The Milton Surgery

Updated 24 February 2017

The practice is located in Weston Super Mare, a seaside resort town close to the M5 motorway, eighteen miles south west of Bristol, in the county of North Somerset. The practice provides primary medical services for the town and its suburbs.

The practice is located in a detached building previously used for housing and has undergone a number of modifications and extensions. The facilities include a ramp to the front entrance, a large waiting area and ground floor access to treatment and consultation rooms. At the time of the inspection the exterior and interior of the practice showed signs of wear and tear and was in need of decoration. In addition the building showed signs of damp in some clinical rooms.

The practice has a population of approximately 9100 patients. The practice has a higher than England average population of female patients over 55 years of age and a lower than England average population of patients under 39 years of age. The practice has a deprivation score of 21 which is slightly lower than the England average of 22 and higher than the North Somerset average of 16.

The practice has a Personal Medical Services contract (PMS) with NHS England to deliver primary medical services. The practice provides enhanced services which include facilitating timely diagnosis and support for patients with dementia; childhood immunisations and learning disabilities.

The practice team includes six GP partners (three male and three females GPs) whom provide the practice with 48 GP sessions per week. A female advanced nurse practitioner (ANP) provides 4.5 sessions per week. In addition the team comprises of four female practice nurses, one health care assistant, an interim practice manager and sixteen part time administrative staff which include a manager, receptionists and secretaries. The practice also employs an apprentice receptionist undertaking an intermediate level apprenticeship in NVQ Business & Administration.

One GP holds a diploma in Occupational Medicine and provides advice to a number of local employers through the GP partners specialist company called Occupation Medical Services that operates from the surgery premises.

The GPs had special interests and additional skills in areas including minor surgery, family planning and post-natal checks. The advanced nurse practitioner had a special interest in care of older people in care homes.

The practice is open between 8am to 6.30pm Monday to Friday. Appointments are for 10 minutes each and mainly run on a 'book-on-the-day' system. Although the practice operates a predominantly book on day policy, patients are allowed to pre-book appointments if they have difficulty getting in to the practice. Appointment times are generally available each morning from 9.00am to 12 noon and on each afternoon from 3.30pm to 5.30pm. One GP acted as a duty Doctor each day dealing with emergencies, telephone care and treatment and management of home visits.

The practice is a training practice for GP trainees, foundation Doctors and medical students. (The foundation programme is a two-year training programme for doctors at Weston General Hospital who have just graduated from medical school). At the time of our inspection an ST2 and an ST3 Specialist Trainee were placed at the practice.

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

Updated 24 February 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Milton Surgery on 18 January 2017. 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 and recording significant events.
• 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.
• 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.
• Patients said they found it easy to make an appointment with a GP and urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs. However, the overall internal decoration of the practice required updating. Areas of damp and mould were seen within treatment and consultation rooms where patients with respiratory illness were seen.
• 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 area where the provider must make improvement is:

• Ensure that formal action plans are implemented to address any improvements identified as a result of the annual infection control audits.

The areas where the provider should make improvement are:

• Ensure that carers are identified and supported appropriately.

• Ensure the timely implementation of the practice’s refurbishment plan.

• Conversations taking place in consultation and treatment rooms should not be overheard from the corridor or from one room to another.

• To consider a formal protocol for call handlers to work to with regards to managing urgent requests for consultations and home visits.

• Ensure that any identified risks are formally assessed and recorded to aid the management of the risks and to implement mitigating actions. This includes risk assessments regarding legionella, the absence of child defibrillator pads and health risks to staff and patients due to indoor dampness and mould within clinical rooms.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 24 February 2017

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

• Practice nurses had lead roles 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.
• 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.
• Performance for diabetes related indicators was in line with the local and the national average.

Updated 24 February 2017

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.
• The practice uptake for the cervical screening programme was 82%, which was comparable to the clinical commissioning group (CCG) and national averages.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• We saw examples of joint working with midwives, health visitors and school nurses. The practice hosted midwifes to perform ante natal care from the practice.
• The practice operated a duty doctor system which provided telephone access to patients to discuss concerns and see children urgently.

Updated 24 February 2017

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. Although the practice operated a predominantly book on day policy, patients were able to pre-book appointments if they had difficulty getting in to the practice.
• The practice was responsive to the needs of older people and offered home visits and urgent appointments for those with enhanced needs.
• The practice took part in the Admissions Avoidance scheme for avoiding unplanned hospital admissions.
• End of life planning and discussions were taken with patients regularly and the practice liaised with the local hospice service.
• Patients at the local care homes were visited weekly by the advanced nurse practitioner for advance care planning and chronic disease management.

Updated 24 February 2017

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 open until 6:30pm and there was scope to see patients between 5.30 and 6.30pm.
• The practice offered the full range of health promotion and screening that reflected the needs for this age group.
• Patients had access to telephone consultations with clinicians.

Updated 24 February 2017

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

• Performance for mental health related indicators was better than the local and the national average.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. The practice liaised with the Primary Care Liaison service (the single point of access for mental health problems) regarding patient care.
• Mental health reviews were completed for patients with significant mental health problems. These included an overview of general health and a look at medical risk factors for disease prevention and medicines reviews. Results were used to make necessary changes to the patients’’ care and treatment.
• 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.
• Staff had a good understanding of how to support patients with mental health needs and dementia.

Updated 24 February 2017

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 those with a learning disability.
• The practice offered longer pre-booked appointments for patients with complex needs and/or a learning disability.
• Hospital discharge summaries were routinely checked for any safeguarding issues by administrators and clinical teams.
• The practice regularly worked with other health care professionals in the case management of vulnerable patients. The duty GP had been readily accessible to patients, staff, community teams and social workers.
• 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.
• GPs had extensive experience of involvement in complicated safeguarding cases for patients with a learning disability including participation in best interest decision making.