Bramblehaies Partnership Also known as Bramblehaies Surgery

Updated 25 October 2017

Bramblehaies Partnership is a GP practice which provides a Personal Medical Service contract for approximately 6758 patients.

The practice is situated in the rural town of Cullompton, Devon which is increasing in population with the development of many new homes.

The practice is open Monday, Wednesday and Friday between 8.30am and 7pm and from 8.30am until 7.30pm on Tuesdays and Thursdays. Calls before 8.30 are answered by the out of hours provider. Any urgent issues are transferred to the GPs. Patients can make pre bookable appointments for six weeks in advance. Outside of these hours patients are directed to the local NHS out of hours provider (NHS 111). This information is displayed outside of the practice and on the practice website.

The practice population is in the eighth 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 similar to national figures with males living to an average age of 80 years and females living to an average of 84 years. There was a higher than average number of patients with a long-standing health condition. For example, 62% average compared with the 53% England Average.

There are four partners (three male and one female) and one salaried GP (female). Together the GPs provide a whole time equivalent of 3.4 hours. The GPs are supported by a nurse practitioner, four practice nurses, and two health care assistants. There is a team of 10 reception and administration staffm who are managed by the practice manager. The practice employes a team of two cleaning staff.

The practice is a teaching practice for medical students in years two to five of their medical training.

The practice is registered to provide regulated activities which include:

Treatment of disease, disorder or injury, surgical procedures, maternity and midwifery services and Diagnostic and screening procedures and operate from the main site of:

Bramblehaies Surgery

College Road

Cullompton

Devon

EX15 1TZ

The practice was last inspected by CQC in August 2015 when it was rated as Good.

Updated 25 October 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bramblehaies Partnership

on Tuesday 8 August 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.
• There was evidence of effective working with health care professionals and care homes in the area. The practice provided a dedicated direct telephone number so health care professionals could speak with the practice promptly.
• 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.
• Staff told us that new parents were sent a birth congratulations card. New patients were sent a welcome letter and fridge magnet which contained the practice contact details.
• The practice offers extended hours on Tuesday, Wednesday and Thursday until 7:30pm and until 7pm on Monday and Friday.
• The practice carried out advance care planning for patients living with dementia. In-house dementia training sessions had been delivered by a local charity in May and the practice had been recognised with the Culm Valley Action Dementia Alliance
• 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.

We saw one area of outstanding practice:

• A health facilitator is employed by the practice for four hours per week to offer social prescribing, support and motivation to selected patients within the practice. The aim was to develop self-care regarding diet, exercise, smoking cessation and social activity to reduce social isolation. Patients could access a community LIFE Hub (LIFE stood for Listening, Involving, Friendship and Education). The hub provided patients with activities including groups for; seated exercise, parenting, creative writing, knitting, walking, pilates, information and advice and depression and anxiety. Data from 2016/17 showed that of 15 randomly selected patients six had reduced their number of appointments with the GP following interaction with the health facilitator.

The area where the provider should make improvement are:

• Ensure the consent form used for minor surgery meets relevant national guidelines.

Professor Steve Field

CBE FRCP FFPH FRCGPChief Inspector of General Practice

Updated 25 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. Annual reviews were offered to all patients with a long-term condition and high risk medicines. A review of this had identified further medicines to be included in these reviews.
• The diabetic nurse was able to offer diabetic patients insulin initiation and insulin titration. This avoided patients being referred and travelling to the hospital, resulting in a reduction in secondary care referrals and providing care closer to home. The practice ran a joint clinic with the community diabetic specialist nurse (CDSN) and the practice diabetic nurse four times a year for the purposes of jointly consulting patients with complex needs. The GPs and nurses held a virtual clinic with the consultant and CDSN, twice a year at the practice. This opportunity enabled staff to discuss clinical pathways, and provide clinical support for patients with complex health needs.
• Newly diagnosed diabetic patients were offered an appointment with the practice health facilitator for health promotion advice and support.
• 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.
• The practice had a Community Life Hub resource which was available to all patients
• An onsite INR monitoring service for patients on blood thinning medicines was offered (near patient testing) to enable patients to have immediate results and a prescription.
• Cardio call equipment was purchased and was helping to reduce the level of secondary care appointments required for heart monitoring.
• 24 hour blood pressure machines had been purchased by the friends of the practice group to facilitate GPs diagnosing high blood pressure.
• The GPs attended monthly complex care team meetings led by the community matron. These meetings with health and social care professionals and voluntary agencies were held to focus on vulnerable patients, those with complex needs, and some newly discharged patients, for provision of support, intervention, rehabilitation and greater anticipatory care.
• The practice had a machine which enabled blood samples to be taken throughout the day, helping speed up test results for patients.
• Palliative care team meetings occurred every two months with relevant professionals including GPs and Hospice care staff.

Updated 25 October 2017

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

• There were systems to identify and follow up children living in disadvantaged circumstances, who were at risk, ‘looked after’ families, and those who had had a high number of accident and emergency (A&E) attendances.
• Immunisation rates were relatively high for all standard childhood immunisations. A dedicated member of staff was responsible for organising invitations and follow up immunisations. Information on vaccinations and immunisations was available in alternative formats via the practice website.
• 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. For example, an automated door had been purchased by a patient supported access to all, particularly helpful for those in wheel chairs and parents with buggies.

• The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.
• The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications.
• CAMHS staff (Child and Adolescent Mental Health Service) utilised a room familiar to patients at the practice when required.

Updated 25 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 identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.
• 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.
• Carers of older people received information at registration or at the point of recognition to help support their caring role.
• The practice had effective working relationships with care homes in the area and provided a dedicated direct line telephone number so staff could speak with the practice promptly.
• The practice employed a health facilitator who was able to offer support and signpost patients to support groups.

Updated 25 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 hour surgeries were offered on three evenings a week. Early morning appointments were offered for blood tests and specific medicals.

• 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.

• Patients could access online services, including appointments, repeat prescriptions and personal record.

Updated 25 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. In-house dementia training sessions had been delivered by a local charity in May and the practice had been recognised as part of the Culm Valley Action Dementia Alliance

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  The practice team knowledge on patients often resulted in triggering contact with the GP or nurse

• The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.

• The practice formally met with multi-disciplinary teams every two months for 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.

• 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.

Updated 25 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 worked effectively with the community learning disability nurse to support 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.
• The practice had experienced an increased number of non-English speaking patients registering (currently 140). Therefore, the website and interpreter services had been reviewed to ensure they were suitable for translation into multiple languages.
• An ‘easy read’ leaflet was offered to new patients if this met their communication needs.
• The patient-check in machine allowed patients whose first language was not English to check in for their appointment.
• Advance care planning and TEPs (treatment escalation plans) were in place for patients at the end of life, along with a ‘just in case’ procedure to ensure these patients received relevant medicines promptly.