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Inspection Summary


Overall summary & rating

Good

Updated 20 June 2017

Letter from the Chief Inspector of General Practice

We carried out an announced desk based review on 11 April 2017 to follow up concerns we found at Ashgate Manor Primary Care Centre on 10 November 2015. Overall the service is rated as good.

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

  • There was a process in place to ensure the safe handling and security of blank prescription pads held at Ashgate Manor Primary Centre and when distributed to other locations.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 20 June 2017

The practice is rated as good for providing safe services.

We carried out an announced desk based review on 11 April 2017 to follow up concerns we found at Ashgate Manor Primary Care Centre on 10 November 2015. Overall the service is rated as good.

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

  • There was a process in place to ensure the safe handling and security of blank prescription pads held at Ashgate Manor Primary Centre and when distributed to other locations.

Effective

Good

Updated 4 October 2016

The provider is rated as good for providing effective services.

  • Our findings showed that systems were in place to ensure that all members of the district nursing team were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • Health care assistants (HCAs) received training in the role of the HCA in end of life care. We saw evidence of these training records during our inspection.
  • There was evidence of appraisals and personal development plans for all staff.
  • There was evidence of clinical audit, clinical supervision and reflective feedback processes for all staff to ensure the delivery of high quality patient care.

  • Staff received training relevant to their roles and were up to date with all mandatory training.

  • The service worked closely with the GP out-of-hours service and with patients’ own GPs. Information was shared with the evening and overnight district nursing service through Rightcare plans and special notes, ensuring that the patient’s needs and wishes were known.

  • Staff had access to counsellors and de-brief sessions should they have required support following a particularly traumatic, emotional or upsetting home visit.

Caring

Good

Updated 4 October 2016

The provider is rated as good for providing caring services.

  • In the comment cards patients completed for us they said they were treated with dignity and respect by helpful, polite and caring staff.

  • Patients were satisfied that they were involved in decisions about their care and treatment.

  • We saw evidence of a ‘Derby City ‘Dignity Campaign’ certificate of achievement’ in recognition of their work to promote dignity and respect.

  • Some members of staff were Dementia Friends and Dignity Champions.

  • Staff treated patients with kindness and respect, and maintained patient and information confidentiality at all times.

  • Two members of the district nursing team had recently been nominated and received an internal recognition award for the outstanding level of care shown to two individual patients who were at end of life.

  • A daily comfort call system was in place for patients referred into this service with palliative care needs and those at the end of their life. These patients received priority visits when required.

Responsive

Good

Updated 4 October 2016

The provider is rated as good for providing responsive services.

  • The provider undertook continuous engagement with patients to gather feedback and held regular patient and public involvement sub-committee meetings to review suggestions for improvements. Changes were made to the way it delivered services as a consequence of this feedback. Patient satisfaction, patient safety, friends and family test results and healthwatch information were also discussed.
  • The service understood the needs of the population it served and engaged with the local Clinical Commissioning Group to provide services that were responsive to the needs of the population.
  • Rightcare plans were developed by the patient’s GP and shared with evening and overnight district nursing service for patients with higher levels of need such as patients with long term conditions, complex health needs and those at the end of their life. The district nursing service worked jointly with the GP out-of-hours service which ensured staff had access to Rightcare plans and special notes which were used to record relevant information about patients.
  • Information about how to complain was available and easy to understand. Evidence showed that the service responded quickly and sensitively to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 4 October 2016

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

  • It had a clear vision with quality and safety as its top priority. The service was responsive to feedback and used performance information proactively to drive service improvements.

  • The views of patients were taken into account and acted upon through active public engagement.

  • The organisation had a number of policies and procedures to govern activity and held regular governance meetings.

  • There was an overarching governance and performance management 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 senior management team encouraged a culture of openness and honesty.

    The service had systems in place for knowing about notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken.

  • There was a strong focus on continuous learning and improvement at all levels, staff were encouraged to continually learn and develop their skills.