Kennet and Avon Medical Partnership

Updated 17 January 2017

Marlborough Medical Practice is located in the market town of Marlborough in Wiltshire. The practice population is drawn from the market town of Marlborough and a large number of surrounding villages. Patients are also registered from a number of schools including boarding schools. Many local residents commute into Swindon, Oxford and London for work. The practice population has significantly lower than local and national averages of patients between the ages of 20 to 40, and those under 10, and significantly higher numbers of 15 to 19 years olds and those over 85, and slightly higher than average of those over the age of 80.

The practice population has a low incidence of social deprivation and a high percentage of patients who are white British. The practice delivers services to a registered population of approximately 11,800 patients.

The premises are situated over two floors with all the clinical rooms for patient access on the ground floor with good level access. The practice has a dispensary offering pharmaceutical services to those patients on its practice list who live more than one mile (1.6km) from their nearest pharmacy. The practice dispenses medicines for approximately 4,000 patients and is signed up to the Dispensing Services Quality Scheme, which rewards practices for providing high quality services to patients from their dispensary.

The practice has five partners (three male, two female), three associate GPs (female) and uses three regular locum GPs. The GPs are supported by a nurse led nursing team of 11, including three nurse prescribers, a practice manager and a patient services manager, a dispensing lead and four dispensers, a reception lead and eight receptionists, a secretarial lead and three secretaries, and four administrators. 

The practice is open between 8am to 6:30pm Monday to Friday with telephone access between 1pm and 2pm. Appointments were from 8am to 1pm and 2pm to 6:30pm every afternoon. Extended hours appointments were offered from 7.30am - 8am Tuesday to Friday and 6.30pm - 7pm Monday to Thursdays.

The dispensary is open from 8:30am to 1pm and 2pm to 6:30pm every week day.

The practice has opted out of providing out of hours services to their patients. Out of hours services are provided by Medvivo which is accessed via NHS 111.

The practice has a personal medical services (PMS) contract to provide medical services to the patients (A PMS contract is a locally agreed alternative to the standard GMS contract used when services are agreed locally with a practice which may include additional services beyond the standard contract).

The practice is registered to carry out its regulated activities from the following location:

George Lane

Marlborough

Wiltshire,

SN8 4BY

This was our second inspection of Marlborough Medical Practice.

Updated 17 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Marlborough Medical Practice on 12 December 2016. Overall the practice is rated as good.

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

• There was a clear leadership structure and staff felt supported by the partners and the management team. The practice proactively looked for improvements and acted on staff recommendations. We saw a high level of staff satisfaction and very good staff retention rate. Staff told us they were proud of the practice as a place to work. The practice also had an active patient participation group who were very engaged in the practice and supporting improvements for patients.

• There was an open positive learning culture in the practice and a transparent approach to safety with an effective system in place for reporting and recording significant events. The practice valued opportunities to learn from any events, near misses or suggestions.
• Risks to patients were assessed 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.
• 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.
• The practice staff we spoke to recognised that patient care was central to the ethos of the practice and told us the practice treated patients as individuals and was proactive in considering their needs and expectations.
• The practice had taken a number of measures to engage with the local community and had been liaising with the local town council, local members of parliament and local patient representatives to promote their services explain their challenges and help meet the patient expectation and use the information sharing to help tailor and improve services.
• The provider was aware of and complied with the requirements of the duty of candour.

The areas where the provider should make improvement are:

• Ensure that the governance around Controlled Drugs is improved in order to accurately record running balances; record patient returned medicines and improve the security of the key to the CD cupboard.

• Review the location of the defibrilator.

• Ensure that all prescriptions for repeat medicines are signed by a prescriber before the medicines are supplied to a patient.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 17 January 2017

The practice is rated as good for the care of patients 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.

• Performance for diabetes related indicators were in line with the local and national averages, for example:

• The percentage of patients with diabetes, on the register, in whom the last blood pressure reading was in the target range in the preceding 12 months (2015/16) was 94% which was better than the clinical commissioning group (CCG) average of 93% and the national average of 91%.

• Longer appointments and home visits were available when needed.

• The practice reviewed patients with multiple conditions and before recalling them for any review ensured their appointment was the correct length to ensure all their needs could be reviewed.

• All patients over the age of 65 with seven or more medications on their repeat medication list are identified and included on a register. These patients are offered an extended appointment with the GP in order that their care and treatment for all conditions is reviewed and adjusted at one appointment.

• 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.

Updated 17 January 2017

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

• 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 patients who had a high number of Accident and Emergency (A&E) attendances. Immunisation rates were relatively high for all standard childhood immunisations.

• The practice had engaged with a local secondary school and provided information about support available, information about support groups, help for carers and emergency key rings.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals.

• The practice’s uptake for the cervical screening programme was 81%, which was below the CCG average of 86% and the same as the national average of 81%.

• Appointments were available outside of school hours and the premises were suitable for children and babies. Children could access online booking from the age of 14.

• The community Midwife ran a weekly clinic in the practice. Six week baby checks and post-natal checks were carried out with the midwife and a GP.

• We saw positive examples of joint working with midwives and health visitors.

Updated 17 January 2017

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

• The practice offered proactive, personalised care to meet the needs of the older patients in its population.

• The practice had access to a scheme where emergency admission beds were available to older patients in local care homes supported by GPs to help reduce avoidable hospital admissions. The practice team also held an annual review meeting to discuss issues and how they could support the care homes.

• The GP held a weekly ward round for their patients in the local care homes to assess and review care needs, on occasion accompanied by a specialist in the care of the elderly.

• The practice arranged medicine compliance aides, assisted in the completion of repeat prescription requests and offered large print labels for older patients

• All patients in care homes and those patients outside of care homes who were identified as being at high risk of admission were included on the admissions avoidance register and had their End of Life care plan regularly reviewed with the aim to reduce the number of admissions to hospital. On receipt of a discharge notice from hospital these patients were followed up by the local care coordinator.

• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

Updated 17 January 2017

The practice is rated as good for the care of working-age patients (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 offered extended hours appointments from 7.30am - 8am Tuesday to Friday and 6.30pm - 7pm Monday to Thursday. Telephone consultations were also available.

• The practice offered online appointments including repeat prescription requests, 22% of patients had signed up for this service.

• Patients who had registered a mobile number or email address with the practice received a reminder of their appointment.

• The practice was proactive in offering a full range of health promotion and screening that reflects the needs for this age group.

Updated 17 January 2017

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

• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
• The practice carried out advance care planning for patients with dementia.
• Staff had a good understanding of how to support patients with mental health needs and dementia.
• The percentage of patients with dementia who had their care plan reviewed in the last 12 months was 87% which was in line with the local average of 88% and the national average of 84%.
• Performance for mental health related indicators were similar or above the local and national averages, for example:
• The percentage of patients with a serious mental health condition who had their care plan reviewed in the last 12 months (2015/16) was 95% compared to the CCG average of 92% and the national average of 88%.
• The practice had access to local support systems for patients experiencing poor mental health and referred for support where possible. The practice worked with the community nurses and the drug and alcohol advisors and gave them priority phone access to the GPs, and held joint consultations where appropriate.
• The practice encouraged the dispensary and reception teams to highlight any concerns to the GPs where patients may be experiencing poor mental health and had systems in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

Updated 17 January 2017

The practice is rated as good for the care of patients whose circumstances may make them vulnerable.

• The patient registration policy was an inclusive policy enabling patients living in vulnerable circumstances and homeless patients of no fixed abode to register at the practice.

• The practice offered regular health checks and 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.