Letter from the Chief Inspector of General Practice

St Thomas Health Centre was inspected on Wednesday 8 October 2014. This was a comprehensive inspection.

St Thomas Health Centre is one of four practices belonging to the partnership named St Thomas Medical Group, who provide a service to approximately 35,000 patients in the city of Exeter.

St Thomas Health Centre has a branch called Pathfinder Surgery. The Pathfinder branch, Exwick Health Centre and Exeter University Student Health Centre, were not inspected on this occasion.

St Thomas Health Centre provides primary medical services to approximately 15,500 patients living in the city of Exeter and the surrounding areas. The practice provides services to a diverse population age group and is situated in a city centre location.

There was a team of nine GP partners. GP partners hold managerial and financial responsibility for running the business. In addition there were four additional salaried GPs, ten registered nurses, four health care assistants, a practice manager, and additional administrative and reception staff.

Patients using the practice also had access to community staff including district nurses, community psychiatric nurses, health visitors, physiotherapists, speech therapists, counsellors and midwives.

We rated this practice as outstanding.

Our key findings were as follows:

The practice was well led and responded to patient need and feedback. Innovative and proactive methods were used to improve patient outcomes even where no financial incentives or contractual agreements were expected.

The practice was caring and had an active carer and patient support network which had identified lonely, isolated or vulnerable patients. The group had worked to provide voluntary services and support, which promoted well-being and reduce isolation.

Patients reported having good access to appointments at the practice and liked having a named GP which, they told us improved their continuity of care. The practice was clean, well-organised, had good facilities and was well equipped to treat patients. There were effective infection control procedures in place.

Feedback from patients about their care and treatment was consistently positive. We observed a non-discriminatory, person-centred culture. Staff told us they felt motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. Views of external stakeholders were very positive and aligned with our findings.

The practice was well-led and had a leadership structure in place with the practice manager playing a central role in the co-ordination of the running of the practice. Staff displayed a sense of mutual respect and team work. There were systems in place to monitor and improve quality and identify risk and systems to manage emergencies.

Patients’ needs were assessed and care was planned and delivered in line with current legislation. This included assessment of mental capacity to make decisions about care and treatment, and the promotion of good health.

Suitable recruitment, pre-employment checks, induction and appraisal processes were in place and had been carried out thoroughly. There was a culture of further education to benefit patient care and increase the scope of practice for staff.

Documentation received about the practice prior to and during the inspection demonstrated the practice performed comparatively with all other practices within the clinical commissioning group (CCG) area.

Patients felt safe in the hands of the staff and felt confident in clinical decisions made. There were effective safeguarding procedures in place.

Significant events, complaints and incidents were investigated and discussed. Learning from these events was implemented and communicated to show what learning, actions and improvements had taken place.

We saw several areas of outstanding practice including:

The practice were responsive to the needs of patients and provided services even when the service provided was not included in the GP contract. For example:

• The practice nurses and health care assistants performed complex leg ulcer dressings in the practice following extended training at the local hospital with community nurses who had extended training in tissue viability. The practice nurses had also worked with the dermatology department at the local acute trust to obtain training and advice. St Thomas staff input meant patients were able to receive this complex treatment at the practice avoiding the need to attend the community leg ulcer clinic on the other side of the city. This service was over and above what was expected from the practice in the GP contract and had improved outcomes for patients.

• An additional service was provided by staff at the practice for patients with indwelling intravenous lines used for prolonged treatments. For example, chemotherapy, long term antibiotics and intravenous feeding. Patients were normally required to go to hospital for management of this intravenous line. However, staff at the practice had completed extended training to enable patients to receive care locally, at the practice.

• Staff at the practice and the Friends of St Thomas Health Centre had raised money to fund equipment, transport and maintenance of a pain relieving gas for complex wound dressings. The practice had also facilitated extended staff training to enable patients to stay at home and be treated at the practice and in the community rather than remaining in hospital for complex wound care.

In addition, the practice had responded by making sure information was provided to help patients with learning disabilities understand the care available to them. For example, administration staff had recognised the literature given out regarding the practice and health checks was inadequate and had changed the documents to easy read versions for these patients.

The practice had a very active carers support and Friends of St Thomas Health Centre group. The group of volunteers was co-ordinated by a member of staff employed at the practice and offered services to all patients, but especially to isolated and lonely patients and carers. The group offered services such as lunch clubs for housebound patients, a telephone support service, sitting and befriending services, weekly social events and carers support groups. The aim of the service was to prevent isolation and loneliness of patients and carers.

The practice had recognised that some patients were not fit enough to join the city walking group or wanted to remain in a smaller group. The practice had worked with three other local practices to set up a ‘strollers group’ for patients, until they were fit enough or more confident to join the city walking group.

However, there were also areas of practice where the provider should make improvements.

The provider should ensure that:

• All clinical staff receive training in the Mental Capacity Act (2005).

• The GPs should offer each other the same level of support and risk assessments as they do for other staff at the practice, to proactively prevent, reduce and identify work related stress.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

St Thomas Medical Group is rated as Outstanding overall. (the previous inspection October 2014 – Outstanding)

For purposes of the report the practice will be referred to as ‘the group’.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Outstanding

Are services caring? – Good

Are services responsive? – Outstanding

Are services well-led? - Outstanding

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Outstanding

People with long-term conditions – Outstanding

Families, children and young people – Outstanding

Working age people (including those recently retired and students – Outstanding

People whose circumstances may make them vulnerable – Outstanding

People experiencing poor mental health (including people with dementia) - Outstanding

We carried out an announced comprehensive inspection of the St Thomas Medical Group on Tuesday 16 January 2018 and Thursday 18 January 2018 as part of our inspection programme.

At this inspection we found:

• The group had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen there was a genuinely open culture in which all safety concerns raised by staff and people who use services were highly valued as opportunities for learning and improvement.

• The group routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

• Patients with diabetes received effective care and were cared for by an experienced team of six nurses specialising in diabetic care.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

• The group were organised, efficient and had effective governance processes.

• The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care and were clear, supportive and encouraged creativity.

• There had been many organisational changes and annual changes in university patient population. In response to this, the leadership had maintained positive patient outcomes, effective communication, positive feedback from patients and provided a popular place for staff to work.

We saw two areas of outstanding group:

People’s emotional and social needs were seen as important as their physical needs and the group had recognised that there were a high number of socially isolated patients within the community. As a result the group had responded by employing a volunteer coordinator who ran a proactive team of over 40 volunteers within the league of friends group. Together the volunteers offered; a telephone service to ring lonely older adults every one to two weeks to offer support, a full programme of social events during the week, a medicines delivery service, a sitting service for carers and shopping services. The services offered by the volunteers, in conjunction with the group, had been welcomed by patients and was successful in attracting new members after they themselves had been supported.

The staff were proactively responsive to the needs of the local population and services were delivered in a way to ensure flexibility, choice, convenience and continuity of care for patients. For example, the group offered additional services for their own patients and others in the community including vasectomy service (268 patients had received this service in 2017), rheumatology clinic (599 appointments in the last year), headache clinic (304 patients had been seen and treated in the last year) and leg ulcer service (85 patients had been seen at the leg clinic in the last two years and 53 ulcers had healed through the effective treatment provided). Students at the University Health Centre had access to additional proactive services including close co-ordination with the University Well Being Centre, prescription services and reviews during non-term time.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice