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Inspection Summary


Overall summary & rating

Good

Updated 23 April 2015

Letter from the Chief Inspector of General Practice

Mevagissey Surgery was inspected on 3rd February 2015. This was a comprehensive inspection. Overall, we rated the practice as good.

Mevagissey Surgery provides primary medical services to people living in Mevagissey, Pentewan, Caerhayes, Gorran Haven, Sticker, Polgooth and St Austell. During the summer months the practice experiences a large influx of temporary residents. Mevagissey Surgery is situated in a rural coastal location. The practice also had a dispensary. A dispensing practice is where GPs are able to prescribe and dispense medicines directly to patients who live in a rural setting which is a set distance from a pharmacy.

At the time of our inspection there were approximately 4,953 patients registered at the service with a team of three GP partners and one GP registrar. GP partners held managerial and financial responsibility for running the business. In addition there was a practice manager, nurses, health care assistants, dispensary staff together with administrative and reception staff.

Patients who use the practice have access to community staff including district nurses, community psychiatric nurses, health visitors, physiotherapists, mental health staff, counsellors, chiropodist and midwives.

Our key findings were as follows:

We rated this practice as good. Patients reported having good access to appointments at the practice and liked having a named GP which improved their continuity of care. The practice took into account the cultural needs of the local area. Patients could identify themselves as being Cornish on patient records and questionnaires. The practice was clean, well-organised, had good facilities and was well equipped to treat patients. There were effective infection control procedures in place.

The practice valued feedback from patients and acted upon this. Feedback from patients about their care and treatment was positive. We observed a patient centred culture. Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. Views of external stakeholders were positive and were aligned with our findings.

The practice was well-led and had a clear leadership structure in place whilst retaining a sense of mutual respect and team work. There were systems in place to monitor and improve quality and identify risk and systems to manage emergencies.

Patients’ needs were assessed and care was planned and delivered in line with current legislation. This included assessment of a patient’s mental capacity to make an informed decision about their care and treatment, and the promotion of good health.

Suitable staff recruitment, pre-employment checks, induction and appraisal processes were in place and had been carried out. Staff had received training appropriate to their roles and further training needs had been identified and planned.

Information received about the practice prior to and during the inspection demonstrated the practice performed comparatively well with all other practices within the clinical commissioning group (CCG) area.

Patients told us they felt safe in the hands of the staff and felt confident in clinical decisions made. There were effective safeguarding procedures in place.

Significant events, complaints and incidents were investigated and discussed. Learning from these events was communicated and acted upon.

There were areas of practice where the provider needed to make improvements.

The provider should:

Consider arrangements for monitoring room temperatures in rooms where medicines are stored to ensure the integrity of those medicines. The minimum and maximum range of fridge temperatures should also be recorded in writing for the same reason.

We found examples of outstanding practice. These included

To address the significant care gap left by restrictions to the local community nurse team, the practice deployed their own practice nurses to patient’s own homes. Elderly and vulnerable patients received home visits from the practice nurses and from practice GPs. This went beyond the contractual obligations of the practice.

Nurses at the practice carried out combined chronic disease management appointments to include all conditions experienced by one patient. This facilitated fewer appointments and was very convenient for the patient. The practice nurses also visited families in their own homes if they had suffered bereavement to offer emotional support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 23 April 2015

The practice is rated good for being safe. Patients we spoke with told us they felt safe, confident in the care they received and well cared for

The practice had systems to help ensure patient safety and staff had appropriately responded to emergencies.

Recruitment procedures and checks were completed as required to help ensure that staff were suitable and competent. Risk assessments had been undertaken to support the decision not to perform a criminal records check for administration staff.

Significant events and incidents were investigated both informally and formally. Staff were aware of the learning and actions taken. For example, a significant event involving end of life care showed that exemplary care had been provided and best practice from the event shared with other staff at meetings.

Staff were aware of their responsibilities in regard to safeguarding and the Mental Capacity Act 2005. There were suitable safeguarding policies and procedures in place that helped identify and protect children and adults from the risk of abuse. There was a lead GP for safeguarding and child protection.

There were suitable arrangements for the efficient management of medicines within the practice.

Relevant policies had been updated within the last 12 months.

The practice was clean, tidy and hygienic. Suitable arrangements were in place to maintain the cleanliness of the practice. There were systems in place for the retention and disposal of clinical waste.

Effective

Good

Updated 23 April 2015

The practice is rated good for being effective. Supporting data obtained both prior to and during the inspection showed the practice had effective systems in place to make sure the practice was efficiently run.

The practice had a clinical audit system in place and three recent clinical audits had been completed. These included a minor surgery audit and a medicines audit. These audits were repeated through the year, demonstrating a full audit cycle was in place.

Care and treatment was delivered in line with national best practice guidance. The practice worked closely with other services to achieve the best outcome for patients who used the practice. For example, the practice had close liaison with dementia care nurses and with local care and nursing homes to support patients there.

Information obtained both during and after the inspection showed staff employed at the practice had received appropriate support, training and appraisal. GP partner appraisals and revalidation had been completed.

The practice had extensive health promotion material available within the practice and on the practice website.

Caring

Good

Updated 23 April 2015

The practice is rated as good for being caring. Data showed patients rated the practice higher than others for many aspects of care. Feedback from patients about their care and treatment was consistently positive.

We observed a patient centred culture and found evidence that staff were motivated to offer kind and compassionate care and worked to overcome obstacles to achieving this. We found many positive examples to demonstrate how patients’ choices and preferences were valued and acted on.

Patients spoke positively about the care provided at the practice. Patients told us they were treated with kindness, dignity and respect. Patients told us how well the staff communicated with them about their physical, mental and emotional health and supported their health education.

Patients told us they were included in the decision making process about their care and had sufficient time to speak with their GP or a nurse. They said they felt well supported both during and after consultations.

Responsive

Good

Updated 23 April 2015

The practice was rated good for being responsive. Patients commented on how well all the staff communicated with them and praised their caring, professional attitudes.

Patients told us the staff listened to them and responded promptly to meet their needs. There was information provided on how patients could complain although access to this information on the practice website could be improved. Complaints were managed according to the practice policy and within reasonable timescales.

The practice recognised the importance of patient feedback and had encouraged the development of a patient participation group to gain patients’ views.

Practice staff had identified that not all patients found it easy to understand the care and treatment provided to them and made sure these patients were provided with relevant information in a way they understood. There was a hearing aid induction loop and large print leaflets available at the practice.

Patients said it was usually easy to get an appointment at the practice and were able to see a GP on the same day if it was urgent. However, one patient reported that they sometimes had to wait up to two weeks to get a routine appointment with a GP of their choice.

Well-led

Good

Updated 23 April 2015

The practice had a clear vision which had quality and patient safety as its top priority.

The practice is rated as good for being well led. The practice had a vision and strategy. Staff were clear about the vision and their responsibilities in relation to this. There was a clear leadership structure and staff felt supported by management. Nursing staff, GPs and administrative staff demonstrated they understood their responsibilities including how and to whom they should escalate any concerns.

Staff spoke positively about working at the practice. They told us they were actively supported in their employment and described the practice as having an open, supportive culture and being a good place to work.

The practice had a number of policies to govern the procedures carried out by staff and regular governance meetings had taken place. There was a programme of clinical audit in operation with clinical risk management tools used to minimise any risks to patients, staff and visitors.

Significant events, incidents and complaints were managed as they occurred and through a more formal process to identify, assess and manage risks to the health, welfare and safety of patients. The practice used significant event reporting to include events which had gone well particularly well, in order to share best practice with all staff and with other practices.

The practice sought feedback from patients, which included using new technology, and had an active patient participation group (PPG) who met with us during our inspection.

Checks on specific services

Older people

Good

Updated 23 April 2015

The practice is rated as good for providing care to older people.

Older patients are well represented in the practice population; the number of patients aged over 75 is higher than the national average. The practice is conscious that this population group tends to have more complex needs and be on more medication. The practice took into account that this population group may also be less able to access health care and are at increasingly at risk of financial hardship.

Patients in this population group had a named GP for continuity of care.

The practice had carried out regular audits looking specifically for unmet needs in the elderly and prescribing in this population group. Nurses and GPs at this practice carried out a higher number of home visits rate than other comparable practices in the Kernow Clinical Commissioning Group. The practice stated that they had a low threshold for carrying out home visits due to the rural nature of the area, the poor public transport links and the large numbers of patients in this population group.

GPs at the practice email each other when they encounter anyone with a significant diagnosis to help keep care coordinated. Practice staff also telephone patients on receiving their hospital discharge summaries to check all is well and make sure that Multi-Disciplinary Team (MDT) meetings are regular and minuted. These MDT meetings include representatives from social services to ensure a joined up approach to patient care.

Practice nurses provide coordinated care by carrying out above average numbers of home visits. The practice nurses also filled the gap left by a restricted district nursing service by carrying out blood tests when needed at short notice, chronic disease checks, medicines monitoring, vaccinations and bereavement support.

The practice liaised with other agencies to support this population group. Age concern provided a chiropody clinic every week in the practice. The local church and community groups enjoyed close links with the practice to support this population group in communal gatherings for mutual support and socialisation.

The practice has a high visiting rate especially for the elderly. This combined with utilising practice nurses to do visits for frail elderly, domiciliary flu injections, chronic disease and bereavement visits is an example of best practice.

People with long term conditions

Good

Updated 23 April 2015

The practice is rated as good for providing care to people with long term conditions.

Many patients at the practice have a number of parallel long term conditions. The practice has a community matron to help monitor and manage this population group on a weekly basis.

The practice has implemented specialist clinics for this population group. This has assisted in both providing support for patients and in reducing the number of visits patients need to make over the course of a year. This assisted in improving the efficiency of the services offered by the Surgery.

The practice has been involved in the Living Well project in Cornwall which suggests that a pragmatic approach looking less at medical outcomes and more at what people can actually do may be more useful to patients.

As a result of this work the practice places an emphasis on longer appointments, good quality multidisciplinary meetings and referral to services near home to improve outcomes for patients in this population group.

Patients with complex conditions are added to a specific GP partner only list to enable continuity where it is most needed. Practice nurses hold weekly Coronary Heart Disease, diabetes and COPD clinics. The practice diabetes lead nurse has regular input from a specialist consultant on diabetes. The practice had regular liaison with the palliative care nurse and the heart failure nurse to discuss changing patient needs and updates on any best practice. The practice palliative care list is reviewed at monthly meetings.

Families, children and young people

Good

Updated 23 April 2015

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

The practice has close links with the local midwifery team. Feedback from the midwife team stated that the practice went beyond contractual obligations by offering 24 hour baby checks at home for new mothers, because of how difficult it can be to get out with a new baby.

The practice staff paid attention to when parents can bring in their children and accommodated work and school time commitments with suitably timed appointments.

The practice stressed the importance of providing appropriate services for young people. The practice had attained an EEFO kite mark level 1 for engaging with young people and plans were in place to improve this to level 2. EEFO kite marks a services that meets young person friendly quality standards across Cornwall and the Isles of Scilly. The term EEFO is not an abbreviation. EEFO is a word that has been designed by young people, to be owned by young people.

The practice offered a low threshold for seeing children whose parents are concerned and offering an open door in the event that they need further review.

The practice invited the local health visitor and school nurses to their monthly multi-disciplinary team meeting to discuss children or families where there is clinical or social concern.

The practice was aware that issues around privacy and confidentiality are often important for young people. The practice had looked at the possibility of providing appointments at alternative venues away from the practice.

A full range of child vaccinations was available from the practice. Family planning clinics and contraceptive services were also available.

Working age people (including those recently retired and students)

Good

Updated 23 April 2015

The practice is rated as good for providing care to working age people. The practice provided appointments on the same day. If these appointments were not available then a telephone consultation with a GP would be booked and extended practice hours would accommodate the patient if needed to be seen. Patients could book appointments and repeat medications on line.

The practice offered regular evening surgeries between 6.30pm and 8pm specifically for patients in this population group, although they could also be taken up by other patients as necessary. Wherever possible the practice fitted appointments around peoples’ working commitments.

A great deal of written positive feedback was in evidence from summer periods when working age people had their holidays. During the summer when Mevagissey experiences an influx of temporary residents there is a significant increase in demand placed upon the practice. The practice planned for this contingency to ensure that standards were maintained. Cleanliness, easy access to appointments and the attitude of staff had been praised and comparisons with temporary resident’s home practices were very positive. This feedback often reflected the availability of on the day triage appointments at the practice instead of waiting for routine slots.

People whose circumstances may make them vulnerable

Good

Updated 23 April 2015

The practice is rated as good for people whose circumstances may make them vulnerable. The practice had a vulnerable patient register to identify these patients. Vulnerable patients were reviewed at the multidisciplinary team meetings.

Staff told us that there were no patients who had a first language that was not English, however, interpretation requirements were available to the practice and staff knew how to access these services. This service could also be accessed during the busier summer months with its influx of temporary residents, not all of whom may speak English.

Patients with learning disabilities were offered and provided a health check every year during which their long term care plans were discussed with the patient and their carer if appropriate. Reception staff were able to identify vulnerable patients and offer longer appointment times where needed and send letters for appointments.

The practice had identified local hard to reach groups whose circumstances may make them vulnerable. This included patients who are reluctant to attend the practice. The local public health team in liaison with the practice had offered a series of Fishermen’s medicals.

Mevagissey practice was not aware of problems with homelessness or travellers in the area but alcoholism and drug dependence is present and sometimes difficult to address. The practice was working to improve drug and alcohol services in future through the attainment of further staff training in alcohol and drug management.

Where there are concerns over vulnerability or safeguarding, patient’s needs are discussed at the monthly multi-disciplinary team meeting where input from social services or local support organizations was valued.

People experiencing poor mental health (including people with dementia)

Good

Updated 23 April 2015

The practice is rated as good for providing care to people experiencing for mental health.

The practice hosted support services for patients with poor mental health in one of their treatment rooms as well as providing health checks for their carers. Any missed appointments were reviewed. There was signposting and information available to patients. The practice referred patients who needed mental health services as well as support services being provided at the practice.

GPs from the practice attended multi-disciplinary team meetings every month. This is a dedicated hub meeting attended by a psychiatrist, community mental health services and a local counselling service. Patients suffering poor mental health were offered annual health checks and testing for depression and anxiety as recommended by national guidelines. GPs and nurses had training in the Mental Capacity Act (MCA) 2005 and had an understanding of the act or appropriate guidance was available in relation to the Act when caring for patients with Dementia.

The practice identified that dementia brings additional challenges for the carer and wider family, making co-ordination a priority which can be difficult with regular changes of staff, for example in the dementia practitioner service.

The practice stated that early detection of dementia is now being incentivized by the NHS which may enable earlier introduction of support systems. Staff at the practice considered the spouses and family of those affected by dementia and offered them priority access. This is taking into account their increased risk of anxiety and depression which was explored in a practice questionnaire. The practice maintained an up to date carers’ register which was used to offer communal meetings and support for carers.

One of the GP partners at the practice has an interest in mental health with a diploma in primary care mental health. There was a register of patients with mental health issues. GPs kept regular contact with these by telephone review. Practice staff shared a commitment to supportive and holistic management of patients in this population group.

The practice stated that their easily approachable access to GPs meant that anyone in the community or healthcare team can voice their concerns from chemist to dispenser or community warden with quick access to duty GP who can arrange an urgent assessment.

Due to the small patient list and stable population with a long serving staff group the practice was able to provide flexible care according to the patient’s needs.