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Nettleham Medical Practice Outstanding Also known as Dr Waller and partners

Inspection Summary


Overall summary & rating

Outstanding

Updated 28 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Nettleham Medical Practice on 28 April 2016. Overall the practice is rated as outstanding.

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. There was a coordinator in place for significant events who produced a regular significant event newsletter to ensure all staff were aware of recent incidents and ensured lessons learned were shared with all practice staff.

  • Risks to patients were assessed and well managed. The practice had an effective risk register in place and had carried out numerous risk assessments which were reviewed on a regular basis.

  • 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 were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • The practice provided a memory clinic held in-house on a monthly basis for patients.This service was delivered by a community mental health nurse and a consultant in old age psychiatry.

  • 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 had good facilities and was well equipped to treat patients and meet their needs.

  • The practice achieved the highest dementia diagnosis rate within Lincolnshire West CCG of 94 patients diagnosed during 2014-15, with an increase in diagnosis to 122 patients during 2015-16.

  • If families had suffered bereavement, their usual GP sent a letter to the bereaved family member/s or carer of the deceased patient and offered an appointment at a convenient time and access to bereavement services. The practice had received numerous letters and cards of thanks for the support offered by staff at times of bereavement.

  • The practice provided health pods in the waiting area for patients which enabled them to check their own blood pressure reading and weight measurements.This system was available in numerous different languages and automatically updated the patient care record with this information. Patients could use this system at a convenient time to the patient.

  • 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.

During our inspection we saw four areas of outstanding practice:

  • The practice worked in partnership with the patient participation group. A voluntary driver scheme was formed in 2009 in response to difficulties patients experienced in attending consultations at either practice.There were 13 dedicated voluntary drivers who had carried out 11,146 patient journeys for approximately 360 patients since the scheme began.

  • The practice provided a memory clinic held in-house on a monthly basis for patients.This service was delivered by a community mental health nurse and a consultant in old age psychiatry.The practice also had an effective alert system system in place within the patient care record to ensure clinicians carried out effective dementia screening for patients who required this. The practice had achieved the highest dementia diagnosis rate within Lincolnshire West CCG of 94 patients diagnosed during 2014-15, with an increase in diagnosis to 122 patients during 2015-16. This provided an early diagnosis for patients and enabled GPs to provide the most effective care, treatment and support to help them to manage their condition.

  • The practice carried out an on-going palliative care audit. Three full cycle audits had been carried out at the time of our inspection. The aim of this audit was to identify all patients who required palliative care and to review the levels of care delivered to these patients and those at end of life, and assessed whether appropriate end of life care planning had been provided. The practice aimed to ensure the best possible care was for provided to these patients at all times. As part of this audit process, the practice produced its own standards in line with the Department of Health 2008 end of life care strategy to ensure clinicians continually monitored and delivered high quality care for patients. The practice carried out a full review of all of these patients during multi-disciplinary meetings to ascertain whether these standards had been achieved and carried out a significant event analysis to identify where improvements could have been made in the delivery of care.

  • The practice provided an in-house leg ulcer clinic which provided holistic care for patients of the practice who suffered leg problems.This service had been introduced approximately 12 years ago. The practice had a higher than average elderly population who had increased risk of developing chronic oedema and other leg problems and the nearest specialist lymphedema clinic was approximately 40 miles away from the practice.14.1% of the practice patient population were over the age of 75 compared to the CCG average of 8.4% and national average of 7.5%.The aim of this service was to provide early intervention and long term management of patients, reducing costs to the NHS, reducing admissions to hospital and enhancing quality of life for patients. 2.71% of the practice patient population were being seen in this clinic at the time of our inspection. 88% of patients seen in this clinic had successfully healed venous leg ulcers. We saw numerous examples of case studies of patients whose treatment had been successful.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 28 September 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events.The practice held a register of all significant events and incidents.There was a coordinator in place for significant events who produced a regular significant event newsletter to ensure all staff were aware of recent incidents and ensured lessons learned with shared with all practice staff.

  • 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. Patients identified as at risk of abuse were discussed and reviewed during regular multi-disciplinary meetings.

  • Risks to patients were assessed and well managed. The practice had an effective risk register in place and had carried out numerous risk assessments at both the main and the branch surgery which were reviewed on a regular basis.

  • Clinical and dispensary staff received alerts from the Medicines and Healthcare Products Regulatory Agency (MHRA). All alerts were coordinated by the practice manager and staff were notified of these alerts via an electronic system.

  • Patients prescribed high risk medicines were provided with personalised drug monitoring books for an additional 19 shared care and high risk medicines which included Amiodarone and Sulfasalazine as well as for Methotrexate and Lithium monitoring books which existed nationally.

  • The practice held evidence of Hepatitis B status and other immunisation records for clinical staff members who had direct contact with patients’ blood for example through use of sharps.
  • The practice carried out regular checks to ensure that members of the nursing team were registered with the Nursing and Midwifery Council (NMC). A register was held by the practice which included full details NMC registration numbers and expiry dates. This register also held details of DBS checks and General Medical Council (GMC) registration numbers for all GPs.
  • The practice had implemented a comprehensive library of patient alerts and clinical protocols within their clinical system which highlighted key information regarding the patient. 

Effective

Outstanding

Updated 28 September 2016

The practice is rated as outstanding 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.

  • The practice had an on-going audit programme in place and clinical audits demonstrated quality improvement. The practice produced its own standards in line with the Department of Health 2008 end of life care strategy to ensure clinicians continually monitored and delivered high quality care for patients at the end of their life. An audit was in place to monitor this.

  • All deceased patient were reviewed during multi-disciplinary meetings, significant event analysis were carried out where necessary to identify where improvements could have been made in the delivery of care for patients.

  • 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.

  • The practice provided a memory clinic held in-house, on a monthly basis for patients. This service was delivered by a community mental health nurse and a consultant in old age psychiatry.

  • The practice achieved the highest dementia diagnosis rate within Lincolnshire West CCG of 94 patients diagnosed during 2014-15, with an increase in diagnosis to 122 patients during 2015-16.

  • The practice’s uptake for the breast screening programme was 83% which was higher than the CCG average of 74% and the national target of 70%.

  • The practice provided an in-house leg ulcer clinic which provided holistic care to patients of the practice who suffered with leg problems

    .

  • The practice carried out ‘virtual medicine reviews’.  Approximately one month prior to a medicines review being due, a GP would carry out a full review of the patient care record to ensure any blood tests and other health screening requirements dependent upon the needs of the patient were arranged all within the one appointment.

Caring

Good

Updated 28 September 2016

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.

  • Written information was available to direct carers to the various avenues of support available to them. The practice provided a carers section on its website which provided full contact details of local carers support groups which included a video link. There was also links to other relevant information for carers which included a dementia carer’s handbook.
  • If families had suffered bereavement, their usual GP set a letter to the bereaved family member/s or carer of the deceased patient and offered an appointment at a convenient time and access to bereavement services. The practice had received numerous letters and cards of thanks for the support offered by staff at times of bereavement.

Responsive

Good

Updated 28 September 2016

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

  • Members of the patient participation group (PPG) provided a voluntary transport service for those patients who resided in surrounding rural villages who had difficulty in attending the practice.

  • 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 access to ‘Language Line’ interpreter services for patients whose first language was not English.

  • The practice offered extended opening hours on a Saturday morning from 9am until 12noon for working patients who could not attend during normal opening hours.
  • GPs provided weekly visits to patients who resided in local nursing homes.

  • The practice had what they referred to as a ‘golden ticket’ appointment system in place for patients identified as at risk of unplanned admission to hospital and those at end of life or who suffered severe disability.  This system ensured priority access appointments were given to these patients when required and enabled these patients to book a routine appointment up to five weeks in advance.

Well-led

Outstanding

Updated 28 September 2016

The practice is rated as outstanding 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.

  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.

  • 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.

  • The practice was also a training practice for nurse students who were enrolled with the University of Lincoln. Members of the nursing team were trained to support student nurses during placement with the practice.

  • The practice was a training practice and delivered training to GP registrars.  (A GP Registrar is a fully qualified doctor who is training to become a GP).
Checks on specific services

Older people

Outstanding

Updated 28 September 2016

The practice is rated as outstanding 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.

  • GPs provided a weekly visit to patients residing in care and nursing homes.

  • The practice provided same day access to either an appointment, telephone consultation or home visit for older people who required this.

  • The practice were ranked 4th out of 36 practices for returning bowel screening data within NHS West Lincolnshire CCG, uptake was 68% compared to the CCG average of 58% and national target of 60%.

  • The practice worked in partnership with the patient participation group. A voluntary driver scheme was formed in 2009 in response to difficulties patients experienced in attending consultations at either practice.There were 13 dedicated voluntary drivers who had carried out 11,146 patient journeys for approximately 360 patients since the scheme began.

People with long term conditions

Outstanding

Updated 28 September 2016

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 patients at risk of hospital admission were identified as a priority.

  • Performance for diabetes related indicators was 98% which was higher than the national average of 89%.This included an exception reporting rate of 7% which was lower than the CCG average of 10%.

  • 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 multi-disciplinary package of care.

  • The practice provided a leg ulcer and leg care clinic for those patients requiring this service.

Families, children and young people

Outstanding

Updated 28 September 2016

The practice is rated as outstanding 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.

  • The practice’s uptake for the cervical screening programme was 82%, which was in line with the CCG average of 84% and the national average of 82%.

  • 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.

Working age people (including those recently retired and students)

Outstanding

Updated 28 September 2016

The practice is rated as outstanding 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 proactive in offering online services such as ordering repeat prescriptions appointment booking and viewing patient summary care records as well as a full range of health promotion and screening that reflects the needs for this age group.

  • The practice participated in an electronic prescribing service.

  • The practice offered a text reminder service for booked appointments.

  • The practice provided appointments on a Saturday morning from 9am until 12noon at the main surgery.

  • The practice offered telephone consultations for patients who were unable to attend for an appointment.

  • The practice provided health pods in the waiting area for patients which enabled them to check their own blood pressure reading and weight measurements. This system was available in numerous different languages and automatically updated the patient care record with this information. Patients could use this system at a convenient time to the patient.

People whose circumstances may make them vulnerable

Outstanding

Updated 28 September 2016

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

  • The practice 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.These appointments were carried out jointly with a practice nurse who offered a 50 minute appointment, followed by an appointment with a GP.

  • 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.

  • Vulnerable patients were discussed and reviewed during regular clinical meetings to ensure their needs were being met by the practice.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 28 September 2016

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

  • Performance for mental health related indicators was 100% which was higher than the national average of 93%. This included an exception reporting rate of 8% which was lower than the CCG average of 15%.
  • 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 provided a memory clinic held in-house, on a monthly basis for patients.This service was delivered by a community mental health nurse and a consultant in old age psychiatry. The practice achieved the highest dementia diagnosis rate within Lincolnshire West CCG of 94 patients diagnosed during 2014-15, with an increase in diagnosis to 122 patients during 2015-16.

  • 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.

  • The practice offered longer appointment times up to 30 minutes for patients experiencing poor mental health including dementia.