Peverell Park Surgery

Updated 8 July 2016

The practice is situated in the city of Plymouth. The practice provides a primary medical service to approximately 14,800 patients of a diverse age group.

The practice has a considerably higher proportion of patients under the age of 65 when compared to the England average. For example, currently there are 5419 patients registered at the practice that are between the ages of 17 to 24 years old. Information published by Public Health England rates the level of deprivation within the practice population group as six 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 eight partners, six are GP partners the other two are a practice manager partner and a nurse practitioner partner. There are three male and three female GPs who work the whole time equivalent is 4.75 GPs. There are also and three salaried GPs, two female and one male who work the whole time equivalent was two GPs. They are supported by a practice manager, two nurse practitioners, four practice nurses, three health care assistants, and a team of administrative staff.

Patients using the practice also have access to community nurses, mental health teams and health visitors. Other health care professionals visit the practice on a regular basis.

The practice is a training practice for medical students and nursing students. The practice is looking forward to becoming a teaching practice in November 2016.

The practice is open between theNHS contracted opening hours of8am and6.00pm Monday to Friday. Extended hours are offered on Tuesdays and Thursdays 7am until 8am and from 9am until 1pm very fourth Saturday.

In addition to pre-bookable appointments can be booked up to three weeks in advance, telephone consultations are offered as the first mode of access, and same day appointments are made as required. Outside of these times patients are directed to contact the Devon Doctors out of hour’s service by using the NHS 111 number.

The practice has a Personal Medical Service (PMS) contract and provides additional services, some of which are enhanced services; for example, extended hours and minor surgery.

The practice provides regulated activities from its primary location at The Stables, Outland Road, Plymouth and at a branch surgery at University Medical Centre, 27 Ensleigh Place, Plymouth, PL4 9DN. We did not visit the branch surgery as part of our inspection.

Updated 8 July 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Peverell park Surgery on 14 June 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 and recording significant events.
• 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.
• Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.

• The practice was one of the two GP practices with patients who were students at Plymouth University. The practice had a branch surgery at the university. Practice staff attended fresher’s week and offered on campus health assessments for students wishing to register. The practice was open every day and saw any student needing to be seen acutely on the day, when their lectures were finished. The practice gave health education talks including topics such as sexual health, giving advice on contraception and advice on general health and wellbeing.

• There was a dedicated part of the practice web site for the students. It was specifically designed for younger users and had a wealth of information and advice tailored to their needs: For example, sections on self-care for freshers, emotional wellbeing, contraception and sexual health advice.

• 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.

We saw several areas of outstanding practice:

• The practice demonstrated creative innovation. For example by the introduction of a “Web GP” system. This additional access to GPs was provided via a web link from the practice website and enabled patients to secure a GP or nurse consultation by email within 24 hours. This service was advertised in the waiting room and significantly improved access to GP advice and treatment. Data showed that since March 2016 136 patients had completed an on line assessment and of these 75 had received an e consultation and the others were signposted to other relevent agencies, such as their pharmacist.

• Every Monday morning a nurse practitioner followed up all patients that had accessed the 111 service, out of hours care (Devon Doctors) or the emergency department at the district hospital. They reviewed their records and either contacted them to offer further support, an appointment and ensured the information was updated onto their records. This approach ensured all patients received prompt and effective access to follow up care and treatment if needed.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 8 July 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 worked closely with the community specialists and held consultant led community based virtual clinics where the consultant worked alongside the practice nurse staff to monitor and manage those patients who required additional care. For example for those patients with diabetes.

• The practice had employed a pharmacist to help manage the patients’ medicines and related issues. This appointment had improved medicines reviews for patients, helped ensure medicines alerts were communicated promptly amongst clinical staff and ensured the latest prescribing guidance was followed.

• Patients with long term conditions benefitted from continuity of care with their GP or nurse. 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 nurse practitioner undertook reviews of housebound patients within their own homes. This could include mobile spirometry (a test to monitor lung function).

• The practice worked with external agencies in other aspects of long-term condition management such as diabetic retinopathy screening and podiatry ensuring appropriate support was provided promptly.

  The practice was actively involved in research regarding the management of some long term conditions and patients who may benefit from exercise and activity as part of their condition management. This was ongoing research and no preliminary results were available at the time of the inspection.

Updated 8 July 2016

The practice is rated as outstanding 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 high for all standard childhood immunisations.

• Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

• 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.

• All doctors offered ante-natal care and mothers and babies were given 30 minutes each for post-natal checks to ensure their health and wellbeing. The practice had a good working, effective relationship with the appointed health visitor and midwife, having quarterly multi-agency meetings to discuss caseloads and families of concern. The midwife held a weekly clinic at the practice and shared concerns about patients with the GPs to ensure appropriate follow up appointments were made. For example, if post-natal depression was indicated.

• Women could access a full range of contraception services and sexual health screening. Two female GPs had specialist interests in this area and were trained in sexual health and family planning. The nurse practitioner was also trained in sexual health and female health to a higher level. These skills and services had helped minimise the prevalence of sexually transmitted diseases and unwanted pregnancies in this patient group at the practice.

• All staff had been trained at the appropriate level for safeguarding adults and children. Reception staff and nurses had an alerting system in place to be able to inform GPs or the practice manager of any children who did not attend immunisation appointments. Where safeguarding concerns were identified referrals were made to relevant agencies.

• The Practice operated a ‘C-card’ scheme where young people were able to access free condoms. The practice had a dedicated notice board for teenager’s which was positioned in a discreet area of the practice that had up-to-date, age appropriate information which was relevant and practical. In response to younger patients comments, over 11 year old children were offered their own on-line access which was password protected, to allow them privacy when asking for information, advice or an appointment.

Updated 8 July 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.

• The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. One of the nurse practitioners visited patients at home to review their health care and give annual vaccines as required.

• The Practice had pop-up alerts on the clinical system which highlighted patients who were becoming increasingly frail. GPs and nurses had undertaken end of life training and alongside this the practice had introduced on-line modular training to ensure all staff were kept up to date with this aspect of patient care.

• The practice supported carers. There was a carer’s board and all staff pro-actively looked to identify carers. A support group called Timebank visited the practice quarterly, they offered professional advice and social activities for carers of people with mental health Issues such as dementia.

• The practice had employed a pharmacist to assist with polypharmacy (patients who take multiple medicines) reviews in elderly patients. All patients over the age of 75 had an allocated named GP, but were also able to choose which GP they preferred.

• A full vaccination programme was offered at the practice, including flu, shingles and pneumococcal, the nurse practitioner attended housebound patients to ensure vaccines were given.

Updated 8 July 2016

The practice is rated as outstanding 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 reflected the needs for this age group.

• Peverell Park Surgery provided GP services to approximately half of the University of Plymouth’s students. Data showed that the practice population for working people including those patients in full or part time education was 78.2% which was significantly higher than the local average of 60% and national average of 61.5%. The practice had responded to this by improving access to appointments or GP advice for these patients.

• An important need of this patient group was the type of appointments required by students. There was a proportionately lower demand for future appointments for chronic problems and a proportionately higher demand for same day (or more immediate) appointments. In 2014 the practice changed the mode of access and improved appointment availability. They also recognised that many of the consultations were about seeking advice, requests for documentation or other problems which did not necessarily require a face to face appointment. Consequently the practice switched to telephone consulting as the first mode of access. Patients were able to speak to a GP on the day. There was flexibility about the call back time to work around lectures or work commitments and patients could be brought into the practice for a face to face appointment if required.

• The practice also provided alternative forms of GP access through systems such as“Web GP”. This system allowed patients to complete an on-line consultation at any time of the day and night and guaranteed a response within two working days.

• There was a dedicated area on the web site for the students. It was specifically designed for younger users and had a wealth of information and advice tailored to their needs: For example, sections on self-care for university fresher’s, contraception and sexual health advice.

• The Practice offered a varied appointments service including able to book routine appointments three weeks in advance, accessing same day telephone triage and an appointment if required. Extended hours were provided 7am to 8am twice a week, along with Saturday morning appointments 9am to 1pm, once a month. Full on-line access was available for appointments, prescriptions and test results.

• The surgery had an active patient participation group (PPG) and they had set up a virtual PPG to allow patients to stay engaged and receive information and give feedback on current issues, topics.

• The Practice provided an NHS health check scheme for its own patient group, offering cardiac health checks to patients aged 45 and over. In addition it was one of five practices in Plymouth offering health checks to non-registered patients. The practice also offered in-house near patient testing to make it convenient for patients for such things as INR testing, fasting blood tests and ECGs.

• The practice offered in-house minor surgery clinics for toe nail removal, joint injections and minor surgical procedures, as well as in house contraceptive procedures.

• The Practice offered electronic prescribing to all patients enabling prescriptions to be sent to a chemist of their choice.

The practice had two GPs with special interests including clinical areas of sexual health and family planning.

Updated 8 July 2016

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

• 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 had a lead GP for dementia and had started working to becoming a Dementia Champion practice with a member of the administration team training towards being the ‘champion’. The practice proactively identified patients more at risk of dementia using a specialist assessment tool called the EMIS Dementia Quality Toolkit to aid with early diagnosis. A pop up alert was added to the patients records where dementia was indicated to allow the GP to start having an early conversation with the patient about the condition and carry out a full medicines and health review if necessary.

• The practice had close working links with Plymouth University Mental health team, meeting regularly with the university mental health workers, and had a system in place whereby students once assessed as needing extra support were able to get immediate advice from the GP and have an urgent appointment if needed.

• Regular meetings were held with the local community psychiatric nurse (CPN) to discuss patients of concern, all patients with mental health concerns were discussed at weekly clinical meetings, to encourage safe case management and shared learning.

• The practice used social media and their website to send information out to patients regarding latest health campaigns, and actively looked to post relevant information such as exam stress, dementia awareness week and mental health awareness.

Updated 8 July 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.

• 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.

• The practice had a lead nurse practitioner in charge of learning disabilities, who undertook home visits and in-house clinics for these patients.

• All staff had been trained in the principals of the Mental Capacity Act.

• Data showed the practice had carried out 91% of the annual reviews for patients with learning disabilities in 2105/16.

• The Practice actively promoted ‘Active Plus’, a veteran exercise programme set up to help ex-service personnel to cope when exiting the services and used the skills, experience and expertise of injured military veterans to deliver unique programmes that built confidence, motivation and self-belief. These programmes unlocked the potential of participants, all of whom were from vulnerable or potentially vulnerable groups. Veterans were also given priority for treatment and referrals in line with the military veterans covenant, particularly those who had become disabled. For example, through referrals to rehabilitation services.

• The practice had a policy in place which gave homeless people and traveller’s full access to the services provided at the practice.

• The practice had a growing group of transgender patients. The practice used the patients preferred name and gender and always offered a safe, non-judgemental environment. The GPs had recognised that the number of transgender patients was increasing and had undertaken further learning to enable them to keep updated and provide good care. The practice had access to information such as the South West Lesbian, Gay, Bisexual and Transgender (LGBT) Directory which GPs could use to signpost these patients to local support groups.