James Fisher Medical Centre

Updated 30 June 2016

James Fisher Medical Practice was inspected on Wednesday 25 May 2016. This was a comprehensive inspection.

The practice is situated in the town of Bournemouth, Dorset. The practice provides a general medical service to approximately 12,900 patients of a diverse age group. There is ample parking outside the practice and regular bus services in the area.

Information published by Public Health England rates the level of deprivation within the practice population area as eight on a scale of one to ten. Level one represents the highest levels of deprivation and level ten the lowest.

There is a team of nine GPs (six female and three male). Six of these GPs are partners and three are salaried GPs. The GP partners hold managerial and financial responsibility for running the business. The GPs were supported by a practice manager, assistant practice manager, an independent nurse prescriber, six nursing team members and additional administration and reception staff.

Patients using the practice also have access to community nurses, mental health teams and midwives. The health visiting team and an anticipatory care team are based at the practice. Other health care professionals visit the practice on a regular basis.

James Fisher Medical Practice is a training practice for medical students GP trainees and F2 doctors. There are three GP trainers at the practice.

The practice is open to patients between Monday and Friday 8am until 6.30pm. Outside of these times patients are directed to contact the South West Ambulance Service Foundation Trust out of hour’s service by using the NHS 111 number.

The practice offer a range ofappointment types including book on the day and advance appointments and can request telephone consultations. Appointments are available for pre-booking up to five weeks in advance and there is a GP triage system for patients wishing to be seen for a same-day appointment. The triage/ duty doctor is available from 8am to 6.30pm Monday to Friday. Patients can book and cancel appointments face to face, online or on the phone. The practice provides 6.50 hours of extended hours appointments each week. These are from 6.30pm – 8pm on Monday and Tuesday evening. These appointments include appointments with the nursing team on Tuesdays.

The practice provided regulated activities from its primary location at 4 Tolpuddle Gardens, Muscliffe, Bournemouth, BH9 3LQ

Updated 30 June 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at James Fisher Medical Centre on Wednesday 25 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 an effective system in place for reporting, recording and learning from any significant events.
• Risks to patients were assessed and well managed.
• Patients said they found it easy to make an appointment with a GP, although two of the patients said this was sometimes harder to do if they wanted an appointment with a specific GP.
• 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.

• The involvement of other organisations and the local community was integral to how services were planned to make sure the practice met people’s needs. For example, the practice worked well with voluntary sector, either through a website signposting or through direct access provided within the practice voluntary suite.

• There were innovative approaches to providing integrated person-centred pathways of care that involved other service providers, particularly for people with multiple and complex needs. For example, the practice referred patients including victims of domestic violence, those with mental health problems, and women who have been trafficked to the Sunshine midwifery team for advice and support.

• There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that meets these needs. For example, the practice offered effective pre-conception advice, on site health visiting team and services of a GP who had a special interest in Paediatrics (GPwSI paeds) who could offer direct support rather than referral to the local hospital.

• The practice offered contraceptive counselling and services which included lThe GP contraception lead was a faculty registered trainer, who facilitated on-going training for GPs and nurses from other practices.

• Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
• The practice efficiently identified patients who were carers and offered them written information and guidance and offered ongoing support.
• 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 and concerns.
• 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. 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 provided and offered a room free of charge to voluntary services and charities. The space allowed the practice staff to work in collaboration with a number of local charities to provide services to the local community. Amongst these were the Alzheimer’s charity and CRUSE (a bereavement charity).

We saw one area of outstanding practice:

The practice was involved in a collaborative project with two other local practices in response to the needs of the over 75 year population group who were high risk of hospital admission. The project was funded by Dorset clinical commissioning group and known as the Anticipatory Care Team (ACT). The project was aimed at reducing emergency hospital admissions by offering routine care, urgent care, regular reviews and provision of proactive personalised anticipatory care plans for frail older patients who could not easily access practice facilities. We saw data that showed an 11.1% decrease in patients over 75 years attending the emergency department compared to the same period the year before. This related in real terms to 59 less patients being admitted to hospital. Data also showed an 18.2% reduction in self-referral to the emergency department. The team had also provided falls assessments, medicines reviews and, dementia assessments and screening. The team had referred patients for further care and updated care plans.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 30 June 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 monitored and supported people with long term conditions to optimise their health and wellbeing.

• Patients with a long term condition were able to access a named GP. There were same day GP appointments if needed, as well as on the day telephone advice if required.

• Specialist nurses provided dedicated appointments for those with chronic conditions as well as providing telephone support if needed. There were additional clinics working with the community hospital nurse specialist. Patients could access in the practice general nursing, wound dressings, ECG test (heart monitoring), Doppler readings such for leg ulcers, spirometry (breathing assessment), 24 hour BP monitoring, contraception services and immunisations.

• There was a named GP for a local care home who was involved in the long-term management of these patients and provided a point of contact for liaison for staff at the home.

• The practice had a specialist nursing team particularly for the over 75 year old patients. The team were able to respond to acute problems for this group of patients by visiting at home as well as providing ongoing management of long term conditions.

• Practice staff worked closely with the community matrons who managed patients with more complex healthcare needs in this group. They regularly talked with GPs either face to face or via the computer system. The specialist nursing team and community matrons attend the monthly multidisciplinary team (MDT) meetings where any patients identified as having additional medical or social needs were discussed.

• There was a carers' lead at the practice. Carers were identified at the time of registration or by the GPs or any of the nursing teams. Each carer was provided with a carers' pack which provided information regarding practice contacts, support and other services.

• The practice had a voluntary services hub within the practice which offered support from various voluntary and charity groups.

Updated 30 June 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 monitored and supported people with long term conditions to optimise their health and wellbeing.

• Patients with a long term condition were able to access a named GP. There were same day GP appointments if needed, as well as on the day telephone advice if required.

• Specialist nurses provided dedicated appointments for those with chronic conditions as well as providing telephone support if needed. There were additional clinics working with the community hospital nurse specialist. Patients could access in the practice general nursing, wound dressings, ECG test (heart monitoring), Doppler readings such for leg ulcers, spirometry (breathing assessment), 24 hour BP monitoring, contraception services and immunisations.

• There was a named GP for a local care home who was involved in the long-term management of these patients and provided a point of contact for liaison for staff at the home.

• The practice had a specialist nursing team particularly for the over 75 year old patients. The team were able to respond to acute problems for this group of patients by visiting at home as well as providing ongoing management of long term conditions.

• Practice staff worked closely with the community matrons who managed patients with more complex healthcare needs in this group. They regularly talked with GPs either face to face or via the computer system. The specialist nursing team and community matrons attend the monthly multidisciplinary team (MDT) meetings where any patients identified as having additional medical or social needs were discussed.

• There was a carers' lead at the practice. Carers were identified at the time of registration or by the GPs or any of the nursing teams. Each carer was provided with a carers' pack which provided information regarding practice contacts, support and other services.

• The practice had a voluntary services hub within the practice which offered support from various voluntary and charity groups.

Updated 30 June 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.

• 1007 patients over 75 years old were registered at the practice which represented approximately 8% of the patient list. These patients all had a named GP and were encouraged to see the same practitioner for regular appointments for continuity. The GPs offered a same day duty triage system to allow most patients to be seen urgently by a practitioner of their choice and offered home visits to all housebound patients.

• The practice used a variety of tools to help identify the most vulnerable elderly patients including local intelligence and specialist computer software. These patients were then reviewed by their GP, where an anticipatory care plan was developed.

• Monthly multidisciplinary team meetings were held to discuss and support the most vulnerable patients. These were attended by representatives from the district nursing team, community matrons, social care and voluntary sector representatives, GPs, practice nurses and the anticipatory care team.

• Patients were offered influenza, shingles and pneumococcal vaccines either in the practice or in the patients' own home. The practice offered screening for dementia and atrial fibrillation during the flu clinics.

• There were established close links with the local nursing home. The GPs visited to review any patients as required.

• The practice worked in collaboration with two local practices and used funding from the Dorset Clinical Commissioning Group to establish an over 75’s anticipatory care team. This comprised of a nurse practitioner, registered nurse and administrator. The team provided a proactive service for moderately frail patients, performed comprehensive assessments, maintained anticipatory care plans and also a provided a reactive acute visiting service. The project’s aim was to reduce emergency hospital admissions by identifying potential issues earlier and managing or signposting appropriately. The team currently had 126 active patients representing 12.5% of the practices over 75 population. We saw data that showed an 11.1% decrease in patients over 75 years attending the emergency department compared to the same period the year before. This related in real terms to 59 less patients being admitted to hospital. Data also showed an 18.2% reduction in self-referral to the emergency department. The team had also provided 131 falls assessments, 119 medicines reviews and, 78 dementia assessments and screening. The team had referred 53 patients for further care and updated 116 (74%) care plans.

Updated 30 June 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 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 reflects the needs for this age group.

• James Fisher Medical Centre offered GP appointments from 8am in the morning as well as holding two late surgeries until 8pm on Mondays and Tuesdays. Nurse appointments were available until 7.30pm on most Tuesdays.

• Patients could access online booking for appointments and for ordering repeat prescriptions, which allowed people at work to order relevant medicines and organise appointments. There was a facility for patients to view their medical record through the online system.

• In 2015 the practice joined the electronic prescription service enabling GP’s to send patient prescriptions electronically to the pharmacy of the patients’ choice.

• The GP triage system allowed all patients to have the opportunity to access same day appointments with a GP. This could be telephone or face to face, at the GP’s discretion.

Updated 30 June 2016

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

• The practice could identify patients experiencing poor mental health including those holding a mental health care plan and those with dementia.
• The practice strived to recognise the difficulties that people experiencing poor mental health and their carers could experience when initiating and accessing ongoing care. Access was supported through planned and invitation reviews as well as ad hoc review and through the daily GP triage access. Patients of particular concern were identified to the receptionists as ‘to be always offered a same day appointment’ when they made contact.
• There were active opportunistic screening programmes for dementia. These patients were monitored regularly according to need, as assessed by their usual GP or in conjunction with other services. They were invited for at least an annual review of all physical and mental health needs.
• The practice had introduced an annual health and wellbeing check for all carers of dementia patients, resulting in positive feedback. Many dementia patients were also supported by the practice anticipatory nurse team who helped plan, monitor and organise services. The Memory Assessment Gateway which offered assessment and support at any level of concern to both patient and carers;
• People with post-natal depression and significant young person’s mental health concerns were identified through multidisciplinary discussion and monitoring.
• The practice regularly supported patients to access local services including:

• Steps 2 Wellbeing ( a comprehensive group and individual support/ counselling and psychotherapy service);
• The Sunshine midwifery team who provided care to vulnerable women, including victims of domestic violence, those with mental health problems, learning difficulties, women who have problems with substance misuse, teenagers and women who have been trafficked.
• Live Well Dorset offering support on physical wellbeing particularly to vulnerable groups;
• Voluntary Sector – either through website signposting or through direct access in the practice voluntary suite.

• The practice worked closely with other professional service including

• Young person’s counselling services;
• Community mental health teams (CMHT) and the local pharmacy to regulate medicines in patients with mental health illness when appropriate

• The practice follow up every out of hours contact by one of our patients experiencing poor mental health until they were satisfied that they had addressed concerns.
• A voluntary sector space has recently opened within the surgery building. The space allows the practice staff to work in collaboration with a number of local charities to provide services to the local community. Amongst these are the Alzheimer’s charity and CRUSE (a bereavement charity).

Updated 30 June 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 homeless people, travellers and those with a learning disability.

• 69.4% of patients on the practice learning disability register had attended for an annual health check last year which was in line with local and national averages.

• Vulnerable patients were routinely offered longer appointments and all had a named GP. They had a personalised anticipatory care plan covering physical, mental and social health issues with provision for end of life care planning when appropriate. These care plans were updated regularly and shared with out of hours and emergency services.

• There was same day access for vulnerable patients and their carers via the duty GP service. A system of managed triage appointments encouraged continuity of care.

• The practice provided a service to several residential facilities including 18 patients at a local disabilities care home. Staff fostered a strong and constructive working relationship with staff at these facilities and aimed to provide continuity of care whenever possible.

• Vulnerable patients with high risk of recurrent admission were discussed at the monthly multidisciplinary team meetings. Proactive personalised anticipatory care plans were in place for each of these patients. These care plans reflected patient identified goals and included information such as a falls risk assessment, medicines management, social and mental health issues and end of life choices. The care plans were shared with other professional and the out of hour’s service to ensure good continuity of care.

• Practice staff provided support and reviews for carers. This process had been recently formalised to encourage uptake and engagement. Annual health checks were offered to all carers of patients with dementia.

• Disabled parking, ground floor disabled toilets and waiting room wheelchairs were all available at the practice.

• 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.

• Care for patients who abuse drugs and alcohol was shared between the practice and relevant local agencies.