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Marysville Medical Practice Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 26 November 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Marysville Medical Practice, on 24 June 2015. Overall the practice is rated as outstanding.

Specifically, we found the practice to be outstanding for providing effective, caring and responsive services and good for providing safe and well led services. It was outstanding overall for the services it provided to older people; people with long-term conditions; families, children and young people; working age people; people whose circumstances may make them vulnerable and people experiencing poor mental health.

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.
  • Risks to patients were assessed and well managed, with the exception of those relating to recruitment checks.
  • 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. The practice valued the importance of quality, improvement and learning and were actively involved in the training and education of GPs, student nurses and counsellors.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Patients rated the practice highly in surveys and described the practice as caring and helpful.
  • 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 flexibility of access to appointments.
  • 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.

We saw areas of outstanding practice:

  • The practice had developed and led on a project known as the Care Homes Advanced Scheme (CHAS) for care homes in the locality of Shrewsbury and Atcham, Shropshire. The aim of the project was to increase clinical input into care homes. The project was evaluated and recognised by the local CCG as an important initiative in preventing unplanned hospital admissions and providing more continuity to patients’ in care homes. All GP practices had agreed to provide a service to a small number of care homes. Before this, patients living in care homes received care and treatment from as many as 14 practices.

  • The practice had developed easy read leaflets which were given to patients with a learning disability to help them understand the care and treatment they received.

  • The practice was committed to providing access to as many services as possible at the premises. Physiotherapy, counselling and chiropody services were provided for its registered population. Access to additional services included; British Pregnancy Advisory Service, regional hearing service, pain management service, vasectomy surgery and dermatology surgery were provided for patients registered at the practice and those from other practices. This allowed patients to access local care at the practice rather than a hospital setting.

There were two areas of practice where the provider needs to make improvements.

Importantly the provider should:

  • Review complaints over time to identify any themes or trends.

  • Continue to review recruitment procedures to ensure that all staff who are involved in the direct care of patients such as providing treatment or chaperone duties are risk assessed to determine if a Disclosure and Barring Service (DBS) check is required.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 26 November 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 and addressed. Staff had attended training related to safety. This included areas such as safeguarding, infection control and prevention and chaperone training appropriate to their role. A comprehensive infection control audit had been completed and action was planned for any risks identified. The practice had not completed full recruitment procedures for all staff involved in the direct care of patients such as providing treatment or chaperone duties. Risk assessments had not been completed to determine if a Disclosure and Barring Service (DBS) check was required. Appropriate action was taken by the practice manager at the time of the inspection to address this. There were enough staff to keep patients safe.

Effective

Outstanding

Updated 26 November 2015

The practice is rated as outstanding for providing effective services. Data showed patient outcomes were well above average for the locality. The practice had performed higher than many other practices in several areas and had achieved 95.9% of QOF points in 2014-15. Our findings at inspection showed that systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence guidelines and other locally agreed guidelines. Patient’s needs were assessed and care was planned and delivered in line with current legislation. This included assessing capacity and promoting good health.

The practice had developed and led on a project known as the Care Homes Advanced Scheme (CHAS). This resulted in the practice introducing and being the leaders for the CHAS project pilot scheme for care homes in Shrewsbury and Atcham, Shropshire. The focus of the scheme was to increase and improve clinical input in care homes. The practice had an active involvement in the care homes they provided a service too. Practice staff had ensured patients had comprehensive assessments, care plans completed and received regular health reviews. The practice also provided regular education sessions for care home staff. One of the GPs at the practice was the lead for the scheme.

The practice was committed to providing access to as many services as possible at the premises to patients registered with them and those from other practices. This allowed patients to access local care at the practice rather than a hospital setting. The practice worked closely with other health professionals and community and voluntary services. These included community midwives, substance misuse workers, podiatrist, district nurse team, physiotherapist and the community pharmacist. Other additional services offered included; diabetic foot health screening, counselling, British Pregnancy Advisory Service, regional hearing service, pain management service, vasectomy surgery and dermatology surgery. The GPs had access to dedicated theatre facilities and the support of a theatre nurse who was employed by the practice.

The practice took a proactive role in the development of its own staff and other health professionals and students external to the practice. All practice staff had received training specific to their role in safeguarding, infection control and the role of a chaperone and further training had been undertaken and planned to meet the needs of patients registered with the practice. There was evidence of appraisals and personal development plans for all staff. Staff worked with multidisciplinary teams.

Caring

Outstanding

Updated 26 November 2015

The practice is rated as outstanding for providing caring services. Data showed that patients rated the practice higher than others for all aspects of care. Feedback from patients about their care and treatment was consistently and strongly positive. The patient survey information we reviewed showed patients responded extremely positively to questions about their involvement in planning and making decisions about their care and treatment and rated the practice highly in all areas. The practice had a patient-centred culture. We saw that staff were motivated and inspired to offer kind and compassionate care and staff worked to overcome obstacles to achieving this. Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. We saw that staff treated patients with kindness and respect, and maintained confidentiality. Information to help patients understand the services available was easy to understand. For example patients with a learning disability were given easy read leaflets to help them to understand the care and treatment offered.

Responsive

Outstanding

Updated 26 November 2015

The practice is rated as outstanding for providing responsive services. It reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified.

Following evaluation the CHAS project scheme had been recognised by the local CCG as an important initiative in preventing unplanned hospital admissions and providing more continuity to patients’ in care homes. The project was implemented in phases and had resulted in GP practices agreeing to manage an agreed number of care homes. Before this, patients living in care homes were receiving care and treatment from all 14 practices in this area. This change has resulted in continuity of care for patients and staff working at the care homes now relate to a much smaller number of practices and was in the process of developing guidelines for staff on the management of falls and head injuries sustained in care homes.

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 patient survey information for July 2015 showed that patients rated the practices highly in response to questions about access to appointments. For example, 92% were satisfied with the practice’s opening hours compared to the CCG average of 76% and national average of 75%. One hundred per cent of respondents said they could get through easily to the practice by phone which was higher than both the local CCG and the national average.

A designated GP, practice counsellor and a community mental health nurse ensured that all patients experiencing poor mental health received appropriate treatment from appropriately qualified staff. Together they provided a weekly clinic and comprehensive package of care for those patients experiencing illnesses such as depression and anxiety. The involvement of the community mental health nurse provided an important link to the local mental health services. Patients with more than one long term condition had a full review at the same appointment. For example patients with diabetes were reviewed by the GP, nurse and podiatrist on the same day to avoid patients having to return on several occasions. Records showed for example that 191 of the 200 diabetic patients registered with the practice (95.5%) had received their annual review in this way. The remaining nine patients had their review completed at the local hospital. Learning from complaints was shared with staff.

The practice employed community care co-ordinators to support and facilitate care for vulnerable patients and to assist patients with varied health and social care needs. They supported patients to access services that could prevent further hospitalisation and also assisted vulnerable patients in their homes. This initiative had shown benefits for patients who were socially isolated and this was confirmed by patients.

Well-led

Good

Updated 26 November 2015

The practice is rated as good for being well-led. It had a clear vision and strategy. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. 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. We saw that the practice worked extremely well as a team and worked to make and sustain improvements. All staff were involved in making improvements at the practice and had received training in the problem solving method process mapping. High standards were promoted and owned by all practice staff and the teams worked together across all roles.

Governance and performance management arrangements had been reviewed and took account of current models of best practice. The practice had a number of policies and procedures to govern activity and held regular governance meetings. The practice carried out proactive succession planning. The practice GPs met daily to discuss any issues and share experiences. There was a comprehensive programme of education and training for all staff.

The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group (PPG) was active and the practice engaged well with the group. PPGs are a way for patients and GP practices to work together to improve the service and to promote and improve the quality of the care. The practice used feedback from the PPG to improve the service provided to patients. Staff had received inductions, regular performance reviews and attended staff meetings and events.

Checks on specific services

Older people

Outstanding

Updated 26 November 2015

The practice is rated as outstanding for the care of older people. To address the social isolation older people may experience the practice had employed community care coordinators who helped to fill these gaps in patients care and offered support to older frail patients in their homes. The practice provided a service to two care homes and offered personalised care to meet the needs of the older people in its population. The practice had a proactive role in a range of enhanced services, for example, in response to a CCG initiative “Increasing Clinical Input into Care Homes” the practice had developed and led on a project known as the Care Homes Advanced Scheme (CHAS). The practice also provided regular education sessions for care home staff and was developing guidelines to support care home staff in the management of falls and head injuries. The benefits of the CHAS project had identified a reduction of unnecessary referrals to hospital particularly in patients identified as being at risk of hospitalisation. Staff and patients interacted with a much smaller number of practices which resulted in continuity of care for patients living in care homes.

Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. All patients over the age of 75 had a named GP. The practice was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs.

People with long term conditions

Outstanding

Updated 26 November 2015

The practice is rated as outstanding for the care of people with long-term conditions. We saw that patients with more than one long term condition had a full review at the same appointment to avoid patients having to return on several occasions. For example patients with diabetes were reviewed by the GP, nurse and podiatrist on the same day. Records confirmed that all diabetic patients booked to have their review at the practice 191 had received their annual review in this way. Patients were pleased with this approach to their care. Meetings take place with other relevant health professionals to discuss patients with complex needs and to deliver a multidisciplinary package of care. The community care co-ordinator made telephone contact with any patients on the register within 48 hours of their discharge from hospital to ensure a comprehensive care package was in place and to assess whether any other services were needed.

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 patients with long term conditions had their health and medication regularly reviewed. The practice was involved in the prevention of unplanned admissions enhanced service. It maintained a register created from a risk tool that demonstrated at least 3% of the practice population had received a full care plan and were reviewed every three months by a health care assistant, practice nurses and GPs. This patient group were discussed every month with the multi-disciplinary team. Patients receiving end of life care were discussed every month at the multi-disciplinary meeting and care was delivered through the Gold Standards Framework. The Gold Standard Framework involved practice staff working together as a team and with other professionals in hospitals, hospices and specialist teams to help to provide the highest standard of care possible for patients with advanced disease and their families.

Families, children and young people

Outstanding

Updated 26 November 2015

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. The practice had a higher rate of immunisations than the national and local average. The practice consistently achieved a higher than national and local rate for cervical screening. The practice nurses had developed a personalised letter to send to women who did not attend for their cervical screening appointment.

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, who carried out a weekly clinic at the practice. Contraceptive services and advice were available at the practice.

Working age people (including those recently retired and students)

Outstanding

Updated 26 November 2015

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. Appointments were available outside of working hours.

The practice offered one early morning clinic each week a

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remained open at lunchtime to allow patients, particularly those who were working to access services at the surgery. Booked telephone consultations were offered four evenings each week. This flexibility was extremely popular with patients who would be at work during the practice normal opening hours. Telephone consultations were introduced in response to a patient survey. Patients commented that they would prefer this to appointments in the early morning or at weekends. The practice was proactive in offering online services and patients had access to online appointments and prescriptions. NHS health checks were offered as well as a full range of health promotion and screening that reflects the needs of this age group.

People whose circumstances may make them vulnerable

Outstanding

Updated 26 November 2015

The practice is rated as outstanding for the care of people whose circumstances may make them vulnerable. The practice had systems in place to ensure that they could identify patients living in vulnerable circumstances including homeless people and those with a learning disability. Homeless patients could be registered with the practice and access any of the services as needed. The practice provided a counselling service which patients could access following referral by their GP. Fifty five percent of the 71 patients referred to the counsellor had accepted counselling over the past year (2014 – 2015). The practice employed community care co-ordinators to assist patients with varied health and social care needs. The coordinators signposted patients to appropriate services and support provided by the voluntary sector and assisted them in their homes. This initiative had shown benefits for patients who were socially isolated and this was confirmed by patients. The lead community care co-ordinator contacted all patients on the unplanned admissions register who had been admitted to hospital within 48 hours of discharge. These patients were supported to access any other services that could prevent further hospitalisation.

The practice offered substance (alcohol and drugs) misuse clinics to assess and manage the care of patients who presented with substance misuse health issues. One of the GPs provided a shared care service to patients with substance misuse with the support of community support teams. Information provided demonstrated the effectiveness of this service over the past twelve months. Records showed that of the 19 patients on the practice register there had been a clinic attendance rate of 94 –100 percent over the past year (2014 – 2015). Systems were in place to follow up patients who did not attend for their appointment. The practice maintained a register of patients with a learning disability. Patients were offered annual health reviews and given longer appointments. All patient’s had received a follow-up. There was a designated practice nurse lead for learning disabilities. Easy read leaflets were given to patients with a learning disability to help them to understand the care and treatment offered.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 26 November 2015

The practice is rated as outstanding for the care of people experiencing poor mental health (including people with dementia). The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. A designated GP, the practice counsellor and a community mental health nurse carried out a weekly clinic for patients experiencing poor mental health. The team ensured patients received treatment from appropriately qualified staff. Together they provided a comprehensive package of care for those patients experiencing illnesses such as depression and anxiety. The involvement of the community mental health nurse also provided an important link to the local mental health services. All people experiencing poor mental health had received an annual physical health check. Patients were also encouraged to access local support groups as part of their care package. Practice staff had received training on how to care for people who experienced poor mental health.

The practice had a dementia diagnosis rate of 69.4% which reflected the special interest of one of the GPs in elderly care and the promotion of continuing care in care homes. This rate was significantly higher than other practices in the locality (4th highest out of 44 practices across Shropshire). Shropshire CCG had estimated a diagnosis rate of 49.1% across Shropshire. This achievement had been recognised by the local CCG commissioning lead for dementia. The commissioning lead had approached the practice to discuss how they had achieved this diagnosis rate so that the practice could share their systems with other practices. The practice carried out advance care planning for patients with dementia. The community care coordinator signposted patients and their carers to various support groups available locally.