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Inspection Summary


Overall summary & rating

Outstanding

Updated 16 July 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Neetside Surgery on 6 January 2015. This was a comprehensive inspection. The practice is based at Neetside Surgery and provides primary medical services to people living in the town of Bude and surrounding villages in Cornwall. The practice GPs have sole responsibility for managing 11-16 inpatient beds at Stratton Community Hospital. The practice provides services to a diverse population, covering an area of approximately 50 square miles.

At the time of our inspection there were 4,300 patients registered at the service with a team of two GP partners and two salaried GPs. Neetside Surgery is a training practice. When we inspected there were no students on GP training placements at the practice.

Patients who use the practice have access to community staff including district nurses, community psychiatric nurses, health visitors, physiotherapists, mental health staff, counsellors, chiropodist and midwives.

Overall the practice is rated as Outstanding.

Specifically, we found the practice to be good for providing safe, caring and well led services. We found the practice to be providing outstanding services in respect of being effective and responsive. It was outstanding for providing services to older people, people with long term conditions and people with mental health needs including dementia. The practice was good for families, babies children and young people and working age and vulnerable people.

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

  • There was a strong commitment to providing well co-ordinated, responsive and compassionate care for patients. A named GP and nurse monitored the health and well being of vulnerable patients with a learning disability and/or complex mental health needs. Patient reviews were routinely carried out in their own homes, some of the patients lived in care homes in the local area. This promoted a trusting rapport with patients and had increased patient involvement in the management their health and well being. Practice nurses also routinely visited vulnerable patients in their homes to review and deliver care to them because they were too frail to attend the practice
  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care. Urgent appointments were available the same day and staff were flexible and found same day gaps for patients needing routine appointments.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Audits were used by the practice to identify where improvements were required. Action plans were put into place, followed through and audits repeated to ensure that improvements had been made.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw areas of outstanding practice including:

  • The practice was responsive to patients needs in providing a flexible and extended service for the whole population. For example, equipment been had obtained to provide greater access to health monitoring. This included a centrifuge, which had increased the lifespan of blood samples so that patients did not have to travel for up to five hours on public transport to the local hospital. In the summer months the demand on the practice could increase by a third at the height of summer, with over a 500 temporary patients, as Bude is a popular holiday resort. The practice strived to ensure that the services provided to patients was not affected by the seasonal impact of the influx of patients.

  • The practice takes a truly holistic approach to assessing, planning and delivering care and treatment to people who use services. For example, the practice supported a high percentage of patients needing palliative care support due to the remote setting, overseen by a GP partner who holds qualifications and has extensive experience in the field.

  • All staff were actively engaged in activities to monitor and improve quality and health outcomes for people. For example, data showed the percentage of patients with diabetes who had reviews was better than the national average at 93.3% compared with 77.7%. The practice provided patients with an insulin passport, which contained comprehensive information about how to safely manage this condition and maintain good health. Retinal eye screening was being held at the practice each year to reduce the risk for patients in developing diabetic retinopathy.

  • Staff were consistent in supporting people to live healthier lives through a targeted and proactive approach to health promotion and prevention of ill health. For example, during an audit of patients on anticlotting medicines the practice identified a number of factors influenced blood results.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 16 July 2015

The practice is rated as good for providing safe services.

Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons were learned and communicated widely to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed. Risks to patients were assessed and well managed. There were enough staff, and recruitment practices ensured that staff were fit to work at the practice or safe to carry out chaperone duties.

Effective

Outstanding

Updated 16 July 2015

The practice is rated as outstanding for providing effective services.

Data showed patient outcomes were at or above average for the locality. Staff referred to guidance from National Institute for Health and Care Excellence and used it routinely. The practice takes a truly holistic approach to assessing, planning and delivering care and treatment to people who use services. This included assessing capacity and promoting good health. Staff were consistent in supporting people to live healthier lives through a targeted and proactive approach to health promotion and prevention of ill health.

Neetside is a training practice and the quality of training and support provided for trainee GPs and doctors was rated highly by the deanery. Staff had received training appropriate to their roles and encouraged to extend these with 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. Staff worked with multidisciplinary teams, which included strong links with other health and social care professionals supporting patients at the end of their lives.

Caring

Good

Updated 16 July 2015

The practice is rated as good for providing caring services.

Data showed patients rated the practice higher than others for some aspects of care. Twenty eight CQC comments cards reviewed and discussion with eleven patients on the day all provided positive feedback. A common theme was that the staff were extremely person-centred and patients were always treated with respect and compassion. This was borne out in the way staff engaged with patients with complex communication needs and frailty due to age and/or health conditions. Patients told us that staff went the extra mile.

Staff we spoke with were aware of the importance of providing patients with privacy. Information was available to help patients understand the care available to them.

Responsive

Outstanding

Updated 16 July 2015

The practice is rated as outstanding for providing responsive services.

The practice was responsive to patients needs in providing a flexible and extended service for the whole population.  For example, equipment been had obtained to provide greater access to health monitoring. Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. The impact of a large number of temporary residents during the summer months was lessened for patients by increasing the availability of staff during this period. The practice had good facilities and was well equipped to treat patients and meet their needs. Patients told us the staff went beyond what was expected of them and we saw many examples of this.  Information about how to complain was available and easy to understand and evidence showed that the practice responded quickly to issues raised. Learning from complaints with staff and other stakeholders was reviewed and acted upon.

Well-led

Good

Updated 16 July 2015

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

The practice had a clear vision and strategy, which inspired the team to have a shared purpose of providing high quality care. There was a clear leadership structure and staff felt supported by management to develop and extend their skills to achieve this. There were systems in place to monitor and improve quality and identify risk. The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group (PPG) was active. Staff had received inductions, regular performance reviews and attended staff meetings and events.

Checks on specific services

Older people

Outstanding

Updated 16 July 2015

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

The practice was directly involved in a pilot with Stratton Medical Centre to develop integrated care services by working together with voluntary, health and care services to offer a combination of medical and non-medical support. This included a volunteer led befriending service for vulnerable people. It was too early in this process to determine the impact this might have for patients at the practice.

The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example, in dementia and end of life care. There was a strong commitment to providing well co-ordinated, responsive and compassionate care for patients nearing the end of their lives. Innovative approaches were used, such as the use of aromatherapy to enhance patient well being.

Nationally reported data showed that outcomes for patients exceeded expectations for conditions commonly found in older people. For example, 100% compared with the national average of 81.3% of patients aged 75 or over with a fragility fracture were treated with an appropriate bone-sparing agent.

Patients were experiencing proactive management of emergency and short term pain relief medicine by reviewing this with the patient at intervals suited to their individual needs.

Patients with complex care needs were well monitored by the practice working in partnership with other agencies. The staff were responsive to the needs of older people, and offered GP home visits and rapid access appointments for those with enhanced needs. Practice nurses were also routinely doing home visits to vulnerable frail patients where needed to deliver treatments and care, which could not be provided by the community nursing team. For example, practice nurses had the experience and qualifications to perform specific examinations and treatments for older women and had arranged to see a patient at home on the day of the inspection.

GPs were proactive in reducing risks associated with polypharmacy for older people. For example, patients prescribed multiple different medicines had been frequently reviewed and changes made to reduce these.

Information systems enabled the practice to appropriately share important clinical and social information about patients with complex needs. This facilitated continuity of care for those patients.

Pneumococcal vaccination was provided at the practice for older people. In 2014, the practice had run 26 flu clinics as well as the standard week day appointments. Shingles vaccinations were also provided to patients who fit the age criteria. Patients were contacted to offer them the opportunity to make an appointment to have the vaccination, which had increased the uptake of patients being given this.

The practice held regular carers clinics and works with a community support worker to provide additional help for carers.

The practice worked in collaboration with the local church to distribute food vouchers to vulnerable older people with limited financial resources. This was done compassionately and patients in this position were treated with dignity.

People with long term conditions

Outstanding

Updated 16 July 2015

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

Nursing staff had lead roles in chronic disease management and had dedicated appointments to review patients with diabetes, asthma and/or chronic respiratory disease. Patients at risk of hospital admission were identified as a priority. All these patients had a named GP and a structured annual review to check that their health and medication needs were being met. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care. The practice held multidisciplinary meetings every month to review the needs of all patients with complex long term conditions.

Staff were consistent in supporting people to live healthier lives through a targeted and proactive approach to health promotion and prevention of ill health. For example, during an audit of patients on anticlotting medicines the practice identified a number of factors influenced blood results. A healthcare assistant was supported by GPs to produce a validated information sheet about the dietary impact of foods containing vitamin K. Patients were given this information to help them understand the risks with their diet and medication. It included information about the correct daily portions and values of vitamin K and how this could affect the potency of the medication and therefore increase their blood clotting time.

Longer appointments and home visits were available when needed. Home visits for patients newly discharged from hospital were undertaken jointly with the community nursing team to carry out an assessment and arrange additional support where needed.

The practice recognised the needs of patients and their difficulty with transport to the hospital for appointments. They had arranged for screening for certain conditions to be carried out at the practice. For example, eye screening took place at the practice every year for patients at risk of developing diabetic retinopathy. This was appreciated by some patients we spoke with as it avoided them having to travel to the opthalmology clinic based at the main hospital some 35 miles away.

The practice had links with the external health care professionals to provide advice and guidance as required. GPs and nurses from the practice attended a quarterly virtual Diabetic clinic with hospital specialists, to review patient care and treatment.

Health education around diet and lifestyle was promoted by the practice. The practice took an early intervention approach and helped identify and signpost patients to external support. This included assistance with smoking cessation and contact details for the health worker running this was given to patients.

Families, children and young people

Good

Updated 16 July 2015

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

There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.

Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals. Appointments were available outside of school hours and the premises were suitable for children and babies. The waiting room had toys for children to play with whilst waiting for their appointments.

Emergency processes were in place for acutely ill children, young people and pregnant women with acute complications.

The practice worked collaboratively with midwives, health visitors and school nurses to deliver antenatal care, child immunisation and health surveillance. For example, close working links with the school nurse were used to gain a broader understanding of whether a young person had the maturity to make decisions and understand potential risks before advice or treatment was provided.

The practice was designated as a young person friendly practice having achieved quality standards for information and support available. For example, information about contraception and promotion of health was targeted for young people. Young people had access to information and could request chlamydia screening and be seen by a practice nurse specifically trained in these areas.

Support was being accessed for parents from child specialist workers and parenting support groups where relevant.

The practice was proactive in getting feedback from patients and the patient participation group included parents with young families.

Parents with children attending the practice confirmed that they were always present during consultations. Staff understood Gillick principles with regard to assessing whether a young person was able to understand and therefore consent to treatment. Parents told us that all of the staff engaged well with their children so that they found it a positive experience when attending the practice for appointments.

Working age people (including those recently retired and students)

Good

Updated 16 July 2015

The practice is rated as good for the care of working-age people (including those recently retired and students).

The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. The practice was developing the service so that working patients would be able to book appointments and repeat prescriptions on-line. The practice website offered information about the full range of health promotion and screening available for this group. For example, the practice had extended opening every Monday evening for working patients. Appointments were available for patients to see a GP, practice nurse or health assistant. Patients would be able to request repeat prescriptions on-line within a month, at the local pharmacy or in person at the practice. Repeat prescriptions were being given for up to a month.

Overseas travel advice including up-to-date vaccinations and anti-malarial drugs was available from the nursing staff within the practice with additional input from the GP’s as required.

Opportunistic health checks were being carried out with patients as they attended the practice. This included offering referrals for smoking cessation, providing health information, routine health checks including blood tests as appropriate, and reminders to have medication reviews.

The practice was proactive in seeking feedback and the patient participation group at the practice included working age members.

People whose circumstances may make them vulnerable

Good

Updated 16 July 2015

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

The practice held a register of patients living in vulnerable circumstances including those with a learning disability. It had carried out annual health checks for people with a learning disability and 100% of these patients had received a follow-up. It offered longer appointments for people with a learning disability and their carers for reviews. Home visits by GPs and practice nurse were carried out routinely each week and jointly with the community nursing team to reduce stress and improve communication. The practice liaised closely with the learning disability nurse specialist to ensure information was communicated in a person centred way, for example in easy read or picture formats.

The practice worked closely with the community matron to arrange visits to vulnerable patients to assess and arrange any equipment or other assistance needed by the patient and their carers.

Systems were in place to help safeguard vulnerable adults. The practice welcomed all patients to the practice and had systems in place to temporarily register and communicate with homeless people.

Carer checks were carried out and the practice hosted a carer support worker clinic every month to support patients.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 16 July 2015

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

Flexible services and appointments were available, which enabled patients experiencing poor mental health to have longer appointments at quieter times of the day, avoiding times when people might find this stressful.

Shared care arrangements were in place for patients with complex mental health needs. The practice worked closely with the community mental health team and regularly reviewed each patient. Every patient had a care plan and risk assessment, which was reviewed.

Staff were skilled in recognising and responding to patients experiencing mental health crisis, providing support to access emergency care and treatment. The practice worked collaboratively with the community mental health team and consultant psychiatrists from the mental health partnership trust. Joint reviews were carried out every month which looked at changing risk, to monitor patient safety and mental well being.

The practice had a list of patients with known mental health needs and worked to engage them in healthy living programmes. Each appointment with a patient was seen as an opportunity to screen patients and signpost them to additional services. In house mental health medication reviews were conducted to ensure patients received appropriate doses. For example, patients taking lithium had regular blood tests to ensure safe prescribing.

Advice and support was sought as appropriate from the psychiatric team with referrals made for psychiatry review or entry into counselling. Patients may be encouraged to refer themselves to the counselling service. Information about depression, including a diagnostic questionnaire was available on the practice website for patients to see and use. Patients found this helpful and made them more aware of when to seek help from their GP.

Health education, screening and immunisation programmes were offered as appropriate. This included alcohol and drug screening. Patients with alcohol addictions were referred to an alcohol service for support and treatment and to the local drug addiction service.

Early identification of patients with suspected dementia were being screened and referred to the memory clinic for diagnostic tests. Data showed the practice was above the national average of 54.3% at 60.1% in diagnosing people with dementia. Patients had care plans in place, which supported their on-going changing needs and those of their carers. The practice worked closely with a social centre in Bude to provide services to support patients experiencing poor mental health.