St Thomas Medical Group

This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this service Outstanding –

Are services safe? Outstanding –

Are services effective? Good –––

Are services caring? Good –––

Are services responsive to people’s needs? Outstanding –

Are services well-led? Outstanding –

StSt ThomasThomas MedicMedicalal GrGroupoupQuality Report

St Thomas Health CentreCowick StreetSt ThomasExeterDevonEX4 1HJTel: 01392 676678Website: www.stthomasmedicalgroup.co.uk

Date of inspection visit: 16 and 18 January 2018Date of publication: 17/05/2019

1 St Thomas Medical Group Quality Report 17/05/2019

Contents

PageSummary of this inspectionOverall summary 2

The six population groups and what we found 4

Detailed findings from this inspectionOur inspection team 5

Background to St Thomas Medical Group 5

Detailed findings 7

Overall summaryLetter from the Chief Inspector of GeneralPractice

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

For purposes of the report the practice will be referred toas ‘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 thequality of care for specific population groups. Thepopulation 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 andstudents – Outstanding

People whose circumstances may make them vulnerable– Outstanding

People experiencing poor mental health (includingpeople with dementia) - Outstanding

We carried out an announced comprehensive inspectionof the St Thomas Medical Group on Tuesday 16 January2018 and Thursday 18 January 2018 as part of ourinspection programme.

At this inspection we found:

• The group had clear systems to manage risk so thatsafety incidents were less likely to happen. Whenincidents did happen there was a genuinely openculture in which all safety concerns raised by staffand people who use services were highly valued asopportunities for learning and improvement.

• The group routinely reviewed the effectiveness andappropriateness of the care it provided. It ensuredthat care and treatment was delivered according toevidence- based guidelines.

• Patients with diabetes received effective care andwere cared for by an experienced team of six nursesspecialising in diabetic care.

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

• Patients found the appointment system easy to useand reported that they were able to access carewhen they needed it.

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

Summary of findings


• The group were organised, efficient and had effectivegovernance processes.

• The leadership, governance and culture were used todrive and improve the delivery of high-qualityperson-centred care and were clear, supportive andencouraged creativity.

• There had been many organisational changes andannual changes in university patient population. Inresponse to this, the leadership had maintainedpositive patient outcomes, effective communication,positive feedback from patients and provided apopular place for staff to work.

We saw two areas of outstanding group:

People’s emotional and social needs were seen asimportant as their physical needs and the group hadrecognised that there were a high number of sociallyisolated patients within the community. As a result thegroup had responded by employing a volunteercoordinator who ran a proactive team of over 40volunteers within the league of friends group. Togetherthe volunteers offered; a telephone service to ring lonelyolder adults every one to two weeks to offer support, afull programme of social events during the week, a

medicines delivery service, a sitting service for carers andshopping services. The services offered by the volunteers,in conjunction with the group, had been welcomed bypatients and was successful in attracting new membersafter they themselves had been supported.

The staff were proactively responsive to the needs of thelocal population and services were delivered in a way toensure flexibility, choice, convenience and continuity ofcare for patients. For example, the group offeredadditional services for their own patients and others inthe community including vasectomy service (268 patientshad received this service in 2017), rheumatology clinic(599 appointments in the last year), headache clinic (304patients had been seen and treated in the last year) andleg ulcer service (85 patients had been seen at the legclinic in the last two years and 53 ulcers had healedthrough the effective treatment provided). Students atthe University Health Centre had access to additionalproactive services including close co-ordination with theUniversity Well Being Centre, prescription services andreviews during non-term time.

Professor Steve Field (CBE FRCP FFPH FRCGP)Chief Inspector of General Practice

Summary of findings


The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older people Outstanding –People with long term conditions Outstanding –Families, children and young people Outstanding –Working age people (including those recently retired andstudents)

Outstanding –

People whose circumstances may make them vulnerable Outstanding –People experiencing poor mental health (including peoplewith dementia)

Outstanding –

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC lead inspector, asecond CQC inspector, two GP specialist advisers,a practice nurse specialist adviser, a practice manageradviser and an expert by experience.

Background to St ThomasMedical GroupSt Thomas Medical Group is a group of four GP practiceswhich provide services under a Personal Medical Service(PMS) contract for approximately 38,400 patients The groupis situated in the Devon city of Exeter.

St Thomas Medical Group is made up of four separatepractices with one patient list. This means patients can beseen at any one of the four sites. Patients tended to visit thesame practice for their own convenience. Administrationstaff rotated across all sites but clinical staff tended to bebased at one group to provide better continuity forpatients.

St Thomas Health Centre is open Monday to Fridaybetween 8.30am and 6pm. The practice is closed between12.30 pm and 1.30 pm on Friday lunchtimes for stafftraining. Extended appointments are offered from 7am to8am on a Tuesday and Thursday and 6.30 pm to 8pm onTuesdays and Wednesdays.

Exwick Health Centre is open Monday to Friday between8.30am and 6pm. The practice is closed between 12.30pmand 1.30pm on Fridays for staff training. Extended hours areoffered each day between 7am and 8am.

The student health centre at Exeter University is openduring term time Monday to Friday between 8.45am and6pm. Extended hours are offered from 7am to 8am onTuesdays and 6.30 pm to 8pm on Thursdays during termtime. During University vacations appointments arevariable but include a minimum of three days a weekbetween 9am and 5pm. These days are usually a Monday,Wednesday and Friday.

All calls are managed through the call centre based at StThomas Health Centre. Calls outside of Exeter UniversityStudent Health Centre opening times are automaticallydiverted to St Thomas Health Centre.

Pathfinder Surgery is open on Mondays and Thursdaysbetween 8.30am and 4.30pm but is closed at lunchtime onboth days between 1pm and 2pm.

Calls outside of the St Thomas opening hours are answeredby the Out of hours message handling service by patientsdialling the NHS 111 service.

The group were a member of Exeter Primary Care (EPC), afederation of 16 Exeter GP groups. The EPC group organiseincreased GP access outside of the core hours of 8.30 and6pm. All registered patients are therefore able to be seen,by appointment, by an ExeterGP, at an Exeter GP groupbetween Monday and Thursday 6.30 to 8pm and Saturdayand Sunday 9am and 5pm. St Thomas Medical groupprovides this service every Saturday between 9am and 5pmand on Tuesday and Wednesday evenings between 6.30pmand 8pm.

The group population area is in the seventh decile fordeprivation. In a score of one to ten, the lower the decilethe more deprived an area is. There is a group agedistribution of male and female patients equivalent to

StSt ThomasThomas MedicMedicalal GrGroupoupDetailed findings


national average figures. Average life expectancy for thearea is similar to national figures with males living to anaverage age of 79 years and females living to an average of80 years.

The organisation employs over 110 staff. There is a team of28 GPs (19 female, nine male). Of the 28 GPs, ten are GPpartners, there are two GP registrars (Doctors training tobecome a GP). The whole time equivalent of GPs is justover 14. The team of GPs are supported by a groupmanager, assistant group manager, nurse manager (anadvanced nurse practitioner), paramedic, four lead groupnurses, eight group nurses and eight health care assistants.The group employ an emergency care practitioner who hasexperience of working at the local emergency department.They work within the minor illness clinic at the group. Theclinical team are supported by a clinical team lead, 12clinical administration staff, six prescribing team members,10 secretarial support staff, bookkeeper, volunteercoordinator and care taker.

Patients using the practices had access to community staffincluding community nurses, health visitors, midwives andcounsellors. There is an independent pharmacy on thesame site as St Thomas Health Centre.

The group were a teaching group for GP Registrars, (doctorswho are training to become GPs). The group had also beenidentified as a placement for student nurses and hasscheduled a student nurse to start in April 2018.

The GPs provide medical support to ten residential careand nursing homes.

St Thomas Medical Group is registered to provide regulatedactivities which include:

Treatment of disease, disorder or injury, surgicalprocedures, maternity and midwifery services andDiagnostic and screening procedures and operate from themain locations of:

St Thomas Health Centre, Cowick Street, St Thomas, Exeter,Devon, EX4 1HJ

And three branch surgeries at:

Exwick Health Centre, New Valley Road, Exeter, EX4 2AD

Student Health Centre, Reed Mews, Streatham Drive,University Campus, Exeter, EX4 4QP

and

The Surgery, Brookside, Pathfinder Village, Exeter, EX6 6BT

We visited all these locations as part of our inspection.

Detailed findings


Our findingsWe rated the group, and all of the population groups,as good for providing safe services.

Safety systems and processes

The group had clear systems to keep patients safe andsafeguarded from abuse.

• Each site conducted safety risk assessments as a rollingprogramme of maintenance and had a maintenanceschedule to demonstrate all systems had been testedand calibrated within designated timescales. Forexample, fire risk assessments, environmental riskassessments, electrical and clinical equipment testing.We noted all were up to date during our inspection.

• The group had a set of safety policies which were easilylocated, regularly reviewed and communicated to staff.The policies were reviewed every eight weeks by adesignated member of staff who then coordinated thereview in conjunction with the leadership team. Staffreceived safety information for the group as part of theirinduction and refresher training. New informationregarding safety from guidance or clinical training wascascaded to staff during clinical meetings. Thisinformation sharing was evidenced in meeting minuteswe saw.

• The group had systems to safeguard children andvulnerable adults from abuse. Policies were regularlyreviewed and were accessible to all staff. They outlinedclearly who to go to for further guidance.

• The group worked with other agencies to supportpatients and protect them from neglect and abuse. Stafftook steps to protect patients from abuse, neglect,harassment, discrimination and breaches of theirdignity and respect.

• The group carried out staff checks, including checks ofprofessional registration where relevant, on recruitmentand on an ongoing basis. Disclosure and Barring Service(DBS) checks were undertaken where required,including volunteers who worked on a one to one basiswith patients. (DBS checks identify whether a personhas a criminal record or is on an official list of peoplebarred from working in roles where they may havecontact with children or adults who may be vulnerable).

• All staff received up-to-date safeguarding and safetytraining appropriate to their role. They knew how toidentify and report concerns. Staff who acted aschaperones were trained for the role and had received aDBS check.

• There was an effective system to manage infectionprevention and control. Extensive audits wereperformed each year and actions reviewed four times ayear to ensure patient and staff safety.

• The group ensured that facilities and equipment weresafe and that equipment was maintained according tomanufacturers’ instructions. There were systems forsafely managing healthcare waste.

Risks to patients

There were systems to assess, monitor and manage risks topatient safety.

• There were arrangements for planning and monitoringthe number and mix of staff needed.

• There was an effective induction system for temporarystaff tailored to their role.

• Staff understood their responsibilities to manageemergencies on the premises and to recognise those inneed of urgent medical attention. Clinicians knew howto identify and manage patients with severe infections,for example, sepsis.

• When there were changes to services or staff the groupassessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe careand treatment to patients.

• Individual care records were written and managed in away that kept patients safe. The care records we sawshowed that information needed to deliver safe careand treatment was available to relevant staff in anaccessible way.

• The group had systems for sharing information withstaff and other agencies to enable them to deliver safecare and treatment.

• Referral letters included all of the necessaryinformation.

Safe and appropriate use of medicines

The group had reliable systems for appropriate and safehandling of medicines.

Are services safe?

Outstanding –


• The systems for managing medicines, includingvaccines, medical gases, and emergency medicines andequipment minimised risks. The group kept prescriptionstationery securely and monitored its use.

• The group had a designated prescribing team whocoordinated the prescriptions and ran searches formedicines monitoring. The team produced quarterlynewsletters informing all staff of any manufactureinformation, top tips for staff and protocol changes. Thishelped demonstrate effective medicines managementand ensured patient safety.

• The group had 13,600 online users and 28% of patientsused the online prescription service; an increase of 7%since our last inspection. Online services includemaking appointments, obtaining repeat prescriptionsand accessing other healthcare information. Currentlythere were 8,000 patients signed up and accessing theonline services and a total of just under 10,000 patientsfrom the other groups using the medicine requestservices. Patients were supported by a team member touse the online services on a daily basis by telephone.The group had also offered a Saturday drop in clinic tosupport patients with accessing the online services.

• Staff prescribed, administered or supplied medicines topatients and gave advice on medicines in line with legalrequirements and current national guidance. The grouphad audited antimicrobial prescribing. There wasevidence of actions taken to support good antimicrobialstewardship.

• Patients’ health was monitored to ensure medicineswere being used safely and followed up onappropriately. The group involved patients in regularreviews of their medicines.

Track record on safety

The group had a good safety record.

• There were comprehensive risk assessments in relationto safety issues.

• The group monitored and reviewed activity. This helpedit to understand risks and gave a clear, accurate andcurrent picture that led to safety improvements.

Lessons learned and improvements made

The group learned and made improvements when thingswent wrong.

There was a system for recording and acting on significantevents and incidents. Staff understood their responsibilities

with regard to reporting significant events andsafeguarding. They named the GP leads for key areas suchas these. Staff told us there was support andencouragement to report when events went wrong andadded this was led by the partners and GPs. Staff providedus with examples of significant events and how these hadbeen discussed subsequently at the weekly meetings. Forexample, a positive response to an emergency event at thereception desk demonstrated that, staff had acted swiftlyand had activated an audible alarm. A nurse had attendedand ensured the patient was well. Shared learning from theincident included the use of the computer based alarmsystem rather than solely using the audible alarm, as themajority of staff within the building had failed to hear thealarm. Information from the group review of significantevents indicated subsequent emergencies had used thecomputer based alarm and were more promptlyresponded to.

The group also monitored trends in significant events andtook action as a result. For example, there had been threeattempted suicides at the university. The group hadrecognised the need to keep a risk register of vulnerablepatients which was monitored on a weekly basis.Information was shared with relevant university staff andhad resulted in identifying at risk university health centrepatients who were admitted for further care and treatment.The events had also improved communication with thelocal mental health trust staff.

• There was a system for receiving and acting on safetyalerts. The group learned from external safety events aswell as patient and medicine safety alerts. Informationwas shared at clinical, governance, educational andleadership meetings, federation meetings and alsodisseminated to staff by email.

Arrangements to deal with emergencies and majorincidents

The practice had adequate arrangements to respond toemergencies and major incidents.

• There was an instant messaging system on thecomputers in all the consultation and treatment roomswhich alerted staff to any emergency.

• All staff received annual basic life support training andthere were emergency medicines available in all fourlocations.

Are services safe?

Outstanding –


• The practice had a defibrillator available on eachpremises and oxygen with adult and children’s masks. Afirst aid kit and accident book were available.

• Emergency medicines were easily accessible to staff in asecure area of the practice and all staff knew of theirlocation. All the medicines we checked were in date andstored securely.

• The practice had a comprehensive business continuityplan for major incidents such as power failure orbuilding damage. The plan included emergency contactnumbers for staff.

Are services safe?

Outstanding –


Our findingsWe rated the group, and all population groups, asgood for providing effective services.

Effective needs assessment, care and treatment

The group had systems to keep clinicians up to date withcurrent evidence-based group. We saw that cliniciansassessed needs and delivered care and treatment in linewith current legislation, standards and guidance supportedby clear clinical pathways and protocols. New guidance,care pathways and protocols were shared at clinical,governance, educational and leadership meetings and alsodisseminated by email.

• Patients’ needs were fully assessed. This included theirclinical needs and their mental and physical wellbeing.

• The group used clinical templates embedded within thecomputer system to ensure all health checks wereperformed in line with expected group.

• Reception staff had been provided with guidance ofwho, and how urgently patients should be booked withappointments. For example, cough and breathingdifficulties. Staff also had guidance on the recognitionand management of suspected sepsis.

• The group used guidelines suggested by the DevonPalliative Care specialists and had a ‘just in case’medicine bag for clinicians to use when supportingpatients with some long term conditions. An audit wascarried out in June 2017 on the prescribing,documentation, communication and monitoring of ‘justin case medicines’. As a result the group had re written aprotocol (including the computer system protocol) toachieve a gold standard of group. The main area forimprovement identified was that prescriptions hadoccasionally been issued both electronically and onpaper, arriving at the pharmacy at a different time,leading to the potential for the pharmacy to dispensethese medicines separately and outside of the “pack”.The improved protocol had removed the potential ofduplicate prescriptions being produced.

• Patients with renal failure were also able to access justin case bags. The GPs recognised these patientsrequired slightly different medicines. Members of theprescribing team had designed a protocol whichidentified those patients with renal failure and thenorganised a set of prescriptions dependent on their

personal renal function. The protocol had proved usefulfor clinicians and staff said the process wasstraightforward and efficient in providing patients withthe most effective treatment.

The group was below other groups for antibioticprescribing. For example, the percentage of antibiotic itemsprescribed that were Cephalosporins or Quinolones (typesof antibiotics) between July 2015 and June 2016 was 3%compared with the CCG average of 5% and nationalaverage of 8%. The prescribing rate was achieved throughmore effective patient consultations and the promotion ofself help remedies for self-limiting viral illnesses.

• We saw no evidence of discrimination when makingcare and treatment decisions.

• The group used equipment to improve treatment and tosupport patients’ independence. For example, patientson blood thinning medicines were able to accessequipment which screened their blood (near patienttesting) at the practices to ensure the medicineprescribed was adjusted to maintain the correct level.(Near-patient testing (also known as point-of-caretesting) is defined as an investigation taken at the timeof the consultation with instant availability of results tomake immediate and informed decisions about patientcare).

• Staff advised patients what to do if their condition gotworse and where to seek further help and support.

Older people:

• Older patients who are frail or may be vulnerablereceived a full assessment of their physical, mental andsocial needs. Those identified as being frail had aclinical review including a review of their medicines. Theprescribing team proactively chased up any blood testsfor elderly patients who forgot to book in for screeningor reviews.

• Patients aged over 75 were invited for a health check. Ifnecessary they were referred to other services such asvoluntary services and supported by an appropriatecare plan. Over a 12 month period the group had offered179 patients a health check. 175 of these checks hadbeen carried out and there were good clinical reasonswhy the remaining four had not been completed.

Are services effective?(for example, treatment is effective)

Good –––


• The group followed up on older patients dischargedfrom hospital. It ensured that their care plans andprescriptions were updated to reflect any extra orchanged needs.

People with long-term conditions:

• Patients with long-term conditions had a structuredannual review to check their health and medicinesneeds were being met. For patients with the mostcomplex needs, the GP worked with other health andcare professionals to deliver a coordinated package ofcare.

• Patients at risk of developing diabetes were registeredand recalled to be offered weight checks, lifestyle adviceand a blood test. A monthly computer search wascarried out to identify pre-diabetic patients coded withsigns of diabetes. The search triggered a check to see ifthese patients had received an invitation to have ascreening blood test. There were 311 patients identifiedwith pre diabetes and over the last year 273 of thesepatients had attended the reviews and been supportedto avoid diabetes.

• Patients with diabetes were cared for by a team of sixnurses specialising in diabetic care. Four of these nurseshad been developed by the leadership and were able tostart patients on insulin. Patients were seen every yearor more frequently as required. The diabetic team metweekly to discuss patients and worked with the GPdiabetic lead fortnightly. Monthly joint clinics were heldwith the diabetic specialist nurse from the local acutehospital. Normally five to six patients were discussedeach week.

• The group had a register of 2525 patients with obesity.1,530 of these patients were also identified as havinganother long term condition and were invited to attendan annual lifestyle review. The remaining 995 patientswere invited for an annual review and invitation tocontact the local “Onesmallstep” support group toimprove lifestyle and diet advice. In the last yearapproximately 30 patients had self referred to thisservice.

• Staff who were responsible for reviews of patients withlong term conditions had received specific training.

Families, children and young people:

• Childhood immunisations were carried out in line withthe national childhood vaccination programme. Uptakerates for the vaccines given were in line with the targetpercentage of 90% or above. For example, rates rangedbetween 90% and 95%.

• The group had arrangements to identify and review thetreatment of newly pregnant women on long-termmedicines.

Working age people (including those recently retired andstudents):

• The group’s uptake for cervical screening was 80%,which was in line with the 80% coverage target for thenational screening programme. The Group actively tookpart in the annual “Jo’s” Cervical Screening Awarenessweek. The campaign was displayed in the main foyer aswell as on-going awareness on the website and postersdisplayed in the groups, staff had also attended cervicalawareness training sessions and one of the secretarieshad attended the course.

• The group had systems to inform eligible patients tohave the meningitis vaccine, for example beforeattending university for the first time.

• Patients had access to appropriate health assessmentsand checks including NHS checks for patients aged40-74. There was appropriate follow-up on the outcomeof health assessments and checks where abnormalitiesor risk factors were identified. Proactive immunisationprogrammes were in place for students. For example,during fresher’s week in 2017, when students wereregistering at the student health centre they wereoffered a meningitis immunisation vaccination thereand then. Staff opportunistically vaccinatedapproximately 174 patients entitled to the MenACWYvaccine.

• University students were offered advice on sexualhealth, use of drugs, mental health, alcohol, legal highsand self-harm.

• The GPs based at the University Health Centre were partof the international student health association andattended annual conferences (including one in Japan)to update knowledge of guidelines. In betweenconferences the GPs communicate with colleagues todiscuss themes and complex cases consequentlyimproving treatment outcomes for overseas students.


Good –––


• University students were signposted and encouraged tosign up to a self-care App to help them deal with minorailments. 3,500 student patients had accessed this App.

People whose circumstances make them vulnerable:

• End of life care was delivered in a coordinated waywhich took into account the needs of those whosecircumstances may make them vulnerable.

• The group held a register of patients living in vulnerablecircumstances including homeless people, travellersand those with a learning disability.

People experiencing poor mental health (including peoplewith dementia):

• 89% of patients diagnosed with dementia had their carereviewed in a face to face meeting in the previous 12months. This was higher than the national average of84% and the group had initiatives in place to improvethis figure further.

• 95% of patients diagnosed with schizophrenia, bipolaraffective disorder and other psychoses had acomprehensive, agreed care plan documented in theprevious 12 months. This was higher than the CCGaverage of 85% and national average of 90%.

• The group specifically considered the physical healthneeds of patients with poor mental health and thoseliving with dementia. For example the percentage ofpatients experiencing poor mental health who hadreceived discussion and advice about alcoholconsumption was 90% compared to the CCG average of87% and national average of 91%.

• 77% of newly diagnosed patients with depression hadreceived a review between 10-56 days after diagnosis.This was higher than the CCG average of 67% andnational average of 65% with the group havinginitiatives in place to improve this figure further.

Monitoring care and treatment

The group had a comprehensive programme of qualityimprovement activity and routinely reviewed theeffectiveness and appropriateness of the care provided.Regular searches were performed to confirm that allpatients on certain medicines, screening programmes orreceiving treatment were receiving appropriate and timelycare. For example, monthly checks of patients on blood

thinning medicines were performed to identify they werehaving their blood tests done in a timely way. The reportfrom the last eight months showed a reduction of overdueblood tests from 20 to ten patients.

There was clear evidence of action to monitor and changepractice to improve quality. For example, an atrialfibrillation (AF(abnormal heart rhythm) audit took place inJanuary 2016 following a significant event meeting andfollowing a review of some cases of patients with strokewho had presented with stroke and had AF. The aim of theaudit was to try to increase the overall TTR (time withintherapeutic range) for those patients on warfarin (bloodthinning medicine) for patients with AF. The TTR aim wasover 65% in range, with a gold standard of 72% or above inrange. The first data collection in January 2016 showedthat the original standard for improvement was met. Thesecond data collection in May 2016 showed that thepercentage of patients with an acceptable TTR of over 65%rose from 75% to 80.9%. The percentage of patients withgold standard TTR of 72% or over rose from 61.4% to68.7%.

The most recent published Quality Outcome Framework(QOF) results showed the group had achieved 100% of thetotal number of points available compared with the clinicalcommissioning group (CCG) average of 97% and nationalaverage of 97%. (QOF is a system intended to improve thequality of general practice and reward good practice. Theoverall clinical exception reporting rate was 14% comparedwith a national average of 10%. Exception reporting is theremoval of patients from QOF calculations where, forexample, the patients decline or do not respond toinvitations to attend a review of their condition or when amedicine is not appropriate. We looked at the clinicalreasons for exception reporting and found the turnover ofuniversity students and the large number of patients incare homes, where intensive therapies were notappropriate, were factors, and these decisions had beenappropriate. We also saw other clinical reasons which wereappropriate and validated by our specialist advisor.

• The group used information about care and treatmentto make improvements. For example, cervical smearaudits took place every two years to identify if anytrends and training needs could be identified andamendments to procedures made. The most recentaudit indicated effective testing with no trends wheretesting was questionable.


Good –––


• The group was actively involved in quality improvementactivity. For example, an audit was undertaken in August2017 to see how many patients on the learningdisabilities (LD) Register (114) were up to date with theirscreening including bowel screening, aortic aneurysm,cervical smears, breast screening. The audit identified asmall number of patients that were overdue one ormore of the above routine screening examinations andalso highlighted, that despite reminders, patients werenot always attending for their annual reviews. As a resultthe group had worked with the Exeter learning disabilityteam, who offered to make contact with these patientsand try and encourage them to attend for their annualreview and screening, and/or offer to visit these patientsin their own home rather than attending the group. Thegroup were in the process of obtaining consent from LDpatients, to allow the Exeter Disability Team to makecontact with them.

• Where appropriate, clinicians took part in local andnational improvement initiatives.

Effective staffing

Staff had the skills, knowledge and experience to carry outtheir roles. For example, staff whose role includedimmunisation and taking samples for the cervicalscreening programme had received specific training andcould demonstrate how they stayed up to date.

• Staff told us that the induction programme wasdetailed, structured and offered sufficient time toachieve all the learning objectives. GP registrars hadgiven positive feedback about the support receivedwhen first arriving at the groups. Registrars are fullyqualified doctors who are training to become GPs.

• The group understood the learning needs of staff andprovided protected time and training to meet them. Upto date records of skills, qualifications and training weremaintained. Staff were encouraged and givenopportunities to develop.

• Educational meetings were held on a monthly basis‘after hours’ for clinical staff and during regular Fridaylunchtime meetings where the group was ‘shut down’.Calls were diverted, by prior arrangement, to the out ofhours provider and outside speakers invited to speakwith all staff.

• Quarterly ‘whole group meetings’ were also held whichwere a combination of in hours – cover arranged byprior agreement and out of hours/weekends so they donot affect patients and appointment times.

• New staff told us working at the group had exceededtheir expectations and staff had provided a warmwelcome and substantial support and information.

• The group provided staff with ongoing support. Thisincluded an induction process, one-to-one meetings,appraisals, coaching and mentoring, clinical supervisionand support for revalidation. The group ensured thecompetence of staff employed in advanced roles byaudit of their clinical decision making, includingnon-medical prescribing.

• There was a clear approach for supporting andmanaging staff when their performance was poor orvariable.

• Nursing staff told us how they were provided with ‘timeout’ to perform administration tasks.

• Feedback from GP registrars was positive. We wereinformed GP registrars received suitable support, weeklytutorials, and immediate assistance from the trainer. GPregistrar notes, records and decision making werereviewed by the GP trainers. The GP trainers met everysix months to review student feedback and plan for theforthcoming year.

• There were GPs within the group who had specialinterest in services including the vasectomy service,rheumatology clinics, minor surgery, contraception, endof life care, sexual dysfunction, mental health andteaching. GPs had allocated roles to lead on subjects forQOF. These special interests enable patients to receiveprompt local care and treatment and helped avoid theneed to send patients to the nearby hospital to seespecialists.

Coordinating care and treatment

Staff worked together and with other health and social careprofessionals to deliver effective care and treatment.

• All GPs met daily to discuss any particular cases, offersupport and divide home visits. This also promotedcommunication across the teams.

• Patients received coordinated and person-centred care.This included when they moved between services, when


Good –––


they were referred, or after they were discharged fromhospital. The group worked with patients to developpersonal care plans that were shared with relevantagencies.

• The percentage of new cancer cases (among patientsregistered at the groups) who had been referred usingthe urgent two week wait referral pathway usingappropriate criteria and subsequent cancer diagnosiswas 68% compared with the CCG average of 56% andnational average of 50%. The referral lead for the grouphad reviewed the referral templates to ensure continuedawareness of the criteria. The review did not identify anyinappropriate referrals. The group were in the process ofexpanding the teledermatology triage service for theidentification of more skin lesions.

• The group ensured that end of life care was delivered ina coordinated way which took into account the needs ofdifferent patients, including those who may bevulnerable because of their circumstances.

• The group held core group meetings; thesemultidisciplinary team meetings for complex care staffwere fortnightly and included voluntary sector staff,social workers, community health care professionalsand group staff. The group met to discuss the needs ofvulnerable patients who had complex needs andensured their care plans were routinely updated whereneeds had changed.

• Quarterly safeguarding meetings took place with thehealth visitor to discuss vulnerable families.

• The group distributed the charity ‘Message in a Bottle’pot. Which enabled patients to keep their personalandmedical details on a standard form and in a commonlocation, the fridge, so it could be found by out of hoursGPs and ambulance staff.

• The group had attempted to make patients aware of theAdvanced Summary Care record by including a copy ofthe record in with all the annual flu invites, advertising inthe health centres by way of posters, on the website andincluding in the registration pack. This highlighted 1112eligible patients giving consent to an AdditionalSummary Care record.

• Group staff could access a hospital online ‘whiteboard’to identify any of their patients who were due to bedischarged and used community matrons and staff toorganise follow up care.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients tolive healthier lives.

• The group identified patients who may be in need ofextra support and directed them to relevant services.This included patients in the last 12 months of theirlives, patients at risk of developing a long-termcondition and carers.

• Staff were consistent in supporting people to livehealthier lives through a targeted and proactiveapproach to health promotion and prevention ofill-health, and every contact with people is used to doso. For example, pop up reminders were used at routine,non-related visits to prompt staff to discuss issues withpatients, offer immunisations, screening and medicinereviews.

• Staff encouraged and supported patients to be involvedin monitoring and managing their health.

• Staff discussed changes to care or treatment withpatients and their carers as necessary.

• The group supported national priorities and initiativesto improve the population’s health, for example, stopsmoking campaigns, tackling obesity. For example, thepercentage of patients with a record of offer of supportand treatment for smoking in the last 24 months was99% compared with a CCG average of 90% and nationalaverage of 89%.

• Group staff promoted the Handi app. A mobile phoneapp designed for patients to access up-to-date adviceabout common childhood illnesses and how to treatthem. No data was available to demonstrate how manypatients accessed the app but staff said it was promotedby the staff.

• Patients could be prescribed access to the wellbeingExeter service which offered patients access to exercisesessions including personal training and walkingfootball. A total of 269 patients had so far been referredto this service and anecdotally had helped to reduce thenumber of appointments requested by patients.

Consent to care and treatment

The group obtained consent to care and treatment in linewith legislation and guidance.

• Clinicians understood the requirements of legislationand guidance when considering consent and decisionmaking.


Good –––


• Clinicians supported patients to make decisions. Whereappropriate, they assessed and recorded a patient’smental capacity to make a decision.

• The group monitored the process for seeking consentappropriately.


Good –––


Our findingsWe rated the group, and all of the population groups,as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect andcompassion.

• Staff understood patients’ personal, cultural, social andreligious needs.

• The group gave patients timely support andinformation.

• Reception staff knew that if patients wanted to discusssensitive issues or appeared distressed they could offerthem a private room to discuss their needs.

Results from the July 2017 annual national GP patientsurvey showed patients felt they were treated withcompassion, dignity and respect. 320 surveys were sent outand 91 were returned. This represented about 0.2% of thegroup population. The group was in line or slightly belowfor its satisfaction scores on consultations with GPs andnurses. For example:

• 88% of patients who responded said the GP was good atlistening to them compared with the clinicalcommissioning group (CCG) average of 92% and thenational average of 89%.

• 91% of patients who responded said the GP gave themenough time; CCG - 91%; national average - 86%.

• 95% of patients who responded said they hadconfidence and trust in the last GP they saw; CCG - 97%;national average - 95%.

• 83% of patients who responded said the last GP theyspoke to was good at treating them with care andconcern; CCG– 90%; national average - 86%.

• 93% of patients who responded said the nurse wasgood at listening to them; (CCG) - 94%; national average- 91%.

• 96% of patients who responded said the nurse gavethem enough time; CCG - 95%; national average - 92%.

• 99% of patients who responded said they hadconfidence and trust in the last nurse they saw; CCG -99%; national average - 97%.

• 84% of patients who responded said the last nurse theyspoke to was good at treating them with care andconcern; CCG - 94%; national average - 91%.

• 91% of patients who responded said they found thereceptionists at the group helpful; CCG - 90%; nationalaverage - 87%.

The group manager thought results were mixed becausethe survey had taken place in July 2017 when there hadbeen a time of great change for patients. For example,patients had been unhappy with the use of an ineffectivetelephone system. This had been improved since July 2017with a new telephone system with unlimited telephonelines. There had also been the retirement/departure of fivelong service GPs, who had subsequently been replaced.

The group had seen an increase in patient satisfaction. Forexample, the PPG (Patient participation group) carried outa further internal survey in September 2017. This showedthat 56 of the 59 respondents were happy with the servicethey received.

We spoke with five patients about the consultations withGPs and nurses. All five patients said they felt supportedand cared for, felt respected and treated with compassionand dignity.

All of the 46 patient Care Quality Commission commentcards we received were positive about the serviceexperienced. There were no negative comments about thecare and treatment received or access to services.

This is in line with the results of the NHS Friends and FamilyTest and other feedback received. For example, 45 of the 47patients asked in December 2017 said they would beextremely likely or likely to recommend the practices.

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about theircare and were aware of the Accessible InformationStandard (a requirement to make sure that patients andtheir carers can access and understand the informationthey are given):

• Interpretation services were available for patients whodid not have English as a first language.

• The Group Booklet has also been printed in “large print”for patients who have a visual impairment; this largeprint version was available on request.

• The group had posters advertising “AccessibleInformation” displayed at each Health Centre and alsoincluded within the Registration Pack was a questionasking patients with disabilities if they require anyspecial needs.

Are services caring?

Good –––


• The group undertook a search of the clinical system toidentify visual and audibly impaired patients and anotice had been put on their records outlining theirspecial requirements.

• For patients that did not have a record of their specialrequirements, a letter was sent enclosing the AccessibleInformation request form.

• A message was displayed in the “warning box” on thepatient journal flagging special needs to clinicians andsecretaries. This enabled sufficient time to be bookedfor interpreter or additional support to be given.

• Easy-read letters and leaflets for patients with learningdisabilities.

• Door signage included easy-read instruction in responseto feedback from patient with learning disabilities.

• Staff had access to British sign language interpretersand staff members were familiar in using Makaton tocommunicate with patients.

• GPs at the university routinely passed on anyinformation relating to health and screening into theuniversity newsletter. This was then translated intodifferent languages. Examples seen includedinformation on cervical screening and meningitisvaccination.

The group proactively identified patients who were carersby asking at registration. The group’s computer systemalerted GPs if a patient was also a carer. The group hadidentified 1.3% of the group list as carers and werecontinually looking at other ways to identify further carers.

• The volunteer coordinator acted as a carers’ championto help ensure that the various services supportingcarers were coordinated and effective. The member ofstaff made contact with the carer to signpost them tofurther support and also invited them to use the sittingservice and social events offered by the league offriends.

• Staff told us that if families had experiencedbereavement, their usual GP contacted them. This callwas either followed by a patient consultation at aflexible time and location to meet the family’s needsand/or by giving them advice on how to find a supportservice.

Results from the national GP patient survey showedpatients responded comparably to questions about theirinvolvement in planning and making decisions about theircare and treatment. Results were in line with local andnational averages:

• 86% of patients who responded said the last GP theysaw was good at explaining tests and treatmentscompared with the clinical commissioning group (CCG)average of 90% and the national average of 86%.

• 88% of patients who responded said the last GP theysaw was good at involving them in decisions about theircare; CCG - 88%; national average - 82%.

• 88% of patients who responded said the last nurse theysaw was good at explaining tests and treatments; CCG -92%; national average - 90%.

• 85% of patients who responded said the last nurse theysaw was good at involving them in decisions about theircare; CCG - 89%; national average - 85%.

We asked three patients about their involvement in tests,care and treatment. All said they felt fully involved.Comment cards were also complimentary about thecommunication between clinical staff and the patient aswere thank you cards the group received.

Privacy and dignity

The group respected and promoted patients’ privacy anddignity.

• Staff recognised the importance of patients’ dignity andrespect.

• The group complied with the Data Protection Act 1998.

Are services caring?

Good –––


Our findingsWe rated the group, and all of the population groups,as outstanding for providing responsive services.

The practice was rated as outstanding for providingresponsive services because:

• The involvement of other organisations, volunteergroups and the local community is integral to howservices were planned ensure that services met patient’sneeds.

• There were innovative approaches to providingintegrated person-centred pathways of care that involveother service providers, particularly for people withmultiple and complex needs.

• There was a proactive approach to understanding theneeds of different groups of patients and to deliver carein a way that meets these needs and promotes equality.This includes people who are in vulnerablecircumstances, socially isolated or who have complexneeds.

Responding to and meeting people’s needs

The group organised and delivered services to meetpatients’ needs. It took account of patient needs andpreferences.

• The group understood the needs of its population andtailored services in response to those needs. (Forexample extended opening hours, online services suchas repeat prescription requests, advanced booking ofappointments, advice services for common ailments.

• The group improved services where possible inresponse to unmet needs.

• The facilities and premises were appropriate for theservices delivered.

• An IT support clinic was held to help patients who wereexperiencing difficulty to get online to use the website.As a response to many questions over this process, staffoffered help over the telephone. A Saturday clinic,where patients could attend in a booked appointmentfor assistance to register for on line services, was alsooffered. This clinic was attended by 21 patients who allappreciated this service and were now on line serviceusers.

• The group made reasonable adjustments when patientsfound it hard to access services.

• Care and treatment for patients with multiple long-termconditions and patients approaching the end of life wascoordinated with other services.

• The group hosted external services for the benefit ofpatients. These include the depression and anxietycounselling service, retinal screening and stoma service.

• The group was commissioned by the local clinicalcommissioning group (CCG) to provide regularheadache clinics. A GP at the group had initially set up aheadache clinic for St Thomas patients who hadproblems with recurring headaches. This service wasthen extended, with patients now being referred from allover Devon, thus preventing the need for all patients tobe referred to the acute hospital. The GP hadundertaken extensive research and training. 304patients had been seen and treated in the last year. 45patients registered with the St Thomas Medical Groupwere seen at the Exeter Headache Clinic during the lasttwo years, thus saving them travelling across town tothe Hospital and reducing the amount of waiting time,which was of benefit to a patient suffering with chronicheadache, migraine, cluster headache etc.

• The group also provided a vasectomy clinic on a Fridayand on one Saturday morning each month for patientsand those within the wider community which hadproved popular with patients as it resulted in less timeaway from work. 268 patients had received this servicein 2017 helping reduce the number of unplannedpregnancies in the area.

Older people:

• All patients had a named GP who supported them inwhatever setting they lived, whether it was at home or ina care home or supported living scheme.

• The group was responsive to the needs of olderpatients, and offered home visits and urgentappointments for those with enhanced needs. The GPand practice nurse also accommodated home visits forthose who had difficulties getting to the group due tolimited local public transport availability.

• Care home staff and palliative patients had access to adirect telephone line for prompt access to the groupstaff.

Patients had access to volunteer services to reduce socialisolation and increase wellbeing.

People with long-term conditions:

Are services responsive to people’s needs?(for example, to feedback?)

Outstanding –


• Patients with a long-term condition received an annualreview to check their health and medicines needs werebeing appropriately met. Multiple conditions werereviewed at one appointment, and consultation timeswere flexible to meet each patient’s specific needs.

• The group held regular meetings with the local districtnursing team to discuss and manage the needs ofpatients with complex medical issues.

• The group volunteer drivers provided transport enablingpatients to visit the groups. Approximately 35 patientsbenefitted from using this service. This was provided bythree volunteers. The number of contacts per patientranged from two visits to the groups during the year toone patient who six months ago volunteers werebringing to see the nurse three times a week. During thelast couple of months two new drivers had joined theteam and meant the group could assist and additionalnine patients between the end of December and end ofJanuary.

• The group nursing team took part in a leg ulcer clinic atSt Thomas and a local community hospital. The serviceincluded an ABPI assessment (ankle brachial pressureindex assessment) to ensure the correct treatment isgiven. The service provided continuity for patients,decreased demand on community nursing staff andimproved communication between healthcareprofessionals and patients. Although the service wasfunded by a local enhanced service the group hadfurther developed the scheme by looking at andassessing chronic oedema (water retention causingswelling and skin complications). A total of 85 patientshad been seen at the leg clinic in the last two years and53 ulcers have healed through the effective treatmentprovided.

• The group participated in a CCG funded scheme wherecardiac monitoring was performed at the group andresults sent electronically to hospital for intervention.Three cardiac monitoring machines were availablewithin the groups. 26 patients had been given a cardiocall machine in the last twelve months which resulted inone patient being more promptly referred to secondarycare for ongoing treatment.

• The group offered an in-house rheumatology service. Inthe last year, 599 appointments were booked for 413patients meaning 413 secondary care referrals had beenavoided. 269 patients were given joint injections andjust three were referred on to the rheumatologydepartment at the hospital.

Families, children and young people:

• We found there were systems to identify and follow upchildren living in disadvantaged circumstances and whowere at risk, for example, children and young peoplewho had a high number of accident and emergency(A&E) attendances. Records we looked at confirmed this.

• All parents or guardians calling with concerns about achild under the age of 18 were offered a same dayappointment when necessary.

Working age people (including those recently retired andstudents):

• The needs of this population group had been identifiedand the group had adjusted the services it offered toensure these were accessible, flexible and offeredcontinuity of care.

• Telephone and web GP consultations were availablewhich supported patients who were unable to attendthe groups during normal working hours.

• The group used text messages to remind patients ofappointments, screening and vaccines to help reducenone attendance at appointments.

The group provided a personal medical service toapproximately 21,000 registered patients at the studenthealth centre based at Exeter University. There wereapproximately 7,000 new registrations every year with thenew student intake, with a corresponding de-registration ofstudent patients leaving. The practice manager told us thatthey had an efficient registration system which helpedencourage students to register with a GP group during theirstudies.

The majority of the student patients were physicallyhealthy. Approximately 50% of those student patients whoattended the groups did so as they were experiencing poormental health such as anxiety caused by exam stress andeating disorders. The group had responded to this bydeveloping close co-ordination with the University WellBeing Centre which was adjacent to the Student HealthCentre.

The group provided a mental health worker who workedfrom the Student Health Centre. We saw positive writtenfeedback from the Well Being Centre about the group.

The group maintained a risk register for student patientsconsidered at risk of suicide. There were presently 12students on this register. There had been three attempted


Outstanding –


suicides within the last 12 months. The group supportedthese patients through daily discussion of their cases,which was minuted, and appropriate actions put in place.The group had promoted an iPhone application which theypromoted to the student population. This provided healthand wellbeing guidance and signposting to relevantsupport services for mental health and other issues.

The mobile number of the on call duty GP at the group hadbeen provided to University staff, in order for them to becontacted in the event of a crisis. The group and theUniversity also had a reciprocal arrangement, with patientconsent, to access each other’s databases to find studentpatient’s contact details as mobile numbers and emailaddresses were frequently changed by the studentpopulation. This made it easier for the group to contact itspatients with reminders for appointments and otherrelevant information. Suitable data protection processeswere in place for this process.

Student patients registered with the student health centrecould obtain repeat prescriptions via a computer systemwhen they returned to their homes during end of termholidays The group were sometimes contacted by otherGPs outside of term time to review medicines andtreatment plans. This reduced the inconvenience topatients of having to register at their local groups duringthese holiday periods. The group had developed closeco-ordination with a local pharmacy which broughtmedicines to the group. This reduced the inconvenience ofpatients having to attend a pharmacy in person.

People whose circumstances make them vulnerable:

• The group held a register of patients living in vulnerablecircumstances including socially isolated patients andthose with a learning disability.

• One of the partners has been involved in setting up asocial prescribing project.

The group had recognised that there were a high numberof socially isolated patients within the service. As a resultthe group had responded by employing a volunteercoordinator who ran a proactive team of over 40 volunteerswithin the league of friends group. Together the volunteersoffered:

• A telephone service to ring lonely older adults every oneto two weeks to offer support.

• A full programme of social events during the week. Thegroup employed a coordinator and funds were raised by

a lottery, sales of tea and coffee each day at St Thomasand sale of knitted goods. Activities included a Mondayafternoon get together, monthly educational sessions,wine and cheese evenings, trips to garden centres,skittle evenings, knitting groups, lunch clubs, pamperingsessions, sitting service and memory café.

• The league of friends delivered medicines, arrangedfood and drink for people being discharged fromhospital and offered shopping services.

• DBS checks were performed on volunteers todemonstrate they were suitable to work on a one to onebasis with patients.

• The volunteers also offered a weigh in session at thegroup to support those who could not afford to attend aslimming clinic or wanted a more familiar environmentfor support.

The volunteer coordinator explained that the group wasconstantly attracting new members after they themselveshad been supported. For example, the recent friends of StThomas newsletter showed that eight new volunteers hadbeen recruited.

People experiencing poor mental health (including peoplewith dementia):

• Staff interviewed had a good understanding of how tosupport patients with mental health needs and thosepatients living with dementia.

• The group held GP led dedicated monthly mental healthand dementia clinics. Patients who failed to attend wereproactively followed up by a phone call from a GP.

• The group was registered as a dementia friendly group.Staff had raised awareness during dementia awarenessweek by having a non-uniform day, cake sales,introducing computer pop-ups alerting staff that thegroup was dementia friendly and staff raising funds for adementia charity by completing a cycle event.

• A memory café for patients with dementia and theircarers was held at St Thomas Health Centre and thevolunteers had created dementia friendly toys.

Timely access to the service

Patients were able to access care and treatment from thegroup within an acceptable timescale for their needs.

• Patients had timely access to initial assessment, testresults, diagnosis and treatment.

• Waiting times, delays and cancellations were minimaland managed appropriately.


Outstanding –


• Patients with the most urgent needs had their care andtreatment prioritised.

• The appointment system was easy to use.

Results from the July 2017 annual national GP patientsurvey showed that patients’ satisfaction with how theycould access care and treatment was comparable to localand national averages, with the exception of gettingthrough on the telephone which scored considerably lower.There had been three telephone systems in place. One atthe university, one at Exwick Health Centre and one at StThomas Health Centre.

Survey results from the July 2017 showed:

• 76% of patients who responded were satisfied with thegroup’s opening hours compared with the clinicalcommissioning group (CCG) average of 79% and thenational average of 76%.

• 58% of patients who responded said they could getthrough easily to the group by phone; CCG – 82%;national average - 71%. A new telephone system withunlimited lines and overflow system had recently beenfitted and improvements had been noted.

• 88% of patients who responded said that the last timethey wanted to speak to a GP or nurse they were able toget an appointment; CCG - 90%; national average - 84%.

• 81% of patients who responded said their lastappointment was convenient; CCG - 88%; nationalaverage - 81%.

• 71% of patients who responded described theirexperience of making an appointment as good; CCG -82%; national average - 73%. A new telephone hasrecently been fitted and improvements had been noted.

• 64% of patients who responded said they don’tnormally have to wait too long to be seen; CCG - 65%;national average - 58%.

The practice manager had been aware of patientdissatisfaction at this time and thought this was whenthere had been a time of great change for patients. Forexample, patients had been unhappy with the use of anineffective telephone system. Since this survey a newtelephone system has been installed resulting in anunlimited number of telephone lines available. Call takingwas accessible from all sites along with an “overflow”system in place, where calls could be answered by staffmembers from other teams and not just reception staff.

The practice manager added that there had also been theretirement/departure of five long service GPs, who hadsubsequently been replaced.

The group had seen an increase in patient satisfactionsince these results findings and were monitoring this. Forexample;

• Since the new telephone system had been introducedthere had been no further complaints about gettingthrough on the telephone or being kept waiting on thecall.

• The PPG (Patient participation group) had been askedto carry out a further internal survey in September 2017including requesting information about access toappointments. This showed that 56 of the 59respondents were happy with the service they receivedincluding satisfaction with telephone access.

The friends and family test results had been kept underreview to monitor patient satisfaction. Results for theperiods of November 2017 to January 2018 weresignificantly higher in regard of patient satisfactioncompared to November 2016 to January 2017. There hadbeen no negative comments regarding the telephonesystem since its introduction. Test results showed:

• There had been no changes in the university telephonesystem. This patient group were used as a control andshowed that the percentages of patients likely orextremely likely to recommend the practice rangedbetween 89% and 91% between November 2016 andJanuary 2017 and then 82% and 96% betweenNovember 2017 to January 2018.

• At Exwick Health Centre the percentages of patientslikely or extremely likely to recommend the practicebetween November 2016 and January 2017 had rangedbetween 26% and 80% but had improved to 80% and94% between November 2017 to January 2018.

• At St Thomas Health Centre (which included thePathfinder village patients) the percentages of patientslikely or extremely likely to recommend the practicebetween November 2016 and January 2017 had rangedbetween 53% and 66% and had improved to between79% and 80% during November 2017 to January 2018.

The group were monitoring the calls received and thenumber of call that were abandoned by patients which


Outstanding –


could indicate dissatisfaction with waiting on the line. Forthe period of October 2017 and November 2017 there hadbeen approximately 44,000 calls over the two months withjust nine unanswered or abandoned calls.

We spoke with five patients at Exwick and St ThomasHealth Centre about the telephone system. Patients told usthe difficulty they had experienced before was no longer anissue.

All of the 46 patient Care Quality Commission commentcards we received were positive about the serviceexperienced. There were no negative comments aboutaccess to services or the telephone system.

Listening and learning from concerns and complaints

The group took complaints and concerns seriously andresponded to them appropriately to improve the quality ofcare.

• Information about how to make a complaint or raiseconcerns was available and it was easy to do. Staff

treated patients who made complaintscompassionately. We spoke with a patient who hadmade a complaint. They told us it had been handledpromptly and efficiently with a satisfactory outcome.They added that staff appeared ‘delighted’ to getfeedback despite it being negative.

• The complaint policy and procedures were in line withrecognised guidance. We reviewed 14 complaints andfound that they were satisfactorily handled in a timelyway.

• The group learned lessons from individual concerns andcomplaints and also from analysis of trends. It acted asa result to improve the quality of care. For example,there had been numerous complaints about thetelephone system and patients not getting through onthe telephone system. The group had subsequentlyintroduced a new telephone system and no furthercomplaints had been received.


Outstanding –


Our findingsWe rated the group, and all population groups, asoutstanding for providing a well-led service.

The practice was rated as outstanding for providingresponsive services because:

• The strategy and supporting objectives were stretching,challenging and innovative, while remaining achievable.

• A systematic approach was taken to working withvoluntary groups and other organisations to improvecare outcomes, tackle health inequalities, reduce socialisolation and obtain best value for money.

• Governance and performance managementarrangements were proactively reviewed and reflectedbest practice.

• Leaders had an inspiring shared purpose, strive todeliver and motivate staff to succeed.

• There were high levels of staff satisfaction. Staff areproud of the organisation as a place to work and speakhighly of the culture. There were consistently high levelsof constructive staff engagement and staff at all levelswere actively encouraged to raise concerns.

• There was strong collaboration and support across allstaff and a common focus on improving quality of careand people’s experiences.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality,sustainable care.

• Leaders had the experience, capacity and skills todeliver the group strategy and address risks to it. Staffsaid they felt well led and part of a team.

• The practice managers, senior management team andGP partners were knowledgeable about issues andpriorities relating to the quality and future of services.They understood the challenges and were addressingthem.

• Leaders at all levels were visible and approachable. Staffsaid the practice manager and deputy practicemanagers ‘walked the floor’ and providedencouragement and support. Leaders worked closelywith staff and others to make sure they prioritisedcompassionate and inclusive leadership.

• The group had effective processes to develop leadershipcapacity and skills, including planning for the futureleadership of the group.

• There was strong collaboration and support across allstaff and a common focus on improving quality of careand people’s experiences. The partners had recognisedthat the large organisation could affect communicationand staff morale. As a result the partners had introduceda structured programme of meetings and methods ofcommunicating with all staff and had fostered aninclusive team culture. This included weekly staffbulletins, emails and instant messaging. Staff saidcommunication was very good within the group.

• GPs met at each site daily to discuss any complex cases,offer and receive support and allocate home visits.

Vision and strategy

The group had a clear vision and credible strategy todeliver high quality care and promote good outcomes forpatients. Staff had been involved in this process and wereproud of the care they provided.

• There was a clear vision and set of values. The grouphad a realistic strategy and supporting business plans toachieve priorities. These were kept under review andupdated on a regular basis during the structuredbusiness meetings.

• The group developed its vision, values and strategyjointly with patients, patient participation group andexternal partners.

• Staff were aware of and understood the vision, valuesand strategy and their role in achieving them. Staffadded that the clear lines of accountability and teamresponsibilities had helped staff take ownership of thepart they played in delivering the strategy.

• The strategy was in line with health and social prioritiesacross the region. The group planned its services tomeet the needs of the group population.

• The group monitored progress against delivery of thestrategy.

Culture

The group had a culture of high-quality sustainable care.

• There were high levels of staff satisfaction. There wereconsistently high levels of constructive staff engagementand were actively encouraged to raise concerns. Staffsaid they were happy, staff turnover was low and thatthe organisation was a good place to work. Staff told ustheir line managers were supportive, approachable and

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

Outstanding –


that they felt respected, supported, valued and proud towork in the group. Staff said the leadership inspiredthem to deliver the best care and motivate them tosucceed.

• The group focused on the needs of patients. Stafffeedback and suggestions focussed on how to make theprocesses more streamlined and efficient and improvedcare for patients. For example, staff had suggestedextending the length of some appointments so patientswere not rushed. This was implemented and staff wereencouraged to use their discretion where this wasneeded.

• Leaders and managers acted on behaviour andperformance inconsistent with the vision and values.

• Openness, honesty and transparency weredemonstrated when responding to incidents andcomplaints. Staff said this openness came from theleadership team who were transparent when they hadmade errors or were open to suggestions regarding theirclinical decisions. The provider was aware of and hadsystems to ensure compliance with the requirements ofthe duty of candour.

• Staff we spoke with told us they were able to raiseconcerns and were encouraged to do so. They hadconfidence that these would be addressed.

• There were processes for providing all staff with thedevelopment they need. This included appraisal andcareer development conversations. All staff receivedregular annual appraisals in the last year. Staff weresupported to meet the requirements of professionalrevalidation where necessary.

• Clinical staff, including nurses, health care assistantsand paramedic, were considered valued members of thegroup team. They were given protected time forprofessional development and evaluation of theirclinical work.

• There was a strong emphasis on the safety andwell-being of all staff. Staff told us there was recognitionof positive staff performance and shared mutualsupport for all staff. Staff added that the practicemanager, deputy practice manager and leadership teamwere visible and took an interest in staff well-being bothwithin the organisation and outside.

• The group actively promoted equality and diversity. Itidentified and addressed the causes of any workforceinequality. Staff had received equality and diversitytraining. Staff felt they were treated equally.

• There were positive relationships between staff andteams. Staff said there were clear boundaries but nohierarchy and added they felt part of a team.

Governance arrangements

There were clear responsibilities, roles and systems ofaccountability to support good governance andmanagement. Governance and performance managementarrangements were proactively reviewed and reflected bestgroup.

• Structures, processes and systems to support goodgovernance and management were clearly set out,understood and effective. The governance andmanagement of partnerships, joint workingarrangements and shared services promoted interactiveand co-ordinated person-centred care.

• Staff said there were clear lines of accountability andthey, individually, were clear on their roles andaccountabilities including in respect of safeguarding,prescribing, student health, minor surgery and infectionprevention and control. All GPs held a lead in an area ofmedicine and responsibilities within the group.

• Group leaders had established proper policies,procedures and activities to ensure safety and assuredthemselves that they were operating as intended. Thesehad been extended to ensure they reflected the servicesoffered. For example, new policies for ADHD (Attentiondeficit hyperactivity disorder), eating disorders andgender dysphoria.

• Leaders were aware that communication could be apotential issue in an organisation of over 110 staffacross four sites so had responded by ensuring therewas a clear management structure, departmental leads,regular schedule of meetings and different ways ofdisseminating information. This included weekly staffbulletins, emails and instant messaging. Staff saidcommunication was very good within the group.

• The schedule of meetings included bimonthlyeducational meetings, monthly business partnershipmeetings, weekly management meetings, salaried GPmeetings, strategy away days, whole practice groupmeetings, departmental meetings and GP meetings.

• The practice manager sent a weekly newsletter for staffand used additional emails to communicate to the staffteam.

Managing risks, issues and performance


Outstanding –


There were clear and effective processes for managingrisks, issues and performance.

• Staffing and succession planning was proactivelymanaged with short, medium and long term systems inplace. Staff rotas were monitored and effective buddysystems were in place to cover for expected andunexpected staff absence. For example, the leadershipteam told us how they had ‘over doctored’ to providehigher than required GP levels to cover for annual leave,sickness and staff absences. This was done to reducethe need for locums and also provided more continuityfor patients.

• Succession planning was also monitored closely for oneto two years, three to five years and then ten years. Thishad resulted in staff development. For example,reception staff being offered phlebotomy training.Overall this approach had resulted in better retention ofstaff and a clear timeline of recruitment helping reducegaps in service provision.

• There was an effective, process to identify, understand,monitor and address current and future risks includingrisks to patient safety.

• The group had processes to manage current and futureperformance. Performance of employed clinical staffcould be demonstrated through audit of theirconsultations, prescribing and referral decisions. Groupleaders had oversight of MHRA alerts, incidents, andcomplaints.

We looked at 14 clinical audits and four full cycle audits.Clinical audit and service quality audits were seen as a highpriority at the group and had a positive impact on quality ofcare and outcomes for patients. All members of the teamwere encouraged and supported to monitor and identifywhere changes were needed. For example, nursing staffhad been supported to review diabetic services, theprescribing team were encouraged to look at systems usedand volunteer coordinators had been supported to look atthe numbers of carers identified and consider ways toimprove numbers.

Staff explained that the leadership team had developed apositive culture of change and added that reviews, auditsand monitoring was not ‘taken over’ by the leadershipteam but delegated with full support and guidance andsupport where required. Staff said the service was one that

never stopped looking for ways to improve and develop.Staff added that the leaders inspired change and ensureswork distribution was fair and well identified. Staff addedthat praise was given when changes were made.

There was clear evidence of action to monitor and changepractice to improve quality.

• The nursing team were supported and encouraged totake part in reviews, reflection and audits of services. Forexample, a reflection of the nurse led diabetic annualreview clinics had been carried out. The first review of234 clinics showed positive outcomes for patients. Thesecond review showed continued positive clinicaloutcomes for patients and an increase of just under 50%in patients attending these clinics.

• The group had plans in place and had trained staff formajor incidents.

• The group implemented service developments andwhere efficiency changes were made this was with inputfrom clinicians to understand their impact on the qualityof care.

Appropriate and accurate information

The group acted on appropriate and accurate information.

• Performance information was combined with the viewsof patients. The Patient Participation Group (PPG)representatives said they were considered a criticalfriend and any views shared were acted on positively bythe leadership team.

• Quality and sustainability were discussed in relevantmeetings where all staff had sufficient access toinformation. Staff who were retiring were included in therecruitment and selection procedures of theirsuccessors.

• The group used performance information which wasreported and monitored and management and staffwere held to account if appropriate. For example,prescribing and referral patterns.

• The information used to monitor performance and thedelivery of quality care was accurate and useful. Therewere plans to address any identified weaknesses.

• The group used information technology systems tomonitor and improve the quality of care. For example,using clinical templates embedded within the computersystem; providing online services and developingsmartphone Apps to keep patients informed.


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• The group submitted data or notifications to externalorganisations in a timely way as required.

• There were arrangements in line with data securitystandards for the availability, integrity andconfidentiality of patient identifiable data, records anddata management systems.

Engagement with patients, the public, staff andexternal partners

The group involved patients, the public, staff and externalpartners to support high-quality sustainable services.

• A full and diverse range of patients’ and externalpartners’ views and concerns were encouraged, heardand acted on to shape services and culture. Forexample, patients from the Pathfinder had requestedadditional GP services. A consultation event was heldwith over 100 patients from the village. The leadershipteam negotiated with the 400 patients located in thevillage to provide a service that was acceptable to thembut financially viable for the group.

• Negative feedback from patients about the telephonesystem had resulted in a new system which hadimproved telephone access.

• Feedback from staff was also valued by the leadershipteam. For example, staff had requested a consultationabout pay which had been implemented. The medicalsecretaries’ team had been based in a separate locationto the Student Health Centre and had requested they berelocated inside the group. This had been implementedand the staff felt valued and listened to.

• There was an active patient participation group (PPG) ofapproximately 80 patients, six of whom attended theface to face meetings more regularly. The group inconjunction with other PPGs in the area had providededucational talks for patients on sleep disturbances,foot health and anxiety which had been attended by 40patients. The PPG had also conducted a patient surveyand had contributed to changes in signage, the queuingsystem at St Thomas Health Centre and had influencedthe change in the telephone system. The PPG members

worked with other PPGs in the local area to share ideasand provide support to patients. PPG representativessaid the group staff had been supportive and responsiveto suggestions for change.

• The service was transparent, collaborative and openwith stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuousimprovement and innovation.

• There was a focus on continuous learning andimprovement at all levels within the group. For example,the group held a structured educational programmeand protected learning times for all staff.

• The GPs based at the University Health Centre were partof the international student health association andattended annual conferences (including one in Japan)to update knowledge of guidelines. One of the GPs hadbeen a president of this organisation and was now atreasurer. In between conferences the GPs communicatewith colleagues to discuss themes and complex cases toimprove outcomes for foreign students.

• Staff knew about improvement methods and had theskills to use them.

• The group made use of internal and external reviews ofincidents and complaints. Learning was shared andused to make improvements.

• Leaders and managers encouraged staff to take time outto review individual and team objectives, processes andperformance.

• A GP partner at the university student health centre gavean annual talk on NHS services to internationalstudents. The talk included information on NHS servicesavailable, prescription costs, how to access routine andemergency care, vaccines, advice on how to stay healthyand how to use the student health care app.

• The group functioned as research practices and wererecruiting for five studies at present including an earlyarthritis study, weight management and research intodementia.


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St Thomas Medical Group

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