Combe Coastal Practice

Updated 23 October 2017

Combe Coastal Practice is located on the North Devon coast and cares for approximately 18,500 patients. The practice has three locations; Ilfracombe, Combe Martin and Woolacombe and covers approximately 80 square miles in this rural coastal area. Temporary patient numbers significantly increase the patient list size during the summer months.

The practice population is in the fourth more deprived decile for deprivation. In a score of one to ten the lower the decile the more deprived an area is. There is a practice age distribution of male and female patients equivalent to national average figures. Average life expectancy for the area is comparable to national figures with males living to an average age of 77 years and females to 82 years.

The practice has 13 GP partners, six are female and seven male. Between them they provide 89 GP sessions each week and are equivalent to 10 whole time employees (WTE). The practice also employed one retained GP. The GPs are supported by a nurse prescriber, eight practice nurses, four health care assistants (HCAs) and two phlebotomists. The practice has a practice manager, three deputy managers and 24 administrative and reception staff.

The practice’s main location, Combe Coastal practice is open between 8.30am until 6pm between Monday and Friday. Appointments are available between those times. Extended appointments are available Monday and Tuesday 6pm until 7.30pm.

The branch practice at Combe Martin is open every Monday, Tuesday, Thursday and Friday between 8.30am and 12.30pm and 2pm and 6pm and every Wednesday between 8.30am and 12.30pm. Extended appointments are available on a Monday 6pm until 7.30pm.

The branch practice at Woolacombe is open between 8.30am until 11.30am on Monday, Wednesday, Thursday and Friday.

At the weekends and when the practice is closed, patients are directed to out of hours services by phoning 111.

The practice is a training practice and a teaching practice.

The main location is located at:

Combe Coastal Practice

The Medical Centre,

Ilfracombe,

Devon

EX34 8EG

The branch locations are located at:

Combe Martin Surgery,

Castle Street

Combe Martin

Devon

EX34 0JA

and;

Woolacombe Surgery

Beach Road ,

Woolacombe,

Devon,

EX34 7BT

During this comprehensive inspection we visited Combe Coastal Practice. We did not visit Combe Martin Surgery or Woolacombe Surgery.

Updated 23 October 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Combe Coastal Practice on 26 September 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 a system in place for reporting and recording significant events.
• The practice had clearly defined and embedded systems to minimise risks to patient safety.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
• Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with 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.
• 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.
• In an effort to reach patients who did not attend the practice frequently, the practice had a website, a social media Facebook page, a regular newsletter and frequent articles published in local community publications in this predominantly rural area which promoted the services the practice offered.
• The practice hosted services such as retinopathy screening and abdominal aerotic aneurism (AAA) screening so patients could access these services locally and avoid having to travel long distances for these services.
• The practice was working to build effective partnerships with community groups. They currently had district nurses and midwives co-located and had recently co-located the AIPT (Adult Improving Access to Psychological Therapies) talking therapy health service.
• The practice had participated in the ‘Perfect Week’. This was a project which was delivered in partnership with North Devon NHS Trust and South West Ambulance Service Foundation Trust (SWASFT) in May 2017. It involved the provision of a paramedic and an urgent care nurse attending the practice with the use of a SWASFT response vehicle. These staff visited local nursing homes to support practice patients, together with responding to urgent response calls. This pilot was ongoing and had so far proved effective in working across the large geographical area and helped clinical staff to implement plans for patients to avoid unnecessary trips to hospital and possible admissions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 23 October 2017

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.
• Performance for diabetes related indicators was similar to the clinical commissioning group (CCG) and national averages. For example, 91% of patients with diabetes, on the register, whose last measured total cholesterol (measured within the preceding 12 months) was within a safe range, compared with the CCG average of 81% and the national average of 80%.
• 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.
• All these patients had a named GP and there was a system to recall patients for 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.
• One practice nurse team leader was a specialist diabetic nurse, with a high level of skill that enabled them to manage complex patients. Trained in conversation mapping techniques, this member of staff provided courses for newly diagnosed patients with diabetes to help them to understand their condition and how they manage themselves, in order to reduce the impact in the future. The specialist nurse also provided home visits for diabetic patients who were housebound to ensure they received the same level of care as more mobile patients.

Updated 23 October 2017

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

• From the sample of documented examples we reviewed we found 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.
• Midwives based in the practice offered expectant mothers their ante-natal appointments in the practice. Midwives used the practice clinical system for recording notes to enable joined-up working.
• The practice offered single appointments for new mothers and babies with their own GP for their post-natal and also their baby’s first development check. Providing the baby was well, they could then receive their first immunisations straight afterwards, without the inconvenience of multiple appointments.
• The practice had a baby-changing room and offered mothers the opportunity to breast feed their babies in a private room if required.
• The practice offered influenza vaccinations to children as part of the national programme. The practice had made this service family-friendly by launching its campaign during the half term holiday, then continuing it by offering appointments after school hours.
• The practice provided a range of women’s health services, including the fitting and removal of coils and contraceptive implants, other contraceptive services and smear tests.
• The practice offered a text reminder service (MJOG) which sent a reminder the day before any booked appointment. The practice found this an effective way to engage with younger patients to ensure they attended appointments.
• Immunisation rates were relatively high for all standard childhood immunisations.
• Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals.
• Appointments were available outside of school hours and the premises were suitable for children and babies.
• In the provision of ante-natal, post-natal and child health surveillance clinics the practice liaised with midwives who were based at the practice, as well as health visitors and school nurses.
• The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications. There was a flowchart at reception to help receptionists identify acutely ill children and prioritise their appointments.

Updated 23 October 2017

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

• Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
• The practice offered proactive, personalised care to meet the needs of the older patients in its population.
• The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
• The practice maintained an end of life register. District nurses were co-located at the practice which led to effective communication with practice GPs for urgent issues. Messaging to the complex care team based at the local Tyrrell hospital in Ilfracombe was also very prompt. Practice GPs met with the district nurses, community matrons and the hospice specialist nurse every four weeks, to review all patients on the end of life register and any patients on the vulnerable register with particular issues as well as patients with complex needs cared for in their own homes. The practice informed the out of hours GP service about these patients via the computerised Adastra system.
• The practice held regular Gold Standard Framework (GSF) meetings as a whole practice in a learning and support environment. This meeting was multi-disciplinary and included district nurses, community teams, rapid Intervention and North Devon Hospice representatives. This provided and integrated approach to end of life care.
• Supported by North Devon Healthcare Trust and South West Ambulance Service Foundation Trust, the practice deployed a paramedic team regularly to local residential care homes for home visits, this provided prompt and consistent care for patients.
• The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.
• Where older patients had complex needs, the practice shared summary care records with local care services. Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible.
• For example, in the last 6 months the practice had updated its systems to ensure that the Frailty Index was applied across all patients aged 65+ years. The number of patients in this age group graded as moderately frail was 324 and 44 were severely frail. GP’s were tasked with ensuring annual medication reviews were in place, consent for activation of summary care records was gained and attention was paid to recording falls.

Updated 23 October 2017

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

• The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care, for example, extended opening hours.
• The practice had introduced a Facebook social media page which provided health information such as details of clinics to patients.
• 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, in consultation with its patient participation group (PPG), had improved its website by making it more visual and easier to navigate for patients.

Updated 23 October 2017

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

• The practice carried out advance care planning for patients living with dementia.
• 95% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which was higher than the clinical commissioning group (CCG) average of 87% and the national average of 84%.
• The practice specifically considered the physical health needs of patients with poor mental health and dementia. The practice had invited a dementia specialist to a training event to help staff engage with patients diagnosed with dementia.
• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
• Performance for mental health related indicators was similar to the clinical commissioning group (CCG) and national averages. For example, 98% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in their record, compared to the CCG average of 87% and the national average of 89%.
• The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
• Patients at risk of dementia were identified and offered an assessment.
• The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations. There was a local Depression and Anxiety Service (DAS) in North Devon to which patients could self-refer or be referred by their GP.
• The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
• Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.
• The practice had recently provided a room at the practice on a weekly basis for the AIPT (Adult Improving Access to Psychological Therapies) talking therapy health service so patients could access this service locally.

Updated 23 October 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 homeless people, travellers and those with a learning disability. The practice held a register of 70 patients with learning disabilities.
• 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 had information available for vulnerable patients about how to access various support groups and voluntary organisations.
• Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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 access to support services for patients with alcohol and drug misuse issues through RISE (Recovery Intervention Services). In addition, five practice GPs had been trained to take on the shared care of prescribing of methadone, which ensured that patients could access this service at the practice.