Isca Medical Practice

Updated 4 August 2016

The practice is situated on the outskirts of the city of Exeter. The practice provides a primary medical service to approximately 5,300 patients of a diverse age group.

The practice has a higher proportion of patients over the age of 65 when compared to the England average. Information published by Public Health England rates the level of deprivation within the practice population group as six on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

There is a team of three GP partners, one male and two female and the whole time equivalent was 4.75. There was also a salaried GP due to start in September 2016. The GPs are supported by a practice manager, three practice nurses, three health care assistants, a phlebotomist and a team of administrative staff.

Patients using the practice also have access to community nurses, mental health teams and health visitors. Other health care professionals visited the practice on a regular basis.

The practice is a training practice for year’s two, three and four medical students. The practice is looking forward to becoming a teaching practice for GP trainees in the near future.

The practice is open between the NHS contracted opening hours of 8am and 6.00pm Monday to Friday. Extended hours are offered on every other Tuesday and Friday, 7-8am, and one other evening a month between 6.30pm and 8.30pm dependent on demand.

Patients can pre-book appointments either in the practice or online up to eight weeks in advance. The practice also offer book-on-the-day GP, nurse and health care assistant appointments every morning and afternoon, walk-in GP appointments every morning and afternoon and provided telephone call backs as requested.

Telephone consultations were offered as the first mode of access, and same day appointments made as required. Outside of these times patients are directed to contact the Devon Doctors out of hour’s service by using the NHS 111 number.

The practice has a Personal Medical Service (PMS) contract and provides additional services, some of which are enhanced services. For example, extended hours and minor surgery.

The practice provides regulated activities from its primary location at 38 Polsloe Road Exeter and at its branch surgery at Homefield Surgery, 6 Homefield Rd, Exeter EX1 2QS. We did not visit the branch surgery at this inspection.

Updated 4 August 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Isca Medical Practice on 21 June 2016. Overall the practice is rated as good.

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

• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.

• The practice had safe and effective systems for the management of medicines, which kept patients safe.

• Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

• The practice had a growing group of transgender patients. The practice used the patients preferred name and gender and always offered a safe, non-judgemental environment. One of the GPs had organised a talk for all local GPs on Transgender Medicine by the local Gender Clinic team, to help educate local GPs and provide the best support and management.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Feedback from patients about their care was consistently and strongly positive.

• The practice website was new and very informative, and could be translated into other languages to assist language barriers.

• A hearing loop was available at the reception desk.

• Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients 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.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

• The practice social media webpage helped the practice to engage with young people and other population groups who preferred this method of communication.

• The practice had an active patient participation group (PPG) which influenced practice development. There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
• The provider was aware of and complied with the requirements of the duty of candour.

We saw an area of outstanding practice

A systematic on going effort is being made to reduce demands on the health ecomomy by bringing in initiatives and continually improve patient care. For example the range and accessibility of care provided at the ‘walk in’ clinics.

We saw one area where improvement should be made.

Ensure continued support and identification of carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 4 August 2016

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

• Nursing staff had lead roles in chronic disease management and the management of patients at risk of hospital admission who were identified as a priority. The practice worked closely with the community specialists and held consultant led community based virtual clinics where the consultant worked alongside the practice nurses to monitor and manage those patients who required additional care. For example, for those patients with diabetes.

• GPs met monthly to review any admission of patients with long term conditions, focusing on emergency admissions to hospital and hospital discharges. The practice prescribed anticipatory medicines for those with long term conditions, such as standby antibiotics for those patients with chronic respiratory disease and ‘just in case medicines’ for palliative care patients.

• Patients with long term conditions benefitted from continuity of care with their GP or nurse. All these patients had a named GP and a structured annual review in the month of their birthday to check their health and medicines needs were being met.

• The practice worked with external agencies in other aspects of long-term condition management such as diabetic retinopathy screening and podiatry ensuring appropriate support was provided promptly.

• The practice was actively involved in several research pilots including a new treatment for depression and anxiety and long term conditions such as diabetes. This was ongoing research and no preliminary results were available at the time of the inspection.

• The practice loaned blood pressure monitors for those patients who had hypertension or found it difficult getting to the practice.

• The practice were part of the ‘ISCA active scheme’ for gym membership and weight loss. Diabetic eye screening and abdominal aortic aneurysm (AAA) screening was performed annually in the practice to save patients having to attend hospital.

• All discharge summaries were reviewed on the day they were received ensuring medicines were adjusted and appropriate primary care follow-up was arranged.

• In order to ensure continuity of care for patients in the out of hour setting, details of any patient with complex long-term conditions, or an end of life diagnosis were entered onto the ADASTRA register. This is a computer system which is visible by the out of hours service and ambulance service and contains useful information including treatment plans, escalation plan and past history.

Updated 4 August 2016

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

• 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 high for all standard childhood immunisations.

• 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.

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

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

• On receiving a discharge summary about a birth of a baby, the GPs telephoned the parents to see if there was anything they needed or were worried about. All GPS offered ante-natal care and post-natal checks to ensure their health and wellbeing. The practice had a good working, effective relationship with the appointed health visitor and midwife, and held quarterly multi-agency meetings to discuss caseloads and families of concern. The midwife held a weekly clinic at the practice and shared concerns about patients with the GPs to ensure appropriate follow up appointments were made. For example, if post-natal depression was indicated.

• Patients could access a full range of contraception services and sexual health screening.

• All staff had been trained at the appropriate level for safeguarding adults and children.

• The practice had a dedicated children’s waiting area, with easy clean toys, colouring books and a fish tank. There were baby changing facilities.

Updated 4 August 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.

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

• All patients over 75, or on an admission avoidance care plan had a named GP responsible for their care, but they were given the choice of seeing whichever GP they preferred.

• Home visits were undertaken as required and longer appointments made available for those patients who needed more time.

• For patients approaching their end of life or with complex needs, the practice had monthly multidisciplinary team meetings and quarterly palliative care meetings. These meetings were attended by GPs, nurses, community nurses, the community matron, occupational therapists, community pharmacist and social services. The practice regularly liaised with community support groups to provide further support to their patients.

• Patients residing in care homes received routine regular visits by a GP, allowing early identification of illness and health decline.The practice believed this had improved relationships with the homes and staff and reduced unnecessary unplanned admissions to hospital.

• The practice worked hard to avoid unplanned admissions to hospital by working closely with secondary care providers. For example, GPs used an on call elderly care advice line to obtain advice or get an urgent assessment of patients with complex needs. The practice also had direct access to elderly care specialists for advice on the best treatment and a management, including rapid access clinics for strokes, chest pain and older persons mental health.

• The practice worked closely with local pharmacists, ensuring patients with memory problems had blister packs, or other ways of ensuring safe delivery of medicines. The GPs worked effectively to rationalise medicines and regularly review prescriptions.

• The practice was all one level for easy access, including wheelchair access.

• Patients’ emotional needs were seen as important as their physical needs. The practice could demonstrate caring and empathy toward patients in time of loss and bereavement. Staff told us that if families had suffered bereavement, their usual GP contacted them or sent them a sympathy card. This call was either followed by a patient consultation at a flexible time and location to meet the family’s needs and/or by giving them advice on how to find a support service.

Updated 4 August 2016

The practice is rated as outstanding 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.

• 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.

• The practice had a large proportion of its patients who were under 65 years old (81%) and been responsive to the needs of this population group. For example, the practice offered a walk in clinic every day, twice a day at the branch practice. Minor injuries were also treated at this clinic. Data showed that 51 patients had treated for a minor injury which had prevented attendance to the emergency department at the hospital. The practice also offered appointments up to eight weeks in advance, as well as book on day appointments. They offered early morning and evening appointments for those patients who found access difficult. Patients were able to book, cancel and amend appointments online.

• The practice had a growing group of transgender patients. The practice used the patients preferred name and gender and always offered a safe, non-judgemental environment. One of the GPs had organised a talk for all local GPs on Transgender Medicine by the local Gender Clinic team, to help educate local GPs and provide the best support and management.

• The patient participation group (PPG) was active and continually evolving. They had a large mix of patients on the PPG and found that virtual feedback, by writing/emailing, meant that more patients could be involved. Any patient who had complained, expressed concerns, or complimented the practice were invited to join the PPG.

• Health checks were tailored to the specific needs and risks of individual patients. They offered sexually transmitted disease screening to all under 25 year olds. Patients were able to self-test for chlamydia in the toilets with kits easily available.

• Patients who received repeat medicines were able to collect their prescription at a pharmacy of their choice, have their prescription posted to them or collect it from the practice. The practice sent 70% of prescriptions electronically, which allowed an audit trail and faster delivery.

Updated 4 August 2016

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

• Patients had access to the Depression and Anxiety Service (DAS) for psychological therapies for anxiety and depression. Patients were able to self-refer, or be referred by a GP. Posters and leaflets were widely distributed in the waiting room and information was on the website.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. The practice had close links with the community mental health team and older community mental health team and had rapid access to the crisis team, who would see anyone with a mental health crisis quickly.

• The practice used social media and their website to send information out to patients regarding latest health campaigns, and actively looked to post relevant information such as exam stress, dementia awareness week and mental health awareness.

Updated 4 August 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 people, travellers and those with a learning disability.

• The practice offered longer appointments for patients with a learning disability.

• The practice regularly worked with other health care professionals in the case management of vulnerable patients.

• 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.

• All staff had been trained in the principals of the Mental Capacity Act 2005..

• Data showed the practice had carried out 73% of the annual reviews for patients with learning disabilities in 2105/16.

• Veterans were given priority for treatment and referrals in line with the military veterans covenant.

• The practice had a policy in place which gave homeless people and traveller’s full access to the services provided at the practice.

• Many of the patients had first language which was not English and particularly a large number of patients whose first language was Polish. The practice employed a new receptionist who spoke Polish. They were able to translate during consultations, phone patients with results, book appointments and explain the difference between Polish and English healthcare systems. This was advertised on the practice website. The practice also used a language line for patients who needed a translator.

• The practice reviewed the health of those patients that were recognised as carer’s. These patients were signposted to other outside agencies for additional support as needed.

• The practice had a hearing loop for patients with difficulty hearing and are able to provide communication in large print for those who required it.