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Inspection Summary


Overall summary & rating

Good

Updated 1 March 2018

Letter from the Chief Inspector of General Practice

This practice is rated as Good overall. (Previous inspection August 2015 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at West Moors Group Practice on 9 January 2017 as part of our inspection programme.

At this inspection we found:

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence based guidelines.

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

  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.

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

  • The practice made reasonable adjustments when patients found it hard to access services. For example, the nurses offered home visits for frail patients, who were unable to attend appointments at the practice, to administer the flu vaccine.

  • The practice used a text message system to engage patients with services that helped them to live healthier lives.

  • There was a dedicated frailty lead at the practice, in post since September 2016. During this time, the practice has seen a 5% reduction in unplanned hospital admissions of patients aged over 65 year.

  • The practice proactively identified and supported patients who were carers. For example, the practice had a dedicated carers lead and provided a carers group.

The areas where the provider should make improvements are:

  • Review systems and risk assess the responsibilities and activities of staff to determine if they are eligible for a Disclosure and Barring Service check in line with current guidance.

  • Review systems for all medicine near misses in the dispensary including how recorded and acted upon.

  • Review governance procedures to maintain safety, for example by maintaining a system for receiving and acting on safety alerts.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 1 March 2018

Effective

Good

Updated 1 March 2018

Caring

Good

Updated 1 March 2018

Responsive

Good

Updated 1 March 2018

Well-led

Good

Updated 1 March 2018

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.