Milton Abbas Surgery

Updated 22 September 2016

Milton Abbas Surgery was inspected on Tuesday 28 June 2016. This was a comprehensive inspection.

The main practice is situated in the rural village of Milton Abbas. The practice provides a primary medical service to 3705 patients of a diverse age group. The practice is a teaching practice for medical students, nursing students and a training practice for GP trainees.

The practice nursing team based in this rural area are called an Integrated Nursing Team (INT). The nurses carry out the role of practice nurses, community nurses, palliative care nurses, and community matron. The practice has a dispensary providing pharmaceutical services to patients who lived more than one mile (1.6km) from their nearest pharmacy premises.

There is a team of three GPs partners, one female and two male. Some work part time and some full time. The whole time equivalent is 2.5. Partners hold managerial and financial responsibility for running the business. The team are supported by a practice manager, a deputy practice manager, a nurse prescriber, four practice nurses, two health care assistants, dispensing and additional administration staff.

Patients using the practice also have access to physiotherapists, counsellors, chiropodists, midwives, health visitors and diabetic specialist nurses who visited the practice. Other health care professionals visit the practice on a regular basis.

The practice is open between the NHS contracted opening hours 8am - 6.30pm Monday to Friday. Appointments can be offered anytime within these hours. Extended hours surgeries are offered on Saturday mornings from 8.30am to 10.30am. In addition, the practice integrated nursing team operate seven days a week from 8.30am to 6.30pm.

Outside of these times patients are directed to contact the out of hour’s service by using the NHS 111 number. Information for patients on how to access this service is on the practice website, in the practice information leaflets, on signage within the practice, and on the practice answer machine.

The practice offers a range of appointment types including book on the day, telephone consultations and advance appointments.

The practice has a Personal Medical Services (PMS) contract with NHS England.

The practice provides regulated activities from two locations. The main practice is located at Milton Abbas Surgery, Catherines Well, Milton Abbas, Blandford Forum, Dorset DT11 0AT. The other location is Milborne St Andrew Surgery, Milton Close Road, Milborne St Andrew DT11 0DT. The practice has the same management team, GPs and patient list across both locations. We visited both of these locations during our inspection. This report refers to our inspection of the location at Milton Abbas. A separate report which can be found on our website www.cqc.org.uk refers to the other location at Milborne St Andrew.

Updated 22 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Milton Abbas on 28 June 2016. Overall the practice is rated as outstanding.

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

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the practice directly employed a member of staff and maintained a suitable vehicle for them to support local patients by delivering medicines to their homes in this rural area.
• Feedback from patients about their care was consistently positive.
• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example, the practice had provided treatment rooms for clinics and resources for the health visitor team at the branch location. The practice had also successfully introduced a phlebotomy service at the branch location as a result of patient feedback.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• This dispensing practice had safe and effective systems for the management and dispensing of medicines, which kept patients safe.
• The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result.
• The practice had a clear ethos which had quality and safety as its top priority. The ethos was to provide the highest standard of individualised healthcare in a safe, friendly and welcoming environment. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.
• The practice had strong and visible clinical and managerial leadership and governance arrangements.
• The practice provides regulated activities from two locations. The main practice is located at Milton Abbas Surgery, Catherines Well, Milton Abbas, Blandford Forum, Dorset DT11 0AT. The other location is Milborne St Andrew Surgery, Milton Close Road, Milborne St Andrew DT11 0DT. The practice has the same management team, GPs and patient list across both locations. We visited both of these locations during our inspection. This report refers to our inspection of the location at Milton Abbas. A separate report which can be found on our website www.cqc.org.uk refers to the other location at Milborne St Andrew.

We saw several areas of outstanding practice including:

The regular and consistent sharing of best practice with neighbouring practices by forming working groups to discuss significant events, adult and child safeguarding, dispensing, prescribing, and a military veteran’s policy. GPs were open to new ideas and learning by sharing their own annual appraisal outcomes with each other and then using their shared resources to achieve these outcomes and deploying their expertise as a team.

Innovative in providing care and services to its patients by setting up an Integrated Nursing Team (INT) combining the roles of practice and community nurses, carrying out home visits across this large rural area 365 days a year from 8:30am to 5.30pm. The INT supported patients by setting up care packages including physiotherapy and occupational therapy, to help patients avoid an extended stay in hospital.

Successful deployment of a dedicated carer’s lead had identified 4% of the practice population as being carers. Carers could make appointments with the carer’s lead, receive home visits, and joint visits with GPs. The practice had funded a local gym to support and promote a healthy lifestyle for patients. There was a voluntary patient transport service and an efficient medicine delivery service.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 22 September 2016

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

• The practice Integrated Nursing Team (INT) structure enabled provision of a very high level of care to patients with long term conditions.

• Appointment lengths were varied depending on need and home visits were integral to support patients who were housebound.

• The Integrated Nursing Team undertook assessments in patient's homes to enable a holistic review. Joint visiting of the nurses and GPs for care planning or clinical review of some patients occurred.

• GP’s worked very closely with all practice staff, and other primary and secondary care colleagues to meet patient and carer needs.

• The Integrated Nursing Team (INT) had various specialist roles. These included the role of community matron, district nurse and practice nurse. This enabled continuity of care which patients told us they appreciated.

• Vulnerable adult meetings were attended by social workers and community mental health for older people.

• Monthly gold standard framework meetings to discuss palliative care patients (including patients with complex chronic health conditions) were attended by GP’s, nurses, the practice dispensary lead and the local community palliative care nurse.

• The practice diabetes nurse lead had established a bi-monthly joint clinic with the hospital diabetes nurse specialist, for the purpose of reviewing complex patients, enabling clinical management discussion and opportunities for reflection and learning.

• The INT lead nurse has completed an initiating insulin course, helping patients onto using insulin where appropriate and supporting them in achieving a greater degree of self-care.

Updated 22 September 2016

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

• Antenatal and post-natal care was offered for pregnant women, together with child development checks and vaccinations clinics.

• Midwife and health visitor clinics were held weekly.

• Staff were trained to an appropriate level in safeguarding.

• The practice provided healthcare services for the local boarding school, and held specific clinics for students twice weekly during term time. The practice met regularly with the school, had good communications and offered training support and liaison regarding vaccinations. The nurse team conducted asthma clinics at the school.

• GPs offered confidential sexual health advice at the school for 240 pupils aged from 11 to 18 years, chlamydia testing, and emergency contraceptive procedures.

• The practice provided online and text message services for all patients, with planning in progress to target younger people with health messages.

• Child vaccination rates were in line with national averages and had been significantly improved over the last two years and this achievement had been acknowledged by Public Health England. The practice had taken action to focus upon this area through the introduction of a new nurse team lead.

• The practice was actively supporting the development of a play park locally to enable healthy exercise for young people, promotion of health and well-being.

Updated 22 September 2016

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

• A significant proportion of the practice population was included in this population group. For example, 24.7% of patients were aged over 65 years. This was higher than the national average of 16%.
• The practice had worked with the local community to develop and organise a voluntary transport service called “Neighbourcar” which currently had 35 volunteer drivers and helped to reduce social isolation.
• GPs and the Integrated Nursing Team (INT) shared care provision and treatment for patients, supporting holistic, continuous care.
• The practice supported the initiation of and actively promoted monthly groups which organised social activities aimed at this population group such as ‘Milborne Friendly Visitors’ which had helped approximately 220 patients to avoid social isolation. This had attracted positive feedback from patients.
• Patients had a named GP. Those at high risk of hospital admission or aged over 75 years were supported by an elderly care nurse who proactively identified vulnerable patients and supported access to clinical and social services.
• The practice held bi-weekly multi-disciplinary, vulnerable adult meetings in order to review patient’s needs in a structured way. Records showed regular monthly attendance from other providers to support delivery of holistic person-centred care.
• The practice undertook care planning to support hospital admission avoidance including palliative and end of life care, advanced care planning and having a focus on the patients preferred place of death. The practice team offered bereavement support to families as part of their end of life care. The practice focused on facilitating patients’ preferred place of death. Between April 2015 to March 2016, of the 17 patients receiving end of life care from the practice, 70% achieved their preferred place of death, of which 65% died at home. The national average was 33%.
• The practice worked collaboratively with the local community rehabilitation in-reach nurse on hospital admission avoidance and safe patient discharge from hospital. This helped patients to avoid a prolonged hospital stay.

Updated 22 September 2016

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

• The practice provided extended hours appointments with the GPs and nurses on Saturday mornings from 9am until 12 noon, which were aimed primarily at this population group.

• Online services were provided, including online repeat prescription ordering which had attracted positive feedback from working age patients.

• The practice provided convenient local pick up points for prescriptions in local villages.

• The practice offered NHS health checks and other services appropriate to this population group, including travel vaccinations.

• 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 reflect the needs for this age group.

Updated 22 September 2016

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

• The percentage of patients registered with mental health issues who had a comprehensive, agreed care plan documented in the record, in the last 12 months was 100% which was higher than the CCG average of 92% and national average of 88%.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.

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

• The practice audited medicine compliance to identify and follow up patients who failed to collect their medicines or did not attend their appointments.

• Staff had a good understanding of how to support patients with mental health needs and those living with dementia.

• The practice worked with other professionals to provide advice or treatment to patients in this population group.

• The practice offered weekly counsellor appointments on the premises.

• Multi-disciplinary team meetings included patients experiencing poor mental health and those living with dementia whenever possible or appropriate.

• Appointments were adapted to support patients with mental health issues, for example by providing a longer appointment.

Updated 22 September 2016

The practice is rated as outstanding for the care of people who 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.

• The practice held regular vulnerable patient meetings including the local community mental health teams, and undertook regular medicine reviews relevant to this population group.

• The adult and children’s GP safeguarding leads supported vulnerable patients.

• The Integrated Nursing Team (INT) allowed flexibility of care delivery for this population group, whilst offering continuity of care.

• The whole team developed relationships with patients, due to being a small team, recognising patients and changes in behaviour to highlight potential issues.

• Knowledge of local social events helped the team to support patient interaction with others.

• The practice offered communication in various ways to support the Accessible Information Standard (AIS). The AIS was created by NHS England and states that by July 2016 patients who have a disability, impairment or sensory loss get information that they can access and any communication support that they need. The practice had a portable hearing aid induction loop and appropriate notes on patient records to highlight these needs to practice staff.