Archived: Kington Medical Practice

Updated 31 May 2017

Kington Medical Practice is located on the edge of the Herefordshire market town of Kington. It has 7,250 patients spread over a catchment area of 600 square miles in rural Herefordshire and Powys. The practice provides primary medical care to people living in two care homes in Kington and another in the nearby village of Lyonshall. The practice has on site car parking with spaces for patients with disabilities nearest to the entrance. The practice has a higher than average population of patients in all age groups over 50 and a lower than average population of patients under 40 years. The practice catchment is not in an area of significant social and economic deprivation but has significant challenges. These are due to the geography of the area making some outlying areas difficult to reach in both distance and terrain, particularly in bad weather.

The practice moved in 2012 from town centre premises they had occupied for many years to a purpose designed building on the outskirts of the town. At the time of its conception the practice’s vision for the building was to provide a spacious, well designed community resource. In addition to the GP practice and dispensary the building contains a fully equipped dental practice and consultation rooms for other health professionals. Unfortunately the project encountered numerous problems and only the GP practice and dispensary are in full time use. A number of GPs had left the practice and the remaining three partners had been unable to recruit. This had impacted on the practice’s ability to maintain access to appointments for patients and provide continuity of care. The practice had closed two branch surgeries because they were unable to provide GP cover across three sites.

In September 2015 the practice entered into an arrangement with an external healthcare company to gain support with administration, governance and GP recruitment. Two GPs from this company were intending to become executive partners of the practice. At the time of this follow up inspection the remaining GP partners were due to leave the practice and the external healthcare company were making arrangements to ensure adequate GP cover was maintained, with changes to the partnership and registration arrangements as a result.

There are two nurse practitioners, four practice nurses and a health care assistant. The clinical team are supported by a practice manager and a team of administrative staff and receptionists. The practice is a dispensing practice and has an experienced team of dispensary staff.

The practice is open between 8.30am and 6pm from Monday to Friday. The dispensary is open from 9am to 6pm Monday to Friday. The advanced nurse practitioners run a walk in clinic for patients with minor illnesses five days a week from 8.30am to 4pm. The practice provides patients with information about Taurus Healthcare, an organisation owned and managed by a federation of Herefordshire GPs which provides extended hours GP services between 6pm and 8pm on weekdays and from 8am to 8pm at weekends from three locations in the county.

The practice provides a range of minor surgical procedures. The practice has a patient participation group (PPG). A PPG is a group of patients registered with a practice who work with the practice team to improve services and the quality of care.

The practice has a General Medical Services (GMS) contract with NHS England. The practice does not provide general out of hours services although it does provide some out of hours cover for patients nearing their end of life. Information for general out of hours cover is provided for patients. This service is provided by Primecare, a national health care provider. The service is accessed by using the NHS 111 telephone number. Primecare operate from a number of sites across Herefordshire, one of which is in Kington town centre.

Updated 31 May 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kington Medical Practice on 26 November 2015. The overall rating for the practice was good. The full comprehensive report on the November 2015 inspection can be found by selecting the ‘all reports’ link for Kington Medical Practice on our website at www.cqc.org.uk.

This inspection was an announced focused inspection carried out on 7 February 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 26 November 2015. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Overall the practice rating remains good and is unchanged following this inspection.

Our key findings were as follows:

• Risks had been assessed and managed. Significant events were recorded and we saw evidence of the learning and action that had taken place as a result. The practice was aware of the requirement to inform CQC of certain events and had done so following an incident involving the dispensary.
• All required employment checks were completed for non-clinical staff carrying out chaperone duties or for staff who had unsupervised access to patients.

However, there were also areas of practice where the provider needs to make improvements.

Importantly, the provider must:

• Ensure that relevant historical information about patients is available for clinicians. Patients’ notes had not been summarised prior to 2003.

In addition the provider should:

• Review the provision of regular clinical meetings to facilitate sharing of information and best practice.
• Continue to use the results of the national GP patient survey and other patient feedback to inform further improvements in respect of access to the service.
• Communicate effectively with the practice team the roles and responsibilities of the external healthcare organisation which supports the practice.

In September 2015 the practice had entered into an arrangement with an external healthcare organisation. The intention of this was to stabilise the practice by gaining support with finance, administration, governance and GP recruitment. In November 2015 we found that communication with the practice team regarding the details of these arrangements had been limited.

These areas were highlighted following our inspection in 2015. We found that these areas had not been addressed in our inspection in February 2017.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 18 February 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 patients at risk of hospital admission were identified as a priority.

• National data for 2014/15 showed that the practices performance for managing the health of patients with long term conditions was generally in line with CCG and national averages. Data in respect of how well patients’ diabetes was controlled was lower than local and national averages.

• Longer appointments and home visits were available when needed. This included home visits for patients with no access to transport in remote parts of the practice catchment area.

Updated 18 February 2016

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

• The practice had systems to identify and follow up children living in disadvantaged circumstances and who were at risk of harm. The practice team knew local families well and liaised with other professionals involved in safeguarding.

• The practice nurses worked in partnership with health visitors to ensure that all children received the childhood vaccinations they needed. This included making individual arrangements in specific circumstances.

• Childhood immunisation rates were comparable to the CCG averages and in a number of cases higher.

• Some appointments were available for children outside of school hours between 4pm and 6pm. Children under the age of two were prioritised to be seen as soon as they arrived at the practice.

• A practice nurse ran a weekly well woman and young person’s clinics one afternoon a week. This normally ended at 6pm but the practice told us that on occasions they extended this based on individual need.

• The premises were suitable for families with children because there was ample car parking and space in the practice for prams and pushchairs.

Updated 18 February 2016

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

• The GPs provided home visits for those patients who were unable to come to the practice due to poor health or limited mobility. They also did home visits for patients with no access to transport in remote parts of the practice catchment area.

• The percentage of patients aged 65 or over who received a seasonal flu vaccination in 2013/14 was lower than the CCG and national averages but the practice had identified and addressed the reasons for this.

• The practice provided a responsive service to over 150 patients living or staying in local care homes including three providing nursing care to patients with complex physical care needs and those living with the effects of advanced dementia.

• Information was made available to out of hours and ambulance services to help ensure that patients at the end of their lives received the care and treatment they wished in the place of their choosing.

• The practice had a palliative care register and met with other health professionals to discuss the needs of those patients. The GPs frequently provided out of hours care to patients at the end of life, particularly those in remote areas to ensure continuity of care and make it more likely that they would be able to remain at home rather than being admitted to hospital.

Updated 18 February 2016

The practice is rated as requires improvement for the care of working-age people (including those recently retired and students).

• The practice had a lower percentage of working age patients, students and the recently retired than the national average. Extended hours GP services were available through a local GP federation between 6pm and 8pm on weekdays and 8am to 8pm at weekends but these were provided at other sites which involved journeys of 14 miles or more from Kington. In addition, a GP- led walk-in centre open 8am-8pm, 365 days a year was available in Hereford and it is now possible for patients to register outside their home area, for example, near to their work or study place. The practice was in continued dialogue with the Clinical Commissioning Group and other practices to find workable solutions either individually or as part of a federated approach within Taurus Healthcare (of which it is a shareholder member), to providing improved access to primary care services.

• Patients could book appointments or order repeat prescriptions online. The practice provided a free prescription delivery service to patients and collected prescriptions daily Monday – Thursday, from 4 villages within its catchment area.

• Some health promotion advice was displayed on noticeboards at the practice.

Updated 18 February 2016

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

• Performance in respect of mental health was generally good, for example 93.6% of patients experiencing poor mental health had an agreed care plan. Performance for monitoring aspects of physical health for this group of patients was also better than the CCG and national average.

• The practice had a high prevalence of patients diagnosed with dementia. Their performance for providing face to face reviews in the previous 12 months was 84.1%. This was 2.7% below the CCG and 0.1% above the national average. The practice had zero exception reporting for this.

• The practice worked with multi-disciplinary teams in the case management of people experiencing poor mental health and those with dementia. A specialist mental health worker was based at the practice once a month and a specialist dementia worker had a weekly clinic there.

• The practice worked in partnership with three local care homes which provided nursing care for patients with complex needs arising from living with dementia. Staff at one care home where patients lived with significant behavioural difficulties due to dementia told us the practice was responsive when urgent situations arose.

Updated 18 February 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 travellers and those with a learning disability. Home visits or longer appointments were available for these patients when needed.

• The practice provided annual health checks for people with a learning disability.

• Staff were aware of their responsibilities and what action they should take in respect of adults and children whose circumstances made them vulnerable or placed them at risk of harm.

• The practice responded constructively to support families living in circumstances which might make them vulnerable.

• The practice was aware of the risks to patients living in remote areas and took steps to ensure they could respond to their needs in emergencies; for example they always had portable oxygen available when going out on home visits.