Archived: Bungay Medical Practice

Updated 20 June 2017

Bungay Medical Practice provides services to approximately 11,000 patients in a semi-rural area in Suffolk. The practice has eight GPs; seven female and one male. There is a practice manager and an assistant practice manager on site. The practice employs three practice nurses, a trainee practice nurse, two trainee advanced nurse practitioners and a nurse manager. The practice also employs three health care assistants. East Coast Community Healthcare also provides a primary care practitioner, a community matron, a physiotherapist and a health coach. Other staff include eight receptionists, four secretaries, three admin assistants and five dispensers. The practice holds a GMS contract with NHS England. The practice is able to offer dispensing services to those patients on the practice list who live more than one mile (1.6km) from their nearest pharmacy. We visited the dispensary as part of this inspection. Bungay Medical Practice is a training practice for GP Registrars (qualified doctors who are undertaking training to become GPs) and nurse students.

In ­­­­­August 2015, Bungay Medical Practice formed a partnership with East Coast Community Healthcare Community Interest Company (ECCH), who are the provider for the practice. ECCH is a provider of over 30 community services, which includes four GP practices and has been established for five years. Staff employed by Bungay Medical Practice were due to transfer their employment to ECCH, however there had been delays with this. Therefore at the time of the inspection staff remained employed by Bungay Medical Practice.

The practice is open between 8am and 6.30pm Monday to Friday. Extended hours appointments are available between 7am and 8am on Mondays and between 6.50pm and 8.20pm on Thursdays. Appointments can be booked up to three weeks in advance for extended hour’s appointments only and GPs booked follow ups as required. Urgent appointments are available for people that need them, as well as telephone appointments. Online appointments are available to book up to one month in advance.

When the practice is closed patients are automatically diverted to the GP out of hour’s service provided by Integrated Care 24. Patients can also access advice via the NHS 111 service.

We reviewed the most recent data available to us from Public Health England which showed the practice has a smaller number of patients aged 20 to 39 years old compared with the national average. It has a larger number of patients aged 60 to 84 compared to the national average. Income deprivation affecting children is 15%, which is lower than the CCG average of 26% and national average of 20%. Income deprivation affecting older people is 12%, which is lower than the CCG average of 17% and national average of 16%. Life expectancy for patients at the practice is 80 years for males and 84 years for females; this is comparable to the CCG and England expectancy which is 80 years and 83 years.

Updated 20 June 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bungay Medical Practice on 9 May 2017. Overall the practice is rated as requires improvement.

Our key findings across all the areas we inspected were as follows:

• Survey information we reviewed showed that patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

• Staff demonstrated that they understood their responsibilities in relation to safeguarding children and vulnerable adults. However, some staff we spoke with were unclear about whom the local or regional leads were.

• There was a system for reporting and recording significant events; however learning outcomes from events were unclear. Significant events were not always discussed at meetings in a timely manner.

• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns but learning outcomes were not always recorded.
• ECCH had a clear vision and set of values and but some staff at the practice were not aware of these. Whilst staff felt supported by local leadership, they recognised that ECCH were still in the process of developing those relationships and support structures. The communication between the provider and the location had not always been effective. This had resulted in delays in information being shared and recommendations being acted upon.
• The training matrix for staff showed training had not always been completed in areas such as basic life support and safeguarding relevant to their role.

• We found out of date medicines and devices in GP bags.

• The practice was signed up to receive some, but not all Medicines and Healthcare products Regulatory Agency (MHRA) alerts. The practice had a record of alerts they had received and these were actioned appropriately. The practice signed up to receive all remaining alerts on the day of the inspection.

• Some standard operating procedures for the dispensary had not been reviewed since 2013.

• The infection control lead had not received training specific to the role and a sharps bin was out of date.

• The practice had identified less than 1% of the practice population as carers and had not offered these patients carer health checks.

We saw two areas of outstanding practice:

• East Coast Community Healthcare (ECCH) were actively implementing new models of care; for example they employed a physiotherapist, health trainer and community matron to work at the practice. The physiotherapist saw patients with musculoskeletal pain. Patients could book directly with this service ensuring they had timely advice in the management of conditions such as back pain. This benefitted the patient who did not have to be referred to other services which often incurred protracted delays and the risk of their condition deteriorating. The physiotherapist would triage patients and refer back to the GP if inappropriate. The physiotherapist was available to the GPs and nurses for immediate advice if they needed their specialist skills. Between March and April 2017, the physiotherapist saw 86 patients. Of these, only 1% was referred to a GP and 93% were managed with exercises and advice alone.

• The practice offered a ‘same day team’ which included clinical led triage, same day appointments for vulnerable patients and same day home visits by a primary care practitioner for patients who had conditions making it difficult to attend the practice. The emergency care practitioner was a trained paramedic who liaised with the GP after or during every visit. The community matron was also part of this team and offered same day appointments for acute social problems. The nurse team also had 30 appointments available daily for patients with minor illness.

The areas where the provider must make improvements are:

• Implement an effective process to ensure that medicines kept in GP’s bags are checked routinely and are safe to use.

• Ensure all safety alerts are received, actioned and shared.

• Ensure there is an effective system in place to monitor that actions from significant events are completed and recorded and learning is shared with staff, including dispensary significant events.

• Ensure standard operating procedures for the dispensary are reviewed and updated.

• Implement an effective system for monitoring staff training to ensure staff are up to date for mandatory training including safeguarding and basic life support.

The areas where the provider should make improvement are:

• Continue to identify carers and consider the need for health checks and additional support for this patient group.

• Continue to work towards effective communication to ensure staff understand their roles in relation to incident reporting and complaints.

• Consider the need for additional training for the infection prevention and control lead and ensure infection prevention and control audits are always effective.

• Ensure actions taken in response to complaints are always documented.

• Ensure all equipment is calibrated to ensure it is safe and effective for use.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 20 June 2017

The practice is rated as requires improvement for the care of people with long term conditions. The provider was rated as inadequate for safety and requires improvement for well-led. The issues identified as requiring improvement overall affected all patients including this population group. However there were examples of good practice:

• Nursing staff had lead roles in long-term disease management and were able to review multiple conditions in one appointment. The practice ensured blood tests were completed prior to appointments so results could be discussed during the appointment.

• Performance for diabetes related indicators from the Quality and Outcomes Framework (QOF) was 92%. This was comparable to the local clinical commissioning group (CCG) and national averages of 90%. The prevalence of diabetes was 8% which was the same as the CCG average and comparable to the national average of 7%. Exception reporting of diabetes indicators was 10% which was below the CCG average of 17% and in line with the national average of 12%.

• The practice followed up on patients with long-term conditions discharged from hospital and ensured their care plans were updated to reflect any additional needs.

• The practice had in-house spirometry, urine testing, 24 hour ambulatory BP monitoring and 24 hour heart monitoring devices.

• 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.

Updated 20 June 2017

The practice is rated as requires improvement for the care of families, children and young people. The provider was rated as inadequate for safety and requires improvement for well-led. The issues identified as requiring improvement overall affected all patients including this population group. However there were examples of good practice:

• There were systems 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 accident and emergency (A&E) attendances. These children were discussed at quarterly multidisciplinary team meetings with health visitors and the safeguarding team and safeguarding was on the standing agenda for monthly clinical meetings. The practice also telephoned non-attendees of practice and hospital appointments.

• Immunisation rates were relatively high for all standard childhood immunisations.

• Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals.

• The practice provided support for pregnant women and offered an appointment at 26 weeks gestation, as well as offering six week checks for new mothers and babies.

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

• The practice had same-day appointments available in the nurse led clinic for children with acute problems and young people seeking sexual health advice.

• The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications. For example, receptionists were trained to fast-track any child or pregnant woman who may be acutely ill to the clinical triage team.

Updated 20 June 2017

The practice is rated as requires improvement for the care of older people. The provider was rated as inadequate for safety and requires improvement for well-led. The issues identified as requiring improvement overall affected all patients including this population group. However there were examples of good practice:

• 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 staff were flexible with the appointment system to enable patients to use the community transport to get to the practice.

• The practice had a paramedic trained primary care practitioner who undertook acute home visits three days per week, ensuring patients who may be vulnerable received prompt assessment.

• The practice were proactive in identifying patients who may need palliative care as they were approaching the end of life. Patients were involved in planning and making decisions about their care, including their end of life care. All GPs were trained in palliative care.

• The practice followed up patients discharged from hospital and ensured their care plans were updated to reflect any extra needs. Receptionists telephoned patients who were discharged and offered a follow up appointment.

• Where older patients had complex needs, the practice shared summary care records with local care services such as community nurses. The practice held monthly multidisciplinary team meetings and invited social care staff, ambulance staff and community workers.

• Older patients were provided with health promotional advice and support to help them maintain their health and independence for as long as possible. The practice employed an in-house community matron who offered daily appointments for new referrals such as hospital discharges, falls and dementia care.

• Care homes supported by the practice received weekly ward rounds by a named GP or nurse for continuity. The local rehabilitation ward received a daily ward round and a GP attended the multidisciplinary meetings.

Updated 20 June 2017

The practice is rated as requires improvement for the care of working age people (including those recently retired and students). The provider was rated as inadequate for safety and requires improvement for well-led. The issues identified as requiring improvement overall affected all patients including this population group. However there were examples of good practice:

• The needs of this population group 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 opening hours on Mondays and Thursdays.

• The practice was proactive in offering online services as well as a range of health promotion and screening that reflects the needs for this age group, such as health checks for over 45s, weight management advice and smoking cessation.

• The practice offered a flexible triage approach, which included phoning patients back at times that suited them, such as during lunch breaks during the patient’s working day.

Updated 20 June 2017

The practice is rated as requires improvement for the care of people experiencing poor mental health (including people with dementia). The provider was rated as inadequate for safety and requires improvement for well-led. The issues identified as requiring improvement overall affected all patients including this population group. However there were examples of good practice:

• The practice carried out advance care planning for patients living with dementia.

• 86% of patients experiencing poor mental health had a comprehensive care plan, which was comparable with the CCG average of 85% and the national average of 89%.

• The practice specifically considered the physical health needs of patients with poor mental health and dementia. The practice regularly referred patients with dementia high level needs to the local Dementia Intensive Support Team and offered a Mini Mental State Examination for those with concerns about memory.

• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia and had effective communication with local care homes.

• The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.

• 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 we spoke with had a good understanding of how to support patients with mental health needs and dementia.

Updated 20 June 2017

The practice is rated as requires improvement for the care of people whose circumstances may make them vulnerable. The provider was rated as inadequate for safety and requires improvement for well-led. The issues identified as requiring improvement overall affected all patients including this population group. However there were examples of good practice:

• The practice held a register of patients living in vulnerable circumstances including travellers and those with a learning disability. The practice offered same day appointments for those in the traveller community.

• 58% of patients with a learning disability had attended annual health checks. The practice ensured the records were flagged and double appointments were offered to patients with a learning disability.

• 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 flagged patients with a sensory impairment so all staff were aware and clinicians would come to the waiting area to call these patients in for an appointment.

• The practice regularly worked with other health and care professionals in the case management of vulnerable patients, including the community nursing team.

• The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations, including information in the waiting room.

• Staff we spoke with knew how to recognise signs of abuse in children, young people 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.