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Inspection Summary


Overall summary & rating

Good

Updated 30 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lilliput Surgery on Wednesday 19 October 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they found it easy to make an appointment with a GP and said there were urgent appointments available the same day but added that they sometimes had to wait to see a GP of their choice.

  • The practice had developed three teams to meet specific needs of patients at the practice. These included the routine and long term condition team, the same day care team and the vulnerable and domiciliary team.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice employed a clinical pharmacist to identify and act upon high risk medicines, oversee prescribing patterns, review patients who were taking 10 or more medicines, review post discharge medicines and support long term condition management.

  • Flu clinics were used to offer patients additional screening and reviews. This included a pulse check for all patients over the over the age of 65 years old to exclude abnormal heart patterns, blood pressure checks, asthma checks and chronic obstructive pulmonary disease reviews.

  • Text reminders were used to remind patients of their appointment but could be used to cancel appointments and had resulted in a reduction of ‘did not attend-DNA’.

  • The practice had engaged with the IRIS project (

    Identification and Referral to Improve Safety

    ) IRIS

    is a general practice-based

    domestic violence

    and abuse training support and referral programme

    to raise the profile of potential hidden domestic violence. The training for all staff explored ways of asking patients about domestic violence either as perpetrators or victims.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had developed clinical templates for medicines management and contraception and had shared this learning with other neighbouring practices.

  • Recruitment procedures and checks were completed as required to ensure that staff were suitable and competent.

  • 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.
  • The provider was aware of and complied with the requirements of the duty of candour
  • Governance, administration and performance management arrangements were non-hierarchical, organised, detailed, structured and kept under review by the whole team. The management and leadership had an inspiring shared purpose and motivated staff to succeed and develop services.

  • The practice worked with and actively shared learning with other organisations and the local community to improve how services were planned and delivered to ensure that services meet patient need.

    We saw one areas of outstanding practice:

    The practice had been creative in offering alternative ways to offer patients additional services. For example, using flu clinics to offer additional screening and the use of additional teams to meet specific needs of patients. For example, the practice were offering screening for atrial fibrillation (AF) which is an abnormal heart rhythm. Data showed a rise in AF diagnoses during the autumn flu campaign and a sustained diagnosis rate. Since May 15 the number of patients on the AF register had risen from 365 to 404. The practice had been identified as having higher AF diagnosis rates in the clinical commissioning group (CCG) and had performed 25 long term conditions reviews during the last flu sessions.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 30 January 2017

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events
  • Lessons were shared to make sure action was taken to improve safety in the practice.
  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • Risks to patients were assessed and well managed.
  • Recruitment procedures and checks were completed as required to ensure that staff were suitable and competent.
  • There were appropriate arrangements for the efficient management of medicines.
  • Health and safety risk assessments, for example, a fire risk assessment had been performed and were up to date.
  • The practice was clean, tidy and hygienic. We found that suitable arrangements were in place that ensured the cleanliness of the practice was maintained to a high standard.

Effective

Good

Updated 30 January 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 30 January 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 30 January 2017

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
  • Patients said they found it easy to make an appointment with a GP and said there were urgent appointments available the same day but added that they sometimes had to wait to see a GP of their choice.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.
  • The practice had developed three teams to meet specific needs of patients at the practice. These included the routine and long term condition team, the same day care team and the vulnerable and domiciliary team.

Well-led

Good

Updated 30 January 2017

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

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • The practice had an overarching governance framework which supported the delivery of the strategy and good quality care and was kept under review. This framework was structured, clearly documented and familiar to all staff.
  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.
  • There was a strong focus on continuous learning and improvement at all levels.

Checks on specific services

Older people

Good

Updated 30 January 2017

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

  • The practice offered proactive, personalised care to meet the needs of the older people in its population.
  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • Monthly multidisciplinary meetings were held and were coordinated by the community health and social care coordinator. GPs and nurse practitioners attended along with community nurses, community matron, mental health worker, social worker, and the clinical pharmacist.
  • The practice had introduced longer 15 minute appointments as a routine for older patients with long term conditions.
  • The practice administrator contacted patients to identify issues, and engage the support of the GP, community pharmacist or nursing teams dependent on need. Patients were also signposted to voluntary sector support services.
  • All patients on their 75th birthday were invited to complete a questionnaire to support better care.
  • The practice employed a clinical pharmacist to oversee prescribing patterns, review patients who were taking 10 or more medicines, review post discharge medicines and support long term condition management.
  • Flu clinics were used to offer patients additional services. This included a pulse check for all over 65’s to exclude abnormal heart patterns, blood pressure checks, asthma checks and chronic obstructive pulmonary disease reviews.

People with long term conditions

Good

Updated 30 January 2017

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

  • The Practice had a significant elderly demographic in a low area of deprivation.
  • There was a high prevalence of long term conditions including heart disease, diabetes and cancer.
  • Three nursing staff had lead management roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
  • There was an effective recall system which had enabled the practice to maximise their quality of care.
  • This quality of care was enhanced following the recent appointment of a Clinical Pharmacist.
  • Patients with high blood pressure could borrow ambulatory monitoring and home monitoring equipment, and could check their BP in the reception area self-check machine.
  • Patients with chronic obstructive pulmonary disease (COPD) received self-management plans, rescue medicines if appropriate and referral to local pulmonary rehabilitation services.
  • The local hospital diabetic nurse specialists supported practice nurses with challenging management issues.
  • The practice used flu clinics to offer BP and asthma reviews as well as identifying undiagnosed atrial fibrillation from pulse checks.
  • There was a recall system for patients under surveillance for prostate cancer, ensuring blood screening was monitored and followed up appropriately.

  • Longer appointments and home visits were available when needed.
  • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Good

Updated 30 January 2017

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, and we saw evidence to confirm this.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • We saw positive examples of joint working with midwives, health visitors and school nurses.
  • The practice safeguarding lead was supported by a deputy who was also a clinical commissioning group (CCG) Safeguarding Lead. In addition there was an on-site health visiting team for direct liaison.
  • The practice had engaged with the IRIS project. (This project aimed to educate health care staff and raise the profile of potential hidden domestic violence). The training for all staff explored ways of asking patients about domestic violence either as perpetrators or victims.
  • Children could be booked directly into same day appointments or through the triage service if advice was needed.
  • Two GPs at the practice offered contraceptive implants and one was certified for inter uterine device insertions (coils) to complement the contraceptive services provided.

Working age people (including those recently retired and students)

Good

Updated 30 January 2017

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.
  • Access was enhanced by offering appointments from 8.30am, and ensuring early and later appointments were offered for on-line booking. Evening access was available every Monday.
  • If patients requested same day services they were assessed by the “same day team” which consisted of a GP and nurse practitioner. These appointments were accessed either by GP-led telephone triage or direct appointment.
  • Text reminders were used to reduce DNA (did not attend) rates which also had the facility for patients to cancel appointments if appropriate.
  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.

  • Patients had access to additional services on site such as physiotherapy, minor surgery, joint injections and cryotherapy. (Cryotherapy is the use of extreme cold in surgery, for example skin lesions, or other medical treatment.)

  • The practice offered a “query system” for patients not requesting a direct conversation. Issues were dealt with in a timely manner and supported by the GPs personal assistant system.
  • The practice had a high proportion of patients registered for on-line services, including prescription requests, queries and appointment booking.
  • There was equipment to support patients readily measuring height, weight and blood pressure in the reception area.
  • The practice had systems in place to identify military veterans and ensured their priority access to secondary care in line with the national Armed Forces Covenant.

People whose circumstances may make them vulnerable

Good

Updated 30 January 2017

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

  • The practice had a system to identify these patients and held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • The practice offered longer appointments for patients with a learning disability.
  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.
  • The practice informed 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. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.
  • The practice offered a social prescription scheme which was a voluntary signposting service for engaging isolated patients in activities and groups. The volunteers befriended the patients and took them to meetings by way of introduction.
  • Practice staff had been trained as part of the IRIS project seeking to identify and enquire about potential domestic violence issues.
  • The practice held a daily query and triage list which provided effective and timely communication outside the practice. For example, with paramedic teams requesting assessment to prevent unscheduled admissions, or with hospital teams to discuss medical history.
  • The practice had addressed high ‘did not attend-DNA’ rates and in doing so had identified patients who had been highlighted as frequently not attending for appointments and who were identified as vulnerable or presenting with other problems.

People experiencing poor mental health (including people with dementia)

Good

Updated 30 January 2017

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

  • 84% of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average of 84%.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice carried out advance care planning for patients with dementia.
  • The practice had actively engaged in work to improve dementia prevalence in the last few years. This had included direct assessment of patients thought to be at risk of dementia, and identifying patients with memory related issues but not diagnosed with dementia. Once diagnosed these patients were offered a medicine review and support provided by the local Memory Assessment Service, as well as carer identification and support.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.
  • Patients could self-refer to a talking therapies service at the practice.