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Dr Miles Davidson Good Also known as Stubley Medical Centre

Inspection Summary


Overall summary & rating

Good

Updated 24 November 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Miles Davidson on 14 October 2015. During that inspection we found that a disclosure and barring service (DBS) check had not been obtained for certain staff who acted as chaperones. Also, the practice had not obtained all employment checks required by law in regards to four staff files we checked. 

Overall the practice was rated as good with are services safe requiring improvement in view of the above. After the comprehensive inspection, the practice wrote to us to say what action they had taken to meet the legal requirement in relation to the above breach.

We undertook this desk based review on 21 October 2016 to check that the provider had completed the required improvements, and now met the legal requirement. We did not visit the practice as part of this inspection.

This report only covers our findings in relation to the above requirement. You can read the report from our last comprehensive inspection, by selecting the 'all reports' link for Dr Miles Davidson on our website at www.cqc.org.uk.

Our finding across the area we inspected was as follows:

  • The practice had taken appropriate action to meet the legal requirement.
  • The chaperone policy had been updated to require that an appropriate Disclosure and Barring Service (DBS) check is obtained for all staff who act as a chaperone.

  • Effective recruitment procedures were in place to ensure the required employment checks and information is obtained prior to staff

    working at the practice.

  • The practice had obtained an appropriate Disclosure and Barring Service (DBS) check for all staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 24 November 2016

The practice is rated as good for providing safe services.

  • The chaperone policy had been updated to require that an appropriate Disclosure and Barring Service (DBS) check is obtained for all staff who act as a chaperone.
  • Effective recruitment procedures were in place to ensure the required employment checks and information is obtained prior to staff working at the practice.
  • The practice had obtained an appropriate Disclosure and Barring Service (DBS) check for all staff. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles, where they may have contact with vulnerable children or adults).

Effective

Outstanding

Updated 17 December 2015

The practice is rated as outstanding for providing effective services.

Data showed patient outcomes were generally above average for the locality. The practice had achieved 99.5% in the Quality and Outcomes Framework (QOF) for 2013-14. QOF data showed that outcomes for patients were good for conditions such as rheumatoid arthritis, osteoporosis and coronary heart disease. The practice had achieved 100% of the available points in all of these areas which was above both the CCG and national averages.

Staff had access to National Institute for Health and Care Excellence (NICE) and local guidance and patient pathways of care. There was a process for keeping updated on new and revised guidance.

The practice could demonstrate the effectiveness of its work by the low use of Accident and Emergency (A&E) and the out of hours’ service. Figures for 2014-15, showed that out of hours’ practice contacts were 141 per 1000 population, compared to the CCG figure of 214.

Emergency hospital admission data over a three year period for patients aged over 65 showed the practice to consistently have one of the lowest percentages in the CCG despite the fact that it has a higher number of patients in this age group with accompanying high disease prevalence. Due to the expertise developed in mental health, the practice had the joint lowest rate of adult mental health emergency admissions in the CCG. Data observed over the last three years demonstrated that this was an ongoing achievement.

The role of the champion for frail and older patients ensured that those identified at risk had access to rapid support from the practice and a range of community and voluntary services. There was evidence to support this role had helped reduced emergency hospital admissions and attendance at out of hours’ services.

Patients’ needs were assessed and care was planned and delivered in line with current legislation. This included assessing capacity and promoting good health. GPs had lead areas of responsibility such as prescribing, and provided support and advice to the rest of the team. Staff had received training appropriate to their roles and any further training needs had been identified and appropriate training planned to meet these needs. There was evidence of appraisals and personal development plans for all staff, and these were aligned to practice objectives. Staff routinely worked with multidisciplinary teams including pharmacy and the district nursing and health visiting teams to enhance patient care and outcomes. There was evidence of completed clinical audit cycles and these were used to improve outcomes for patients.

Caring

Good

Updated 17 December 2015

The practice is rated as good for providing caring services.

We observed a patient-centred culture. The practice team were motivated and inspired to offer kind and compassionate care. We found many positive examples to demonstrate how patient’s valued the care given by the practice. For example, the last GP survey results showed that 98% said the last nurse they spoke to was good at treating them with care and concern compared to the CCG average of 93% and the national average of 90%.

There was a proactive approach to the identification of carers and directing them to sources of support. Bereaved relatives were supported and a representative of the practice tried to attend the funeral when a patient had died.

Patients and representatives of the Patient Participation Group we spoke with valued the support given by the practice team and felt that patients received high quality care. We spoke with staff from other services who unanimously told us that the practice offered a very caring and highly supportive approach with their patients.

Responsive

Good

Updated 17 December 2015

The practice is rated as good for providing responsive services.

The practice had excellent facilities and was well equipped to treat patients and meet their needs. It was fully accessible to patients with a disability and accommodated for the needs of all patient groups including a designated children’s play area.

Some of the feedback received from patients reported that access to a named GP and continuity of care was not always available quickly, although urgent appointments were available the same day. The practice had a triage system in place to identify those requiring an urgent consultation, but we observed that the average wait for a routine appointment was between two and three weeks. There were no extended hours’ surgeries to accommodate those who may find it difficult to get to the practice during normal working hours.

Information about how to complain was available although this was not easily accessible. There were no complaints leaflets available and no information on the website regarding how to make a complaint. Verbal complaints were not always recorded. However, the practice responded in a timely and sensitive manner to complaints and there was evidence of learning from the written complaints that had been received.

Well-led

Good

Updated 17 December 2015

The practice is rated as good for being well-led.

It had developed practice specific objectives and ensured that staff were aware of these by incorporating them into the annual appraisal process. Staff understood their responsibilities and worked as a team to achieve good outcomes. There was a clear leadership structure and staff told us that they were supported by management.

The practice had a number of policies and procedures to govern activity and held regular meetings. The meetings were not always documented to provide a record of discussions and highlight actions to be undertaken. There were systems in place to monitor and improve quality and identify risk but these had not always enabled the provider to identify assess and mitigate risk; for example in respect of having safe recruitment procedures.

There was an active patient participation group (PPG) which worked with the practice and helped with events such as the annual flu campaign. The PPG had influenced changes in the practice, for example, a review of incoming telephone calls leading to a re-design of the automated process thereby reducing telephone answering times. The practice had established good links with other local practices and worked well with them. Staff had received inductions and performance reviews, and regularly attended events organised by their CCG.

Checks on specific services

Older people

Good

Updated 17 December 2015

The provider was rated as good for this population group.

The practice had 28.7% of their registered patients aged over 65 compared against a national average of 16.7%, and they had adapted their services to accommodate this need.

A practice nurse was designated as a champion for frail and elderly patients. The nurse chaired a fortnightly multi-disciplinary meeting to review at risk patients or those with complex needs. A dedicated telephone number was available for identified older patients to contact the nurse for advice and support. These patients were allocated an urgent appointment slot if they needed to see the GP.

The nurse visited the patients at home if they were unable to attend the surgery. Home visits were incorporated into the flu vaccination programme and this was used as an opportunity to review whether sufficient support services were in place to support that person in their home. Reception staff were able to identify any at risk patients who called the practice by an icon marked on their records, enabling responsive action to be taken promptly. This work contributed to the practice’s avoidance of hospital admission work and we observed data that this targeted work had reduced emergency admissions. Hospital admissions including A&E attendances, routine day case appointments and acute stays between April–September 2014 was 180, and for the same period in 2015, this had reduced to 131.

Emergency hospital admission data over a three year period for patients aged over 65 showed the practice to consistently have one of the lowest percentages in the CCG despite the fact that it has a higher number of patients in this age group with accompanying high disease prevalence.

Care plans were under development with a target to provide a written plan for all over 75s with by the end of March 2016. An annual safety net audit was undertaken for patients over 75 to identify anyone who had not made contact with the practice so they could be followed up.

Referrals were made to other services when appropriate, such as the community falls service. Patients were also signposted to voluntary organisations including the Stroke Association and befriending services.

A health care assistant (HCA) ran a wound management clinic and communicated with the tissue viability service when this was indicated. The HCA also contributed to the anti-coagulation service provided as part of an additional enhanced service, enabling patients taking Warfarin to be monitored by the practice.

Data showed that flu vaccination rates for patients over 65 at 80.06% exceeded the national average of 73.24%. The practice offered a range of enhanced services including end of life care and dementia.

People with long term conditions

Good

Updated 17 December 2015

The provider was rated as good for this population group.

Due to the high numbers of older people registered at the practice, there was a high prevalence of patients with long term conditions. For example the prevalence of hypertension at 18.82% was 2.5% above the CCG average and 5.09% above the national average.

Patients at risk of hospital admission or those who had been recently discharged were identified as a priority and discussed as part of the fortnightly multi-disciplinary meeting. For those people with the most complex needs, a clinician worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Written care plans were established for all patients with a diagnosis of diabetes and those with severe chronic lung disease as part of the hospital admissions avoidance work. Longer appointments and home visits were available when needed. All these patients had a structured annual review to check that their health and medication needs were being met.

The practice had developed a joint care plan booklet for patients with type II diabetes. This listed appointment dates and allocated a specific annual review month. The plan gave basic information about diabetes and the common types of medication used. It also recorded the last recorded weight, blood pressure and HbA1c (an indication of blood sugar levels) including a target figure. Additionally, the plan signposted patients to websites and a self-help course. The booklet was retained by patients for reference.

Newly diagnosed patients with diabetes were referred into two half day externally facilitated programmes run by a dietician and a diabetes specialist nurse to educate them on managing their condition. Feedback received from patients had been very positive following their attendance.

Remote monitoring of hypertension was undertaken to enable self-management and prevent patients having to attend the practice unnecessarily. The patients submitted their blood pressure readings at agreed intervals for monitoring.

Families, children and young people

Good

Updated 17 December 2015

The practice was rated as good for families, children and young people.

The co-location of the health visiting team in the same building facilitated fast and regular communication on any issues relating to children living in disadvantaged circumstances. Evidence could not be provided to demonstrate that planned and documented meetings took place to review patients where safeguarding concerns had been highlighted. However, we were assured that effective liaison took place with others in order to safeguard children effectively, and this was confirmed in discussion with the health visitor.

Immunisation rates were high for all standard childhood immunisations. For example, immunisation rates for five year olds ranged from 98-100% which was slightly above the national average. Appointments were available outside of school hours. We spoke with the midwife during our visit who ran a weekly clinic at the practice and she told us that the GPs were always available for advice and support if needed.

The practice accounted for the needs of mothers and young children and had a designated play area for children with a television screen at low level showing children’s programmes. Breast feeding facilities were available on site.

Information was displayed regarding how young carers could access support services.

Working age people (including those recently retired and students)

Requires improvement

Updated 17 December 2015

The practice was rated as requires improvement for working age people (including those recently retired).

The services available did not fully reflect the needs of this group. The practice did not offer extended opening hours for appointments, and closed after 1pm on Wednesdays. Telephone appointments were available from 8.30am but no face to face consultations were available until 9am on four days of the week. Appointments were available at 8.30am one day/week and the practice planned to introduce this on a second day in the near future.

Results from the national GP patient survey showed that patient’s satisfaction with how they could access care and treatment was below local and national averages. Some people we spoke to during the inspection, and some of the responses provided on comment cards, stated patients found it difficult to get appointments when they needed them. For example, 53% patients said they felt they normally have to wait too long to be seen compared to the CCG average of 63% and a national average of 58%.

Patients could order repeat prescriptions online, and the practice was trying to encourage greater uptake of this service. Online appointments could be booked but this was limited to six appointments per GP available each week. Health promotion advice was offered and there was some health promotion material available through the practice. Patients could request any additional information to be printed out at reception.

People whose circumstances may make them vulnerable

Good

Updated 17 December 2015

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

The practice held a register of patients living in vulnerable circumstances including those with a learning disability. It had carried out annual health checks for people with a learning disability and 78% of these patients had been seen so far this year. The remaining patients were proactively being followed up to encourage their attendance. The practice offered longer appointments for people with a learning disability. Patients who had been in hospital were contacted by telephone on their return home to check if they were managing sufficiently.

Patients who may be vulnerable were identified and followed up appropriately. For example, the nurse informed us about a frail patient with a diagnosis of dementia who attended the practice. A home visit was arranged to review any additional support they required and this was subsequently arranged to keep the patient safe within their own home.

The prevalence of cancer was high at 4.88% which was approximately 2.5% above the CCG and national average, and this was due to the numbers of older patients registered at the practice. Patients needing end of life care were discussed with the district nursing team and Macmillan nurses. Systems were in place to meet patient needs including special patient notes (which enable out of hours providers to obtain key information about the patient) and just-in-case boxes (anticipating symptom control needs and enabling the availability of key medications in the patient’s home if required).

There were lower rates of emergency cancer admissions at 5.56 per 100 patients on the disease register compared to the expected value of 7.45, demonstrating the effectiveness of the approach taken with cancer patients.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. It had told vulnerable patients about how to access various support groups and voluntary organisations. Staff knew how to recognise signs of abuse in vulnerable adults and children, and were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.

People experiencing poor mental health (including people with dementia)

Good

Updated 17 December 2015

The practice was rated as good for people experiencing mental health (including people with dementia).

The practice scored 100% QOF achievement on mental health indicators which was 2.3% above the CCG average and 9.6% above the national average.

83% of people experiencing poor mental health had received an annual physical health check, and the practice were attempting to engage with the outstanding patients to increase this figure. The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. Work was in progress to develop formal care plans for patients with dementia, although RightCare plans were in place to provide essential patient information for the out of hours’ provider. The practice carried out advance care planning for patients with dementia, and staff understood the application of principles from the Mental Capacity Act.

Signposting information for carers of patients with a mental health problem was available. A support programme for patients with dementia and their carers was displayed in the reception area.

One GP was a qualified cognitive behavioural therapist and saw many of the patients with mental health difficulties, and acted as a resource for the rest of the team with regards any queries.

Due to the expertise developed in mental health, the practice had the joint lowest rate of adult mental health emergency admissions in the CCG. Data observed over the last three years demonstrated that this was an ongoing achievement. The practice also had a low referral rate to community mental health services and had low prescribing rates for anti-depressant and tranquiliser medications.

The practice had told patients experiencing poor mental health about how to access support groups and voluntary organisations. Patients were referred or could self-refer to talking therapies as part of the Improving Access to Psychological Therapies (IAPT) programme for those with mild to moderate conditions including anxiety and depression which may occur due to their long standing health issues. Information on support services was available in the waiting area.

All staff had received training on dementia awareness in August 2014. All three GPs had attended mental health training in the last 18 months including topics on partnership working and prescribing for mental health problems.