Clevedon Medical Centre

Updated 30 November 2016

Clevedon Medical Centre is a practice providing primary care services to patients resident in Clevedon and the surrounding villages.

The practice operates from one location:

Old Street,

Clevedon,

North Somerset

BS21 6DG

The premises are located in a large, modern purpose-built building on a main thoroughfare just outside the main shopping precinct and opposite the local community hospital. They have patient and staff parking and designated blue badge bays in the patient car park.

There is wheelchair access through the power assisted main front door and an accessible toilet facilities are available. All public and consulting rooms are on the ground floor and easily accessible. They have a lift to provide disabled staff access to the first floor administration rooms.

The practice has a patient population of approximately 16,000. Approximately 41% of the patients are over the age of 65 years compared to a national average of 27%. Approximately 59% of patients have a long standing health condition compared to a national average of 54%.

The practice has seven GP partners (male and female), five salaried GPs ,a business manager and an operations manager, three advanced nurse practitioners, six practice nurses, a paramedic, a physician associate, a pharmacist , a health care assistant and four phlebotomists. Each GP has a lead role for the practice and nursing staff have specialist interests such as diabetes and infection control.

The practice is open Monday to Friday 8.30am - 6.30pm and is participating in a pilot to trial weekend opening on alternate Saturdays 9am – 12noon. They offered extended hours on Monday 7.30am - 8.30 am, Tuesday 7am - 8.30am and 6.30pm - 8.00pm. Appointments are available from 8:30am and emergency telephone access is available from 8am. Telephone consultations were available with clinicians for patients and these can be flexible to meet patient availability.

The practice had a Personal Medical Services contract (PMS) with NHS England to deliver primary medical services. The practice provided enhanced services which included facilitating timely diagnosis and support for patients with dementia and childhood immunisations.

The practice is a teaching practice and takes medical students from the Bristol University and trainees from the Severn deanery.

The practice has opted out of providing Out Of Hours services to their own patients. Patients can access NHS 111 or BrisDoc provide the out of hours GP service.

Patient Age Distribution

0-4 years old: 5.2%

5-14 years old: 10.1%

Under 18 years:17.7%

65-74 years old: 24.6%

75-84 years old: 12.5%

85+ years old: 3.8%

Patient Gender Distribution

Male patients: 48.6%

Female patients: 51.4%

Other Population Demographics

% of Patients from BME populations: 1.89%

The practice is situated within a significantly less deprived area than the England average.

The general Index of Multiple Deprivation (IMD) population profile for the geographic area of the practice is in the second least deprivation decile. (An area itself is not deprived: it is the circumstances and lifestyles of the people living there that affect its deprivation score. It is important to remember that not everyone living in a deprived area is deprived and that not all deprived people live in deprived areas).

Patients at this practice have a higher than average life expectancy than the clinical commissioning group (CCG) and national average with men at 81 years and women at 87 years.

Updated 30 November 2016

Letter from the Chief Inspector of General Practice

The Green Practice and Clevedon Riverside Group merged in April 2015 to form the Clevedon Medical Centre. We carried out an announced comprehensive inspection at Clevedon Medical Centre on 1 September 2016.

Overall the practice is rated as good.

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

• The leadership, governance and culture were used to drive and improve the

delivery of high-quality person-centred care.

• 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 area had a high number of older people and the practice employedan Elderly Care Nurse who managed the patients living in care homes, providing proactive care and advice regarding patients and education to the staff in the homes.

• Feedback from patients about their care was consistently positive. Patients told us that the care that they received exceeded their expectations.

• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs. For example they worked closely with the nearby nurse led minor injuries unit and were able to see children and young people when requested.

• 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 they used an audible tannoy for calling patients to appointments and as a result of feedback from patients, were introducing an electronic visual call system.

• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had introduced a new clinical team for urgent care in 2016 to improve accessibility to a clinician. The team comprised Advance Nurse Practitioners, a Physician Associate, Nurse Prescribers, a Practice Pharmacist and an Acute Care Practitioner. This provided additional same day appointment capacity for minor illness appointments. Feedback from the patient participation group members was positive and they told us that they were able to get appointments when they needed them.
• The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result.
• 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.
• The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw some areas of outstanding practice:

• The targeted assessment protocol for the areas of increased health risk in patients diagnosed with Down’s syndrome was in line with best practice and addressed the needs of a vulnerable minority group. We saw findings were used by the practice to improve services. For example, they had identified specific risks for these patients and additional measurements and checks were included in the Learning Disability annual review.

• The practice ran a free half-day course annually for North Somerset sixth form pupils who were interested in a career in medicine. The course was called 'Widening Access to Medicine' and had run for seven years with an average of 15 students per year. The course content had also been shared with the Royal College of General Practitioners and another local practice as a way to support future recruitment into primary care.

The areas where the provider should make improvement are:

• The practice should proactively demonstrate that they can prove that and that patients are happier with phone access and opening hours. Patients need to feel that they have made an improvement.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 30 November 2016

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

• Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.

• The practice proactively identified patients at risk of developing long-term conditions and took action to monitor their health and help them improve their lifestyle. For example, patients with long term conditions were given self-care programs. Information leaflets were advertised in numerous locations around the building, on the website, in the patient newsletter, and by the practice nurses in the chronic disease clinics. Patients attending the clinics were routinely screened for anxiety and depression so that they could be supported appropriately.

• The practice was participating in the 3D Study which looked at the GP management of care for patients with three or more long term health conditions. The aim was to treat the whole patient in a consistent, joined up manner in order to improve their overall quality of life.

• The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.

• There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health such as ‘just in case’ medicines.

• 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. 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.

• The practice proactively identified those patients at risk of developing a long term condition by offering specific health check appointments with the practice nurses. GPs also had an “open access” policy whereby examination, blood tests; BP checks were performed if requested by a patient.

• The practice had a register of the 2% of patients with the most complex needs. Each patient had a care plan tailored to their individual needs, completed by a GP following a face-to-face meeting with them. The care plan was regularly reviewed. Each patient was assigned an appropriate care coordinator. The practice had a special designated telephone line only available to this 2% of patients and their carers.

• The practice offered a home visit service; patients with non-urgent issues were usually seen at lunchtime. Urgent visit requests were dealt with by a designated Duty Doctor and were prioritised during the day so that urgent visits were attended to as soon as was possible.

Updated 30 November 2016

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

• There were systems 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 accident and emergency (A&E) attendances. A+E attendances as well as clinic ‘did not attend’ (DNA) were coded on the child’s notes and reviewed or actioned by a doctor.

• Immunisation rates were relatively high for all standard childhood immunisations.

• 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. Joint six weekly baby and postnatal check were provided for the convenience of new parents and to maximise contact with new born babies.

• The practice offered a wide variety of appointment types to cater for this patient group. These included advanced booking of appointments with options of early morning and late evening and book on the day and minor illness surgery appointments.Children under the age of five were seen as a priority in daily surgeries. They had a user friendly website allowing parents and young people to access medical and practice information.

• The practice offered an annual session for local school children exploring the option of a medical career.

• A confidential ‘No Worries’ sexual health service operated from the medical centre on a weekly basis for 15-24 year old patients.

Updated 30 November 2016

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

• Staff were able to recognise the signs of abuse in older people and knew how to escalate any concerns.

• 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 identified at an early stage older people who may be approaching the end of life. It involved older people in planning and making decisions about their care, including their end of life care.

• The practice had signed up to the Unplanned Admissions Local Enhanced Service and had identified the 2% of patients at higher risk of admission to hospital. Many of these patients are over 75 years old and were followed on their discharge from hospital which ensured that their care plans were updated to reflect any extra needs. Any unplanned admissions to hostpial were discussed at a monthly meeting with the community team.

• Where older patients had complex needs, the practice shared summary care records with local care services such as the community nurse team.

• Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible as the practice offered patient education sessions.

• The two GP practices in Clevedon had jointly employed an Elderly Care Nurse who managed the patients living in nursing and residential homes. They were involved in chronic disease management of this group of patients and provided proactive care and advice regarding patients as well as providing education to the staff in the homes. All patients were visited annually as a minimum for an assessment of their needs, medicine reviews and chronic disease management. The GPs in both practices supported the nurse in clinical matters on a daily basis, and they had a two monthly meeting with the Elderly Care Nurse to plan the clinical services for patients. For example, they had introduced standby antibiotics for patients with an agreed protocol as to when these were to be used for example, for those who had frequent infections.

• The two local practices were working towards agreed overall responsibility for the local care and nursing homes between them to be more proactive in the management of patients in these homes. This model had already been successfully implemented by the practices in a residential home for patients living with dementia where there was a nominated GP who visited twice weekly to do a ward round. Communication between the practice and the home was by telephone or email.

• The practice worked to the Gold Standards palliative care framework and were able to access 24 hour advice from the local hospice.

Updated 30 November 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.

• The practice participated in the pilot e-consultations service for all patients.

Updated 30 November 2016

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

• The practice specifically considered the physical health needs of patients with poor mental health and worked closely with the community mental health teams to ensure patients attended their annual review.

• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.

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

• Patients at risk of developing dementia were identified and offered an assessment; all of these patients had a care plan in place with a copy being given to the patient. The practice had access to direct help from a memory team nurse or telephone advice when needed.

• 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.

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

• The practice used weekly prescriptions and daily dosette systems for some patients to allow close monitoring of their medicine use and good communication with local pharmacists who raised concerns when they had them.

• There was a practice clinical lead for patients with mental health problems, including those on the Mental Health Register and those with depression, anxiety and other mental health problems. The register was reviewed on a yearly basis to ensure all eligible patients were on it. Annual reviews for patients on the register were undertaken both opportunistically and by active recall.

• They had an active monitoring system for patients who were attending the treatment room for anti-psychotic injections so that they could identify anyone who missed their regular injections.

• The practice directed patients needing psychological therapies to a local service ‘Positive Steps’ and encouraged self-referral in order to improve compliance. The practice used the ‘Books on Prescription’ scheme at the local library when patients prefer written material.

Updated 30 November 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 and those with a learning disability. They offered patients with learning disabilities annual health checks either in their own home or at a quieter time at the practice.

• End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

• 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.

• They offered a ‘place of safety’ in conjunction with the local police for vulnerable patients who may be lost or in crisis in the community, and this was advertised on the front door of the building.