Millbrook Surgery - Castle Cary

Updated 17 October 2016

The practice (Millbrook Surgery) is located in Castle Cary; a small town located eight miles south of Shepton Mallet and 15 miles from Glastonbury, in the district of south Somerset. The practice provides primary medical services for the surrounding rural villages and hamlets which includes care and treatment to 93 patients living in eight residential and nursing homes.

The practice is located in a purpose built building completed in 2011. The practice has one branch surgery in Keinton Mandeville, a village in the southeast of Somerset, where an open access surgery is available each weekday morning in the village hall. During our inspection we did not visit the branch surgery.

The practice has a population of approximately 4900 patients. The practice has a slightly higher than England average of patients aged from 60 years of age onwards. The practice is situated in an area with lower deprivation with a deprivation score of 13 compared to Somerset Clinical Commissioning Group (CCG) average of 18 and the national average of 22.

The practice team includes two GP partners, (female and male), a part time salaried GP and a locum GP. In addition two female practice nurses, two health care assistants, a practice manager, four health coaches and administrative staff which include an IT lead, receptionists and secretaries are employed. At the time of our inspection the practice manager was not available.

The practice is a training practice trainee doctors and GPs. At the time of our inspection a trainee GP was being supported by the practice.

The practice had a General Medical Services contract (GMS) with NHS England to deliver general medical services. The practice provided enhanced services which included facilitating timely diagnosis and support for patients with dementia; extended hours opening; childhood immunisations and minor surgery.

Millbrook Surgery has been a first wave pilot for the primary care part of the NHS Vanguard joint venture, developing an Enhanced Primary Care model. In addition the practice has been part of the south Somerset health community since 2015. The project, developed by primary and secondary health care teams and the District Council incorporates social care, and community services. Part of this project, called Symphony, involves redesigning services for patients with complex needs and focusing on them in a ‘virtual hub’, based at Yeovil District Hospital. It also involves patients, carers, and voluntary organisations.

The practice is open between 8.30am to 6.30pm Monday to Friday with extended morning surgeries twice weekly from 7.30am and an extended evening surgery until 7pm once weekly.

The national GP patient survey (January 2016) reported patients were satisfied with the opening times and making appointments. The results were slightly above local and national averages.

The practice has opted out of providing Out Of Hours services to their own patients. Patients can access NHS 111 and an Out Of Hours GP service is available to patients.

In February 2014 the Care Quality Commission carried out a routine inspection to check that essential standards of quality and safety were being met. We looked at five essential standards of quality and safety and found the standard was being met in that the provider was compliant with the Health and Social Care Act 2008 and relevant regulations.

Updated 17 October 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Millbrook Surgery - Castle Cary on 5 May 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 a system in place for reporting and recording significant events.
• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, weekly meetings with the community psychiatric team and virtual patient clinics with specialist doctors and nurses.
• Risks to patients were assessed, mitigated and well managed.
• 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.
• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with appointments available the same day.
• 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, concerns, patient surveys and the patient participation group.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• There was a clear leadership structure and staff felt supported by management and included within decision making processes to improve patient care. 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.
• The practice had strong and visible clinical and managerial leadership and governance arrangements. For example, staff told us the partners were very accessible, listened to concerns and implemented change process to improve the quality of the service.
• The practice undertook pilot projects and was part of the NHS England vanguard, working to deliver an integrated primary and acute care system with health and social care providers.

We saw four areas of outstanding practice:

• The practice had listened to staff and patients around access to care and treatment. For example, the practice implemented an open access system which allowed patients to phone anytime on the day they required care and treatment, speak to a GP and if necessary see a GP of their choice on the same day. This meant patients did not have to wait for routine care and treatment. The practice could demonstrate the impact of this by positive patient survey results.

• There was a focus, by the practice, on continuous improvement of the quality of care and treatment provided. Which meant improved patient outcomes. For example, the employment of health coaches who offered support to patients and their families of any age who had recently been discharged from hospital, had a chronic condition, were vulnerable or isolated. Health coaches provided lifestyle advice, assistance with day to day tasks, access and referral to community services, support and care packages and personalised care plans for those at risk.

• Staff worked together as a team to understand and meet the range and complexity of patients’ social and medical needs and to assess and plan ongoing care and treatment. For example, the practice held a staff led, twice weekly ‘huddle’ meeting for all staff. The meeting enabled any member of staff with a concern about or information about a patient to communicate it to the rest of the team and an action plan implemented. This meant the practice could be proactive and responsive to an individual patient’s care and treatment.

• The practice had a clear focus on learning and continuous improvement. For example, effective responses to feedback from patients and staff; from reviews of audits and significant events; and proactive participation in local pilot schemes and close working with other organisations to plan how services were provided and to improve outcomes for patients.

The areas where the provider should make improvement are:

• The practice should compile a full list of staff immunity against infectious diseases.

• The practice should improve the completion of incidents reporting forms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 17 October 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.

• The practice had organised a virtual clinic with specialist doctors and nurses to enable patients with diabetes to improve the management of their condition.

• Longer appointments and home visits were available when needed.

• All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. Chronic respiratory disease patients were seen six monthly. 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 17 October 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 relatively high for all standard childhood immunisations.

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

• The practices uptake for cervical screening was in line with local and national data.

• 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.

Updated 17 October 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.

• The practice provided additional services to enhance and empower patients. For example, patients at risk of a stroke were invited to a series of stroke prevention meetings.

• Health coaches actively identified older, isolated patients to sign-post and support them within a local network of community support groups.

• A twice weekly ‘huddle’ meeting identified patients at risk and allowed a proactive and responsive care and treatment plan for an individual patient.

Updated 17 October 2016

The practice is rated as good 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 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.

Updated 17 October 2016

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

• Weekly ward rounds were held in a residential home for people with a diagnosis of dementia.

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. For example, a weekly meeting took place with the community psychiatric nurse.

• The practice carried out personalised 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. All these patients had received a telephone call from a health coach within three days of their admission.

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

Updated 17 October 2016

The practice is rated as good 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 and those with a learning disability.

• The practice offered longer appointments for patients who circumstances may make them vulnerable including those 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.

• Health coaches offered support to patients and their families of any age. They provided lifestyle advice, assistance with day to day tasks, access and referral to community services, support and care packages and personalised care plans for those at risk.

• A twice weekly ‘huddle’ meeting identified patients at risk and allowed a proactive and responsive care and treatment plan for an individual patient.

• 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.