Nunwell Surgery

Updated 1 August 2016

Nunwell Surgery is located in the town of Bromyard and provides primary medical care to one fifth of the population of Hereford. There are approximately 9,400 patients registered at the practice. There is a significantly higher than average age group of 50 to 85 years of registered patients. Approximately 3% of registered patients are Eastern European. The practice holds a General Medical Services (GMS) contract, a nationally agreed contract commissioned by NHS England.

The practice is managed by seven part time GP partners (four male, three female) who between them provide 40.5 clinical sessions per week. Three salaried GPs provide an extra 15 clinical sessions. They are supported by two nurse practitioners and four practice nurses who carry out reviews of patients who have long term conditions such as, diabetes. They also provide cervical screening and contraceptive advice. There are three health care assistants (HCA) who carry out duties such as, phlebotomy, health checks and dressings. The practice employs a practice manager, an assistant practice manager, a reception manager, four receptionist staff, four administrators and three secretaries.

The practice offers a range of clinics for chronic disease management, diabetes, heart disease, cervical screening, contraception advice, minor surgery, injections and vaccinations.

The practice is a designated training practice for trainee GPs. These are qualified doctors who are learning the role of a GP. They currently have one qualified doctor (registrar) who is working at the practice and receiving GP training. The doctor is providing four clinical sessions a week.

In March 2016 work on the premises had been completed with the addition of two consulting rooms; providing a total of 12 consulting rooms to improve patient access.

The practice is open from 8am until 6.30pm each day and closes at the later time of 8pm every Monday.

Appointments times vary but on average are available from 9am until 12pm and from 4pm until 6pm. each day and until 7.45pm on Mondays. Further extended hours are provided every Saturday from 9.15am until 11am. Extended hours are by appointment only. The Monday extended hours are provided by two GPs and the Saturday morning session is provided by one GP. The practice operates a triage system for those patients who request a same day appointment. This means that a GP will contact the patient to assess their condition, give advice and if necessary provide a same day appointment. Urgent appointments are available on the day. Routine appointments can be pre-booked in advance in person, by telephone or online.

Patients who live in excess of one mile from a pharmacy are eligible to have their prescribed medicines dispensed from the practice. This equates to 50% of registered patients. The dispensary has six dispensing staff. On the day of our inspection there were two locum dispensers working at the practice to cover for the long term absence of three dispensers. The dispensary closes between 1 and 2pm each day.

The practice has opted out of providing GP services to patients out of hours such as nights and weekends. During these times GP services are provided currently by a service commissioned by NHS Herefordshire Clinical Commissioning Group (CCG).When the practice is closed, there is a recorded message giving out of hours’ details. The practice leaflet includes contact information and there are out of hours’ leaflets in the waiting area for patients to take away with them.

Updated 1 August 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Nunwell Surgery on 21 June 2016. Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded.

• Safe systems were in place for prescribing medicines and eligible patients were able to obtain their dispensed medicines from the practice.

• Staffing levels were monitored to ensure they matched patients’ needs. Safe arrangements were in place for staff recruitment that protected patients from risks of harm.

• Risks to patients were assessed and well managed.

• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training had been identified and planned.

• Patients told us they were treated with compassion, dignity and respect and they were involved in decisions about their treatment.

• All patients who requested same day appointments were triaged to ensure they received appropriate and timely care.

• Information about how to make a complaint was readily available and easy to understand.

• The practice had good facilities and was well equipped to assess and treat patients.

• There was a clear leadership structure and staff told us they felt well supported by senior staff. Management proactively sought feedback from patients which it acted on.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 1 August 2016

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

• Nursing staff had lead roles in chronic disease management.

• Longer appointments and home visits were available when needed.

• Patients with long-term conditions had structured annual reviews to check that their health and medicine needs were being met. Where necessary reviews were carried out more often.

• With the exception of diabetes nationally reported Quality and Outcomes Framework (QOF) data 2014-15 showed the practice had achieved good outcomes in relation to conditions commonly associated with this population group. Arrangements were in place to encourage patients who had diabetes to attend for their reviews.

• Clinical staff worked with health and social care professionals to deliver a multidisciplinary package of care.

• Where necessary patients in this population group had a personalised care plan in place and they were regularly reviewed.

Updated 1 August 2016

The practice is rated 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.

• Alerts were put onto the electronic record when safeguarding concerns were raised.

• There was regular liaison with the health visitor to review those children who were considered to be at risk of harm.

• When needing an appointment all children were triaged and if necessary seen the same day.

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

• Extended hours were in place that allowed children to be seen outside of school hours, appointments were available until 8pm every Monday and from 9.15am until 11am every Saturday.

Updated 1 August 2016

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

• The practice had a much higher than average number of registered patients aged 50 to 85 years.

• Practice staff offered proactive, personalised care to meet the needs of older patients.

• Staff kept up to date registers of patients’ health conditions and information was held to alert staff if a patient had complex needs.

• Home visits were offered to those who were unable to access the practice and patients with enhanced needs had prompt access to appointments.

• Practice staff worked with other agencies and health providers to provide patient support.

• Older patients were offered annual health checks and where necessary, care, treatment and support arrangements were implemented.

• Designated named GPs from the practice made regular, and when requested visits to two care homes to monitor resident’s health needs.

Updated 1 August 2016

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

• The practice had adjusted its services to accommodate the needs of this population group. For example, via telephone consultations and extended hours.

• Telephone consultations assisted those patients who found it difficult to attend the practice or if they were unsure whether they needed a face to face appointment.

• Patients could obtain their test results by telephone.

• Online services were available for booking appointments and ordering repeat prescriptions.

• The practice website gave advice to patients about how to treat minor ailments without the need to be seen by a GP.

• There was a full range of health promotion and screening that reflected the needs of this age group.

Updated 1 August 2016

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

• Patients who experienced poor mental health had received an annual physical health check.

• Practice staff regularly worked with multi-disciplinary teams in the case management of patients who experience poor mental health, including those with dementia.

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

• GPs carried out assessments of patients who experienced memory loss in order to capture early diagnosis of dementia. This enabled staff to put a care package in place that provided health and social care support systems to promote patients well-being.

• Referrals to other health care professionals were made when necessary.

• Clinical staff offered opportunistic screening for dementia to ensure early diagnosis and support plans developed to improve patients’ well-being and lifestyles.

Updated 1 August 2016

The practice is rated 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 who had a learning disability. A GP had the lead role for organising and carrying out reviews and health checks of patients with a learning disability to promote effective relationships. The GP also visited patients with a learning disability who resided in three care homes.

• Practice staff regularly worked with multi-disciplinary teams in the case management of vulnerable patients.

• There was a process in place to signpost vulnerable patients had been signposted to additional support services.

• Staff knew how to recognise signs of abuse, the actions they should take and their responsibilities regarding information sharing.

• There was a clinical lead for dealing with vulnerable adults and children.

• The practice staff were proactive in identifying carers and kept a register of the 6% of patients who were carers. Clinical staff offered them guidance, signposted them to support groups and offered them the flu vaccination each year.