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Inspection Summary


Overall summary & rating

Good

Updated 22 October 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at West Moors Group Practice on 19 August 2015.

Overall the practice is rated as good.

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

  • 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.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles.
  • Risks to patients were assessed and well managed.
  • 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.
  • 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 practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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.

However there were areas of practice where the provider needs to make improvements. Importantly the provider should:

  • Ensure calibration of medical equipment in all GP’s bags and include these in the schedule of medical equipment calibration

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 22 October 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.

Effective

Good

Updated 22 October 2015

The practice is rated as good for providing effective services.

Data showed patient outcomes were at or above average for the locality. Staff referred to guidance from the National Institute for Health and Care Excellence and used it routinely. Patient’s needs were assessed and care was planned and delivered in line with current legislation. This included assessing capacity and promoting good health.

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. Staff worked with multidisciplinary teams.

Caring

Good

Updated 22 October 2015

The practice is rated as good for providing caring services.

Data showed that 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 also saw that staff treated patients with kindness and respect, and maintained confidentiality.

Responsive

Good

Updated 22 October 2015

The practice is rated as good for providing responsive services.

It 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 named GP and that there was continuity of care, with urgent appointments available the same day.

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 that the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 22 October 2015

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

It had a clear vision and strategy. Staff were clear about the vision and their responsibilities in relation to this. 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.

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 virtual patient participation group was proactive. Staff had received inductions, regular performance reviews and attended staff meetings and events.

Checks on specific services

Older people

Good

Updated 22 October 2015

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

Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. 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. It was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs.

The practice provided a tracker service for elderly and vulnerable patients. This included all patients who had been discharged from hospital or had recent falls and those referred to the Tracker team by members of the practice, the local pharmacy, relations or other concerned members of the public. The tracker team had effective contacts with the private and charity sectors as well as being able to refer to occupational therapy, Wheelchair services and social services. This enabled them to assist and support the patient to receive the correct and appropriate care to enable them to remain well and in their own homes for as long as possible.

People with long term conditions

Good

Updated 22 October 2015

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

Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. Longer appointments and home visits were available when needed. 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 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 22 October 2015

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

Immunisation rates were 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 good examples of joint working with midwives, health visitors and school nurses.

Working age people (including those recently retired and students)

Good

Updated 22 October 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. Extended hours appointments were available three evenings a week. 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.

People whose circumstances may make them vulnerable

Good

Updated 22 October 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 patients with a learning disability and 88% of these patients had received a health check. It offered longer appointments for patients with a learning disability.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable patients. 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.

People experiencing poor mental health (including people with dementia)

Good

Updated 22 October 2015

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

At the practice 93% of patients experiencing poor mental health had an agreed care plan documented in their record in the preceding 12 months. The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia. It carried out advance care planning for patients with a diagnosis of dementia.

It had a system in place to follow up patients who had attended accident and emergency when they may have been experiencing poor mental health.

Staff received training on how to care for patients with mental health needs and dementia and had a good relationship with the community mental health team. The practice had a dementia register and offered dementia checks under the dementia direct enhanced service (DES). GP Practices can opt to provide services over and above the essential/additional services normally provided to patients. These services can be a DES and are delivered to a higher specified standard.