination clinics dedicated for children.

Patients had access to a full range of contraception services and sexual health screening including chlamydia testing and cervical screening. There were also designated gynaecological appointments available twice a week.

The waiting room had a defined children's play area.

Updated 18 June 2015

Patients aged 75 and over had an allocated GP but had the choice of having an appointment with another GP if they preferred.

Pneumococcal vaccination and shingles vaccinations were provided at the practice for older people.

The practice maintained a register of the top 2% of ‘at risk’ patients and made sure each person had a care plan which was reviewed every three months.

The practice worked to enable patients to remain at home, to help avoid unplanned admission to hospital. They worked with other health care professionals to provide joint working. Unplanned admissions to hospital were reviewed monthly to identify any gaps in care and treatment or areas for service improvement. The practice worked closely with the community matron to follow up patients discharged from hospital to ensure all their needs were met. The practice had access to a rapid response service and single point of access for referral of patients to specialist services.

The practice provided a service to patients living in four local care homes and worked with the staff to ensure new patients had a full health and medication reviews and treatment escalation plans in place.

There was level access to the surgery and a wheelchair available in the waiting room to assist patients with poor mobility. Arrangements were in place to see patients in ground floor consultation rooms if they were unable to access the first floor. The practice offered home visits to patients due to mobility or medical issues.

The practice had been instrumental in setting up two voluntary organisations, to which they now referred patients. Riverside befrienders offered transport to appointments and prescription collection. Bovey Community Care assisted in a hospital discharge support and have supported patients after their discharge from local hospitals. This support included befriending and social support with tasks such as shopping, carer relief, dementia support and trips out of the house.

Updated 18 June 2015

Routine appointments were bookable up to four weeks in advance and extended opening was available on Monday evening and Saturday mornings at either one of the two practices. The practice offered telephone consultations to any telephone number provided by the patient.

Patients could book appointments and request repeat prescriptions through the website. Prescription requests could be transferred electronically to a pharmacy of the patient’s choice. Adequate supplies of medication were provided for holiday/business trips. Text reminders for appointments were sent to patients.

NHS health checks were offered to patients over 40 years of age. Advice regarding diet, healthy lifestyle and smoking cessation were also available during some of the extended hours, for example on a Saturday morning.

Patients had access to a patient newsletter and could receive this via email.

Flu vaccination clinics were arranged on two Saturdays and patients could choose which practice to attend.

There was a virtual patient participation group at the practice which had a high number of working age members. They used electronic communication to provide feedback to the practice.

Updated 18 June 2015

The practice had a lead GP for mental health and dementia and maintained a patient register for these areas. This register was used to organise and offer annual mental health reviews to patients with long term mental illness and dementia.

Patients who were attending an appointment for a review of their chronic disease were screened and asked about underlying depression.

Patients were encouraged to book double appointments if they wanted longer to discuss mental health issues.

The practice had access to a local Crisis Team and Depression and Anxiety Service.

The duty GP system ensured access at any time of day for patients with acute mental health need. The GPs were able to prescribe medicines for acute mental health problems if appropriate.

Updated 18 June 2015

All patients were registered with a named GP to encourage continuity of care. If appropriate the computer system was flagged with concerns regarding vulnerable patients. The practice maintains a register of its top 2% of at risk patients which may include vulnerable patients with a care plans. These patients were reviewed every three months. Concerns about vulnerable patients were discussed at monthly clinical meetings.

The practice worked closely with the district nurses and health visitors who were based in either of the practice premises. These health care professionals had access to the patient medical records. The practice had access to a rapid response service for vulnerable patients to prevent hospital admission.

The practice worked with two voluntary organisations who provided transport to appointments, prescription collection. GPs could also refer patients who needed help with shopping, reading, help around the house, and companionship. More recently the service has extended to support patients on discharge home from hospital.

Patients with learning disabilities were offered a health check every year during which their long term care plans were discussed with the patient and their carer if appropriate.

Systems were in place for the practice to alert the out of hours service of vulnerable patients with a special message.