Caen Medical Centre

Updated 16 May 2016

Caen Medical Centre is a semi-rural practice covering an area of approximately 100 square miles. There were 12,011 patients on the practice list and the majority of patients are of white British background. The practice has 2.1% black and minority ethnic patients from Afro Caribbean and Asian (Indian, Pakistani, Bangladeshi and Chinese) backgrounds. All 12,011patients have a named GP and linked administrative staff. There is a higher percentage of babies (0-1 years), working age over 55 years and older people compared to the national averages. The practice has a higher number of patients (1.1%) living in adult social care homes on its list, compared with the national average of 0.5%. Nearly half of the patients at the practice have a long term condition, receive support and are monitored closely. The total patient population falls within the low-range of social deprivation.

The practice is managed by seven GP partners (four male and three female).They are supported by a salaried GP (female). The practice uses the same GP locums for continuity where ever possible. There are four female practice nurses and three female health care assistants. All the nurses specialise in certain areas of chronic disease and long term conditions management.

Caen Medical Centre is a teaching practice, with three GP partners approved as GP trainers. Three GP partners are approved teachers with Health Education South West. The practice normally provides placements for trainee GPs and F2 trainees (qualified doctors in the second year of their foundation training). Placements for trainee paramedics have also recently been made available at the practice. Teaching placements are provided for year three, four and five, medical students. Two trainee GPs were on placement when we inspected.

The practice is open 8:30am to 6:30pm Monday to Friday. Extended opening hours are available on Monday, Tuesday and Wednesday with early morning and late evening appointments with GPs listed on the practice website: Early morning appointments are on Wednesday mornings (7:30am – 8am) and late evening appointments are on Monday and Tuesday (6:30pm - 7:30pm). Appointments can be booked up to 6 weeks in advance.

Opening hours of the practice are in line with local agreements with the clinical commissioning group. Patients requiring a GP outside of normal working hours are advised to contact the out of hour’s service provided by Devon Doctors.

The practice has an Personal Medical Service (PMS) contract and provides additional services, some of which are enhanced services:

• Identification of risks associated with alcohol use and providing support to patients.

• Extended hours

• Minor surgery

• Facilitating early diagnosis of dementia

• Influenza, pneumococcal, rotavirus and shingles immunisations for children and adults

• Patient participation in development of services.

Caen Medical Centre aims to bring services closer to home for patients; Dermoscopy, chiropody, orthoptist. Other NHS services are run at the practice such as the depression and anxiety clinic, which is run by the mental health trust. Nurses from the community nursing service are based at the practice.

Updated 16 May 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Caen Medical Centre on 3 February 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, a GP partner was the MacMillan GP facilitator for the area and regional advisor. They shared their knowledge and expertise in this area, providing leadership and facilitation of improvements for patients experiencing the palliative care pathway across the region.

• Feedback from patients who used the service, family members and carers, and stakeholders was continuously positive about the way staff treated them and other patients. Patients said staff went the extra mile and the care they received exceeded their expectations. Feedback from all 48 patients about their care was consistently and strongly 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.It enabled these services to provide clinics for patients at the practice making these more accessible for patients and their carers. For example, strength and balance classes were held for people at risk of falling.

• 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 appointment system had been completely overhauled and patients reported improved access and support.
• A walk in phlebotomy clinic was held every day between 8:30am to 10:30am, and between 2pm and 3pm on Tuesday, Wednesday and Thursday. The latter clinic aimed to provide a later service for patients with chronic health conditions who may find it difficult to attend earlier in the day.
• The practice had good facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand
• The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

We saw several areas of outstanding practice including:

• Caen Medical Centre has embraced the concept of living well and was facilitating the integration of services to specifically bring care and treatment closer to home for patients. Examples included; developing a community hub bringing services closer to home for patients. The promotion of healthier living which was aimed at reducing the risk of unplanned hospital admissions where ever possible and improved quality of life.For example, older patients at risk of falling were able to attend strength and balance classes every week to improve their stamina and reduce the risk of injury from falls.Holding key roles in some of the 19 local charities identified as being able to support patients who could be at risk of social isolation.Developing a local walking group and driving forward the concept of a ‘compassionate community’ within Braunton.Patients were signposted and able to access services from within the practice with the aim of avoiding unplanned hospital admissions.

• The practice engaged with young people in using and developing the services at Caen medical Centre ahead of NHS England publishing the initiative entitled “You’re welcome” encouraging services to explore young people’s needs. The practice undertook a survey with young people in the town and gained some insight into their needs. This work had raised awareness across the team of the young people’s attitudes. As a result of this work, the school nurse, in conjunction with the practices GPs, began running a clinic at the local secondary school once weekly.

• The practice held a carers focus group in June 2015, in which 20 carers had been invited and eight attended. Carer’s suggestions to increase information on the practice website and in the waiting rooms regarding support available. We saw the practice website and information in the waiting room raised awareness about support services such as Devon Carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 16 May 2016

The practice is rated as outstanding for the care of patients 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.

• The percentage of patients with diabetes on the practice register, who had received a flu vaccination in the last 12 months was 96.74%. This was slightly higher than the national average of 94.45%.

• The practice hosted the annual diabetic retinal screening service clinics during the winter months, so that patients avoided the inconvenience of having to travel to the main hospital in Barnstaple.

• Structured diabetic education clinics were held in conjunction with the secondary care hospital based diabetic nurse specialist. This provided diabetic patients with complex needs more support to help them achieve a better level of control of their condition.

• Longer appointments and home visits were available when needed. The practice allocated patients a named GP, wherever possible to see them at home for continuity of care. GPs carried out between three to four home visits each day, which could be up to 10 miles or more away on rural roads.

• All these patients had a named GP and 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.

• Practice nurses had extended their skills so that they were able to treat patients with complex leg ulcers and manage other types of wounds normally treated in secondary care.

• A walk in phlebotomy clinic was held every day between 8:30am to 10:30am and between 2pm and 3pm on Tuesday, Wednesday and Thursday. The latter clinic aimed to provide a later service for patients with chronic health conditions who may find it difficult to attend earlier in the day.

Updated 16 May 2016

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

• Caen Medical Centre is situated close to a military base and provides healthcare for a temporary population of young families living there.

• 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 patients who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.

• 75.84% of patients diagnosed with asthma register had a comprehensive review in the last 12 months, which was comparable with the national average of 75.35%.

• Patients told us that children and young patients were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

• The uptake of women aged 25-64 having had a cervical screening test performed in the preceding 5 years was 81.5% which was higher than the national rate of 74.3%.

• Information displayed encouraged cervical screening, chlamydia and other sexually transmitted infection screening. Chlamydia screening bags were obtainable in the patient toilets.

• Flexible appointments were available for mothers and children. For example, approximately 1400 women benefitted from a flexible and accessible contraceptive service. Appointments, where coils and implant devices could be fitted were available three times a week and appointments outside of school hours.

• We saw positive examples of joint working with midwives, health visitors and school nurses. Midwives were based at the practice and held clinics there every day. An integrated child health surveillance and baby immunisation clinic were held every Monday so that parents had access to a GP, practice nurse and health visitors at the same time.

• There was innovative engagement with young people about development of the services provided or linked with the practice. Focus groups were held with young people and had led to an integrated service run by the school nurse, with support from GPs at the practice, with clinics being held at the local secondary school. This enabled young people to access services and support when they needed it.

Updated 16 May 2016

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

• Caen Medical Centre had a significantly higher than average elderly population.25.28% of patients were aged over 65 compared with a clinical commissioning group (CCG) average of 24.1% and a national average of 16 %.

• The practice took a truly holistic approach providing proactive, personalised care to meet the needs of the older patients in its population. At the heart of this was the promotion of healthier living which was aimed at reducing the risk of unplanned hospital admissions where ever possible and improved quality of life.For example, older patients at risk of falling were able to attend strength and balance classes every week to improve their stamina and reduce the risk of injury from falls.

• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. For example, the GPs supported patients living in four nursing homes, one of which was a specialist dementia care service. They visit each service weekly to review patients as well as providing urgent home appointments when needed.

• The practice hosted a quarterly clinic for the national Aortic Aneurysm screening programme (aortic aneurysm is a swelling (aneurysm) of the aorta – the main blood vessel that leads away from the heart, down through the abdomen).  Men aged over 65 years were eligible for this screening with the aim of early identification and proactive treatment if they were diagnosed with an aortic aneurysm

• The practice provided facilities for other NHS and private services to bring services closer to home for patients. For example, a chiropody service was provided at the practice twice a week.

• Carers were identified on a practice register and had regular access to a local caring organisation, Devon Carers. The practice provided free accommodation so that carer’s clinics could be provided twice a month. The practice provided accommodation free of charge so that the charity was able to run a bimonthly carers clinic, providing support and advice.

Updated 16 May 2016

The practice is rated as outstanding for the care of working-age patients (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. For example, when NHS England stopped funding the text messaging service the practice looked into other systems. At the time of the inspection, it was negotiating a trial of software which would enable voice and email reminders, and text messages to be sent to patients signed up for this service.

• The practice was responsive to the needs of working patients and had a walk in phlebotomy clinic every day. Flu vaccination clinics had been held at weekends during the winter months, or patients were able to have vaccinations at a time that suited them during extended hours.

• 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 supported families of service personnel based at the nearby Chivenor military base. There were systems in place to identify military veterans and ensure their priority access to secondary care in line with the national Armed Forces Covenant.

Updated 16 May 2016

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

• Data showed that the practice achieved high levels of engagement with patients with complex mental health needs. For example, 95.74% of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in their record, in the preceding 12 months.

• Staff knew patients well and were proactive in ensuring reasonable adjustments were made. This included offering appointments later in the day and enabling patients to sit in quieter areas away from busy waiting room to avoid experiencing additional anxiety when attending appointments.

• The practice was proactive in identifying any patients who could be undiagnosed with dementia. As a result the dementia register had increased from 94 patients in December 2014 to 130 by January 2016. 97.71% of patients diagnosed with dementia who had had their care reviewed in a face to face meeting in the last 12 months, which was much higher than the national average of84.01%

• All of the staff had completed or in the process of completing an online course to become ‘Dementia Friends’. This was helping them to identify patients who were presenting symptoms and behaviour associated with dementia so that they could be referred for assessment and appropriate interventions.

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

Updated 16 May 2016

The practice is rated as outstanding for the care of patients 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 multi-disciplinary teams 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.