Archived: The Clock Tower Surgery

Updated 31 March 2015

The Clock Tower Surgery is a unique GP practice commissioned to provide access to NHS primary care services for approximately 563 homeless and vulnerably housed patients. The practice is situated in the city of Exeter and works closely with other mainstream GP practices, health and social care services.

The practice has two salaried GPs who are supported by a qualified nurse. The clinical team comprises of 1 male and 2 female staff. There is an administrative team consisting of a practice manager and a receptionists. The opening hours are: 9.15am to 5pm Monday to Friday. There is a GP and nurse walk in clinic every day from 9.15 – 10.45am, with appointments from 10.45 – 12.15 and 2-5pm. The practice works closely with other community health and social care workers, hosting specialist clinics every day from Tuesday to Friday each week. These provide patients with access to a midwife, consultant psychiatrist, heptology specialist nurse and a physiotherapist. Clinics are held twice a week for vulnerable patients in extreme mental health crisis. Emergency Out of Hours cover is delivered by another provider.

Devon Health Ltd is registered with three locations. This inspection focussed on the Clock Tower Surgery only. The practice does not have a dispensary, however patients are able to collect their medicines from a choice of pharmacies in Exeter.

The CQC intelligent monitoring had insufficient data to band the practice. This was because the practice has a contract with NHS England and has key performance indicators instead. The CQC intelligent monitoring tool draws on existing national data sources and includes indicators covering a range of GP practice activity and patient experience including the Quality Outcomes Framework (QOF) and the National Patient Survey. Based on the indicators, each GP practice has been categorised into one of six priority bands, with band six representing the best performance band. This banding is not a judgement on the quality of care being given by the GP practice; this only comes after a CQC inspection has taken place.

We carried out our announced inspection at the practice on Wednesday 3 December 2014.

Updated 31 March 2015

Letter from the Chief Inspector of General Practice

The Clock Tower Surgery, which is run by Devon Health Limited was inspected on Wednesday 3 December 2014. This was a comprehensive inspection.

The Clock Tower Surgery is a unique primary medical service set up to provide access to health care for homeless and vulnerably housed people in Exeter. The practice provides support to help patients get back into main stream health and social care services as soon as their health and housing status is stable.

The practice provides primary medical services to a diverse population. At the time of our inspection there were approximately 563 patients registered at the service with a team of two salaried GPs. Devon Health Ltd runs the practice, which has a board and executive directors responsible for overall management and financial responsibility for the practice. Supporting the two GPs the team included a registered nurse, practice manager and administrative staff. We spoke with seven staff and two community mental health workers who worked closely with the practice team to support patients.

Patients who use the practice have access to community staff including district nurses, community psychiatric nurses, health visitors, physiotherapists, mental health staff, counsellors, chiropodist and midwives.

The practice is rated as GOOD. Specifically, we found the practice to be good for providing, effective, caring, responsive services and for being well led. It was also good for providing services for all population groups: older people, people with long term conditions, families, children and young people, working age people (including those recently retired and students), people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia)

Our key findings were as follows:

• Patients reported high level of satisfaction with the care and treatment being offered to them. Several reported to us their health had improved as a result of this and felt the practice was unique and promoted equality and compassion.
• Patients reported having good access to appointments at the practice and two GPs which improved their continuity of care. The practice was clean, well-organised, had good facilities and was well equipped to treat patients.
• The practice was seeking patient feedback daily as part of the ‘Friends and Family Test’.
• The practice was well-led and had a clear leadership structure in place. There was an atmosphere of mutual respect and team work. There were systems in place to monitor and improve quality, identify business risk and systems to manage emergencies.

• The practice was responding to patient need. For example, funding had been secured to set up a Health, Wellbeing and Community Hub (HWCH) for patients within central Exeter presenting with complex needs. These include: drug and alcohol dependency, housing needs (homelessness), offending behaviours, access to primary health care services, access to employment and training, together with access to benefit and debt advice. This would provide services under one roof for patients and promote well co-ordinated care and support for them.

We saw several areas of outstanding practice including:

• Eighty three patients commented in person or in writing that the team was exceptional and genuinely cared about their welfare. For example, the practice had a clothing and bedding bank, which provided clean, warm clothing to any patients needing it. In cold weather, the team visited known areas of the city where patients were rough sleeping and offered warm drinks, additional clothing and bedding.
• The practice performance for carrying out cervical screening for female patients with complex mental health needs was well above the target set by the CCG.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 31 March 2015

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

The practice nurse had a lead role in chronic disease management and patients at risk of hospital admission were identified as a priority. Longer appointments and home visits were available when needed. When patients attended the practice for the first time they had a named GP who with the support of the nurse carried out a raft of health screening checks. Patients were then offered an individualised plan, with structured reviews of their health and medicines whilst they remained registered at the practice. The frequency of reviews tended to be greater than in other primary medical services where patients had an annual reviews. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Updated 31 March 2015

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

Children living in disadvantaged circumstances and who were at risk were quickly identified and measures to reduce these risks were put in place. The practice provided GP support for children and young people living in a secure service run by the local authority. This was a collaborative role and included screening and treating patients for chlamydia, blood borne and respiratory illnesses associated with living in disadvantaged circumstances. Access to contraception advice and support was also available to young people. 

The practice did not offer an immunisation service because the children of patients vulnerably housed were registered at other GP practices in the city.

Female patients presenting at the practice had access to midwifery services with set appointments every Tuesday. Emergency processes were in place and referrals made for children and pregnant women who had a sudden deterioration in health.

Updated 31 March 2015

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

Data showed that outcomes for patients were good for conditions commonly found in older people. The practice offered proactive, personalised care to meet the needs of the older people in its population, for example, in dementia and end of life care. Patients at risk of unplanned hospital admission had a care plan in place. It was responsive to the needs of older people, and offered home visits and rapid access appointments as well as a walk in appointment service to see a GP and or nurse every day.

Updated 31 March 2015

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

The practice offered accessible and flexible appointments. Each contact with patients was used as an opportunity to screen and prioritise existing and new health issues. Many of the patients attending the practice were vulnerably housed and did not have access to financial support through the benefits system or paid employment. Assistance was given to patients to help them access financial and housing support so that they might take the first steps towards having a more stable life.

Updated 31 March 2015

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

Staff knew their patients well enough to detect early signs of mental health relapse and worked closely with them to keep them safe. All these patients had a named GP and structured reviews to check their health and medicine needs were being met. Safeguards were in place to make sure that high risk medicines were identified and regularly monitored. The practice held a list of all patients on depot medicines, which included the date when it was last give and next one due. The list was closely monitored by the practice nurse and demonstrated that the team was proactive in engaging with patients on this medicine. Records showed medicines were given as prescribed, which was crucial in stabilising patient’s mental well being so that they did not experience unnecessary hospital admission due to mental health crisis. Patients had experienced a discussion about their lifestyle, about their drinking and smoking habits. The practice performance for carrying out cervical screening for female patients with complex mental health needs was well above the target set by the CCG.

The practice worked closely with multi-disciplinary teams in the case management of people experiencing poor mental health including those with dementia. Shared premises enabled face to face discussions could take place and responsive support available when patients were in crisis.

The practice had sign-posted patients experiencing poor mental health to various support groups and third sector organisations. The practice had a system in place to follow up on patients who had attended accident and emergency or were hospitalised where there may have been mental health needs. Staff had received training on how to care for people with mental health needs and dementia.

The practice had secured funding to set up a Health, Wellbeing and Community Hub (HWCH) for patients within central Exeter presenting with complex needs. These include: drug and alcohol dependency, housing needs (homelessness), offending behaviours, access to primary health care services, access to employment and training, together with access to benefit and debt advice. This would provide services under one roof for patients and promote well co-ordinated care and support for them.

Updated 31 March 2015

The practice is rated as good for the population group of people living in vulnerable circumstances.

The practice was rated as outstanding for the population group of people whose circumstances may make them vulnerable. The target group for the practice was patients living in vulnerable circumstances including homeless people, travellers and those with learning disabilities.

Homeless patients could access a GP from the practice without an appointment at the walk in clinic five times a week. They could also be seen by appointment at different times of the day if they preferred. The practice was responsive and saw all patients needing urgent assessment and treatment within minutes of arriving. The practice offered longer appointments for people with learning disabilities.

Staff knew how to recognise signs of abuse in vulnerable adults and children. They were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in and out of hours.

Patients were only referred on to register with mainstream GP practices when there was evidence that they were permanently housed.