The Blackdown Practice

Updated 21 October 2016

The Blackdown Practice is a dispensing practice and has one registered location providing general medical services at: The Surgery, Station Road, Hemyock, Cullompton, Devon EX15 3SF. There are two branch sugeries, both of which have dispensaries and are located at:

Churchinford - The Surgery Fairfield Green Churchinford Taunton Somerset TA3 7RR

Dunkeswell - The Surgery Culme Way Dunkeswell Honiton Devon EX14 4JP.

The Blackdown practice is situated in a rural area covering over 200 square miles. There are 7450 patients registered with the practice, who are all eligible to use the dispensary services. The majority of patients are of white British background. All of the patients have a named GP. There is much a higher proportion of older adults on the patient list compared with other practices in the area. Nearly half (45%) of the patient population are over 65 years, with a higher prevalence of chronic disease which the practice monitors. The total patient population falls within the low-range of social deprivation.

The practice is managed by five partners (three male and two female GPs).They are supported by a salaried retainer GP (female). The practice uses the same GP locums for continuity where ever possible. The nursing team consists of four female nurses; an independent nurse prescriber and three practice nurses. There are four female health care assistants. All the practice nurses specialise in certain areas of chronic disease and long term conditions management. The nurse practitioner is able to see patients with minor illness. All of the staff work across all three practice sites.

The Blackdown practice is a teaching and training practice, with three GP partners approved as GP trainers. Two GP partners are approved teachers with Health Education South West. The practice normally provides placements for trainee GPs. Teaching placements are sometimes provided for year 3, 4 and 5 medical students. One trainee GP was on placement when we inspected.

The Blackdown practice at Hemyock is open 8.30am to 6.30pm Monday to Friday. Phone lines are open during these times with patients directed to access the out of hours service via the 111 service outside of these times. GP appointment times are from 8.30am to 6pm every day.  The branch surgeries are open every morning from 8.30am to 12.30pm every day, Churchinford branch surgery is open from 3:00pm on four afternoons a week, Dunkeswell is open for two afternoons a week from 3:00pm.  The dispensaries at all three sites are open during the normal opening hours of the practice, except at at Hemyock which closed between 1pm to 2pm every day. Information about this was on the practice website and patient information leaflet.

Opening hours of the practice are in line with local agreements with the clinical commissioning group. Patients requiring a GP outside of normal working hours are advised to contact the out of hours service provided by Devon Doctors via 111. The practice closes for four half days a year for staff training and information about this is posted on the website.

The practice has a general medical services (GMS) contract.

The following regulated activities are carried out at the practice: Treatment of disease, disorder or injury; Surgical procedures; Family planning; Diagnostic and screening procedures; Maternity and midwifery services.

On 30 June 2016, we inspected the Blackdown Practice in Hemyock, including the dispensary based there and at the two branch surgeries in Churchinford and Dunkeswell.

Updated 21 October 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Blackdown Practice on 30 June 2016. Overall the practice is rated as outstanding.

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

• The practice had a strong communitarian approach.
• There was a strong commitment to providing co-ordinated, responsive and compassionate care for patients, particularly patients with long term conditions and older people who are frail and at risk of social isolation.
• There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
• There was a holistic approach to assessing, planning and delivering care and treatment to people using services. Examples included: risks to patients were assessed, well managed through the integrated approach to supporting patients who were vulnerable and/or had long term conditions.
• 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.
• Feedback from all of the 27 patients we spoke with or who provided feedback, who used the service, family members and carers, and stakeholders were continuously positive about the way staff treated them and other patients. Patients said staff went the extra mile and the care they received exceeded their expectations. Patient’s also told us that it was easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs.
• 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 experienced flexible services that aimed to provide choice and continuity of care. The practice was mindful of the rural isolation of many of the patients and brought services closer to home. These included: Retinal screening for patients with diabetes to reduce the associated risks with this condition; All three sites were well equipped so that patients could access the same services at branch surgeries, such as ear irrigation or regular testing of patients with blood clotting conditions.
• The Blackdown Practice was proactive in identifying carers and had a comprehensive overview of their needs and created ways to provide timely support for them.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. Examples included: Collaboration with an adult social care provider to extend their services to include domiciliary care; driving up quality by collaborating with seven other GP practices in a federation.
• The provider was aware of and complied with the requirements of the duty of candour.

We saw two areas of outstanding practice:

The practice was proactive in recognising the pressures on the NHS and a lack of adult social care services in the area and was a founding member of a patient focussed charity and continued to promote the services available to them. Patients had immediate and easy access to the many types of support available from the charity, including information, transport assistance support and social activities for vulnerable patients living in the community. Over 300 patients are supported each year by this service.

Integrated health and social care is strongly advocated and the practice has driven innovation in the integration of community services in the Blackdown Hills area through a long term health conditions project. The practice has developed a specific role of practice community matron providing patients with one point of contact and greater anticipatory care of vulnerable patients. This had reduced the number of unplanned hospital admissions by a third.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 21 October 2016

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

• Integrated health and social care is advocated by the practice and any potential barriers for patients to experience this are reduced.The practices had driven innovation by creating the role of practice community matron as a key point of contact so that there is greater anticipatory care of vulnerable patients and those with long term conditions.Data showed that the practice has reduced the number of unplanned admissions by a third in comparison to averages seen in the locality.

• All of the patients on the long term conditions registers had named GPs, who worked in conjunction with a GP buddy to provide an anticipatory and proactive service to support patients.

• 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 was higher than the national average. For example, the percentage of patients on the diabetes register, with a record of a foot examination and risk classification within the preceding 12 months was 92.2%. (CCG 89.15% and 88.3% national averages).

• The practice followed the Exeter guidelines for management of patients with diabetes. A virtual clinic was held annually with a consultant providing clinical support for patients with complex health needs.Every quarter, a specialist diabetic clinic was held so that patients could be assessed and supported closer to home.This avoided them having to travel to Exeter for this service.

• Longer appointments and home visits were available when needed.

Updated 21 October 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 relatively 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.

• The practice’s uptake for the cervical screening programme was 81.5%, which was higher than the CCG average of 77% and inline with the national average of 82%. There was a policy to offer telephone reminders for patients who did not attend for their cervical screening test. The practice demonstrated how they encouraged uptake of the screening programme by using information in different languages and for those with a learning disability and they ensured a female sample taker was available. 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.

Updated 21 October 2016

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

• The practice offered proactive, personalised care to meet the needs of the older people in its population. All of the patients had a named GP and appointments were well co-ordinated to facilitate good continuity of care.

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

• Initiatives such as the Blackdown Patient support group, provided services such as befriending to reduce the risk of social isolation on patients health and wellbeing. Patients were also able to access transport through this voluntary service to get to and from hospital appointments.

Updated 21 October 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 reflects the needs for this age group.

Updated 21 October 2016

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

• 87.5% of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average of 84%.

• The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive, agreed care plan documented in the record, in the preceding 12 months was 90.6%. This was above average compared with the clinical commissioning group (CCG) (87%) and national averages (88.5%).

• 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 living 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.

Updated 21 October 2016

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

• The co-location of the community nursing team and success of the in house long term conditions project meant that patients experienced well co-ordinated care and support. Data for the long term conditions project for 2014-15 showed that 43 patients were being supported with 292 patient contacts having taken place. Of these 21 patient contacts resulted in the prevention of an exacerbation of the patient’s long term condition through early interventions. There were 40 patient contacts, which had facilitated patients being able to self-manage their condition.

• The practice offered longer appointments for any patients needing these, for example patients with a learning disability.

• The practice had scoped all support groups and organisations available in the rural isolated location and provided information for patients about these. Staff demonstrated they were able to access these in a timely way to support vulnerable patients.

• 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.