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Salisbury Medical Practice Good

Inspection Summary


Overall summary & rating

Good

Updated 31 January 2019

This practice is rated as Good overall. (The practice was previously rated in November 2016 as Outstanding)

The key questions at this inspection are rated as:

  • Are services safe? – Good
  • Are services effective? –Good
  • Are services caring? – Good
  • Are services responsive? – Outstanding
  • Are services well-led? - Good

We carried out an announced comprehensive inspection at Salisbury Medical Practice on 20 November 2018, as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • 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.

We saw a two areas of outstanding practice:

  • The practice had a clear vision of using social prescribing and social care signposting to support patients, by improving their social network, encouraging social activity and making souces of help and advice more easily accessible. There was a small team of staff who led this work and the strategic focus was embedded in policies and annual development plans that were reviewed regularly. They held regular one-off events and had developed a wide range of support groups for patients with particular needs. For example, there was a fibromyalgia and a carers group that met monthly. Staff leading this work also attended nurse led clinics such as the practice diabetic clinic and leg club to give patients information and advice on a range of available support.
  • The practice ran weekly Dementia Friendly Tai Chi sessions for people with dementia and their carers. As part of this service they offered sessions in a number of local care homes.

The areas where the provider should make improvements are:

  • Complete the actions they have identified to improve their system for monitoring the fridge temperatures and take steps to ensure the improvements are embedded in the practice.
  • Improve their assurance systems so the practice can evidence that actions taken as a result of safety and medical alerts have been completed, and learning points identified from significant events and complaints are shared with all appropriate staff including those unable to attend meetings where they are discussed.
  • Review the arrangements for ensuring all staff have completed the training necessary for their role, to ensure it is effective and records are up to date.
  • Take steps to ensure they meet the national target for cervical screening.
  • Take steps to reduce the number of patients they are excepting from their quality outcome data.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Safe

Good

Updated 31 January 2019

We rated the practice as good for providing safe services.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse.

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient safety.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was an effective induction system for temporary staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

The practice had reliable systems for appropriate and safe handling of medicines.

  • The systems for managing and storing medicines (except vaccines), medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed and administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.
  • Shortly before our inspection, the practice had identified required improvements in their cold chain system, which ensured vaccines were kept in a fridge between four and eight degrees Celsius. Whilst there was no risk to the vaccines or patient safety, the practice had identified they needed to write additional guidance for staff and provide additional staff training, but had not yet completed these actions.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed safety using information from a range of sources.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice. However, the practice had not always ensured that all appropriate staff were informed of the learning points, such as those who were unable to attend meetings.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts. We found the practice had no clear process of assurance to ensure the actions required were undertaken and completed.
  • Following the inspection, the practice told us they had revised their Alert Assurance process and implemented additional actions in support of sharing learning from significant events. All staff were advised at induction that they need to keep up to date with information and meetings minutes circulated and added to the shared drive. We have been unable to verify evidence to support the additional actions.We have been unable to verify the evidence of this submission as no further information to demonstrate these actions was received.

Please refer to the evidence tables for further information.

Effective

Good

Updated 31 January 2019

We rated the practice as good for providing effective services.  We rated the population groups as Good for Older People, Working age people (including those recently retired and students), People whose circumstances make them vulnerable,  Families, children and young people and People experiencing poor mental health (including people with dementia). People with long-term conditions were rated as Requires Improvement.

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • The practice offered proactive, personalised care to meet the needs of the older people in its population.
  • The practice had worked with the other local practices to establish an Integrated Older Persons Team service to improve care for older people. The included nurses and administrative staff. One of the aims of this service was to reduce unplanned admissions and we saw data that showed the rate of unplanned admissions by practice patients living in a care home had reduced by 36% in the past 12 months. As part of the service, older patients who are identified as frail or vulnerable receive a full assessment of their physical, mental and social needs, including a review of their medication.
  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • The practice had identified 1861 patients on their list as being aged 75 or over and 1433 (77%) of these had received a health check in the past 12 months.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.
  • Longer appointment times were available.
  • The practice held a register of patients who were military veterans.

People with long-term conditions:

The practice was rated as requires improvement for this population group.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension).
  • We noted that the practice COPD exception rate for the period 01/04/2016 to 31/03/2017 was 22% compared to the CCG average of 14% and national average of 11%. More recent data, not available at the time of our inspection, for the same period in 2017/18 showed no improvement.
  • The practice ran a range of groups for patients with specific conditions or needs. For example, they ran a leg club for the management of ulcer and other leg conditions. These clinics were held weekly to ease access to appointments and reduce social isolation.

Families, children and young people:

The practice was rated as good for this population group.

  • At the time of our inspection the data available to us was for the year 01/04/2016 to 31/03/2017. This showed that of the four areas of childhood immunisation uptake rates, one area, did not meet the target percentage of 90% or above.  Following our inspection, the practice told us that as part of their organisational restructure the practice had centralised all administration activities, which previously had been undertaken by many members of staff and this had resulted in improvements to the take up of the vaccinations. Also following our inspection the data for the period 01/04/2017 to 31/03/2018 became available, which showed the practice had met the 90% uptake rate in all four areas measured. 
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.

Working age people (including those recently retired and students):

  • The practice’s uptake for cervical screening was 73%, which was in line with national and local averages, but below the 80% coverage target for the national screening programme. We saw evidence the practice had taken steps to improve their screening rates which included, ensuring women were set written invitations and offered flexible appointments during the week.  Following our inspection the practice told us that in addition to these measures, they had and recruited two new nurses who are being trained to increase the availability of appointments and increase uptake of appointments. We have been unable to verify the evidence of this submission as no further information to demonstrate these actions was received.
  • The practice’s uptake for breast and bowel cancer screening was in line with the national average.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.
  • The practice is open from 8-8 Monday to Friday, offering late appointments for those of working age who would otherwise find it difficult to attend an appointment.

People whose circumstances make them vulnerable:

  • End of life care was delivered in a coordinated way which took into account the needs of those 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 had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

People experiencing poor mental health (including people with dementia):

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medication.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • The practice offered annual health checks to patients with a learning disability. The practice had identified 152 patients on their list as having a learning disability and 98, or 64%, of these had received a health check in the past 12 months.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles (except in relation to flu vaccinations).

  • The practice understood the learning needs of staff and provided protected time and training to meet them. Staff were encouraged and given opportunities to develop. However, some improvements were required in relation to the training of nursing staff.
  • The practice told us they had reorganised their whole staff structure, this included the clinical and administration and reception teams. Specialist teams had been set up to improve quality and standards. A recent audit of these arrangements had found some issues. One aspect of this was the practice had identified an improved electronic training log was required. At the time of inspection, the practice were in the process of transferring paper refresher systems onto the electronic log and scanning certificates against the log.
  • The electronic log showed some staff had not completed their refresher Child Safeguarding Training to the appropriate level and infection control training. We also noted two nurses, two GPs and two administrative/ reception team members had not completed the appropriate refresher training. The refresher update was based on a cyclical review process. At the time of inspection all members of staff were within this timescale.
  • As part of the recent improvements to the service the practice has amended their safeguarding training requirements to reflect whether this training was being carried out as face to face or whether it was a combination of online and CPD.  The practice considered this to be a more robust process. The new electronic system had been amended to show the revised dates, which are different depending on the method of training.
  • Except in relation to flu vaccination, staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • The practice system for recording staff training showed that staff providing flu vaccinations had received update training in the past 12 months. However, on further investigation we found this training related to the previous year’s program. (Recognised guidance recommends staff delivering vaccination should receive training of the current years vaccination programme, which changes each year, prior to delivering the service.) The practice told us they were arranging for the appropriate staff to complete the updated training.
  • Staff whose role included taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • On the day of our inspection the practice did not have a lead nurse and were in the process of recruiting a person for this role. Staff we spoke to expressed concern at not having a lead nurse. Some said they found it difficult to discuss or report issues to the management team due to them having full diaries. Following the inspection, the practice provided evidence that a lead nurse had been appointed in December 2018.

  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation. The practice was in the process of introducing a new process for doing staff annual appraisals and external consultants had been engaged to support the process this year. We saw that some appraisals were overdue although all staff appraisals were scheduled to be completed by the end of November 2018.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • The practice had set up a range of patient groups which met in the practice café. The aims of the groups were to help signposting patients to other services and providing a support network.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice monitored the process for seeking consent appropriately.

Caring

Good

Updated 31 January 2019

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The practices GP patient survey results were in line with local and national averages for questions relating to kindness, respect and compassion.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them.
  • The practices GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues or appeared distressed reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.

Responsive

Outstanding

Updated 31 January 2019

We rated the practice and some of the population groups, as outstanding for providing responsive services. The population groups for older people, people with long-term conditions and people experiencing poor mental health (including people with dementia), were rated as outstanding. The population groups for families, children and young people; working age people (including those recently retired and students); and people whose circumstances make them vulnerable were rated as good.

Responding to and meeting people’s needs

Services are tailored to meet the needs of individual people and are delivered in a way to ensure flexibility, choice and continuity of care.

  • The involvement of other organisations and the local community is integral to how services are planned and ensures that services meet people’s needs. There are innovative approaches to providing integrated person-centred pathways of care that involve other service providers, particularly for people with multiple and complex needs.
  • Telephone and web GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.
  • The practice had been awarded a platinum award, in 2018, for caring for carers by a local charity working in partnership with the local authority. They had won the award for their work with carers because they ensured priority and flexible access to appointments and an annual health check for this group of patients. 342 (62%) of carers had received a health check in the past 12 months.

Social prescribing and social care signposting.

The practice had a comprehensive strategy of using social prescribing and social care signposting to support patients. Where appropriate they worked with other organisations to provide these services. They had developed a wide range of support groups for patients with particular needs. These groups were advertised on the practice website, in the practice waiting area and on their Facebook and Twitter pages. Anyone could attend these groups, not only patients registered at the practice. The groups met in the practice café where tea and coffee were provided. The practice had a signposting team who led this work. These staff would attend groups when they started but the aim was that they would either be self-sufficient or led by an external facilitator. The team also prepared signposting information for nurse led clinics, such as the practice diabetic clinic and leg club. The team did regular surveys of patients attending these groups and acted to improve the service based on this feedback, where appropriate. We saw evidence in form of case studies which showed the benefits individuals had received from attending these groups. For example, after a patient and their carer attended one group, the carer was signposted to other groups where they received information and support which enabled them claim back council tax and attend a number of other social groups and events. This patients and other patients feedback we saw said the groups had supported their wellbeing and given them the confidence to attend other social events in the city.

The practice hosted a variety of ad hoc events aimed at reaching a wide range of people. Recent events included events on World Diabetes Day and Older Persons Day; and we saw that a veteran’s support event was planned.

Older people:

This population group was rated outstanding for providing a responsive service because:

  • The practice ran a range of groups based on a social model of care for older people. These included a twice monthly knitting group and a monthly Friends after Bereavement group. These groups were open to all, including people not registered at the practice.
  • The practice hosted a range of drop-in services such as an advocacy service, a health trainer service and British Legion drop-in sessions.
  • The practice ran weekly Dementia Friendly Tai Chi sessions for older people and those with dementia. As part of this service they offered sessions in a number of local care homes.

People with long-term conditions:

This population group was rated outstanding for providing a responsive service because:

  • The practice ran a range of groups based on a social model of care for people with long-term conditions. For example, they ran groups for people with hearing loss, a brain injury, fibromyalgia, multiple sclerosis, sight loss and tinnitus. These groups were open to all, including people not registered at the practice.
  • The practice ran a Leg Club for patients who suffered, or had suffered from leg ulcers, in partnership with other local practices. It met weekly and had a drop-in ethos. It was attended by a practice nurse specialising in this area. The club had a written constitution and was affiliated to the national body. The practice did regular surveys of patients attending the Leg Club and took action to improve the service. For example, following patient feedback the practice were introducing the use of graphs to record the size of wounds along a time line. Staff from the practice Signposting team attended this group to give patients information and advice on other support services and groups which may be of interest to them.
  • The practice ran diabetic clinics which were attended by the Signposting team who were able to give patients information on a range of local activities and support groups that were available, and advise on issues such as healthy eating and exercise.

Families, children and young people:

  • We found there were systems 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 accident and emergency (A&E) attendances. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

Working age people (including those recently retired and students):

  • The needs of this population group 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 worked with other local practices to provide greater access to appointments with GPs, Nurses and phlebotomists from 8am to 8pm seven days a week. Routine face to face appointments with a GP were available from 8.30am to 12.30pm and 2pm to 8.00pm. Triaged calls and telephone appointments are from 8:00am to 6.30pm. This gave working people greater flexibility of appointments.

People whose circumstances make them vulnerable:

  • The practice ran a range of groups based on a social model of care for people whose circumstances make them vulnerable. For example, they ran groups for people with learning disabilities. These groups were open to all, including people not registered at the practice.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

People experiencing poor mental health (including people with dementia):

This population group was rated outstanding for providing a responsive service because:

  • The practice ran a range of groups based on a social model of care for people experiencing poor mental health. For example, they ran a memory group for people living with dementia and their carers. These groups were open to all, including people not registered at the practice.
  • The practice hosted a range of drop-in services such as an advocacy service, a health trainer service and a British Legion session.
  • The practice was a Dementia Friendly practice. They had been awarded this status by national charity after meeting a range of criteria such as staff training and having dementia friendly signage.

Timely access to care and treatment

Patients were able to access care and treatment from the practice within an acceptable timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • The practices GP patient survey results were in line with local and national averages for questions relating to access to care and treatment

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care. However, the practice had not always ensured that all appropriate staff were informed of the learning points, such as those who were unable to attend meetings.
  • A recent audit of the complaints procedure had identified that some letters to complainants had not included information about how to escalate the complaint if they were not satisfied with the practice response in line with recognised guidance. We saw evidence the practice had acted to correct this.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 31 January 2019

We rated the practice as good for providing a well-led service.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care.

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • Part of the practice vision was to include a social model of care and to be able to signpost patients to other sources of help and advice and to empower patients to manage their own health. The practice used their café space to host a wide range of support groups covering the whole populations health. Some of these groups were open to patients from other local practices. The practice strategy in relation to health & wellbeing, and the social carer model was embedded in practice policy and strategy documents that were regularly reviewed.
  • The practice had a clear strategy of signposting patients to other sources of help and support. Practice staff had been appointed to lead this work. We saw evidence the strategy had been reviewed and new targets agreed. The practice was developing a directory of local support services and were planning of making more use of on-line and digital solutions to signpost patients.
  • The practice vision of a using a social care model to support the health and wellbeing of patients and the wider community was embedded in practice policy and strategy documents that were regularly reviewed. The practice engaged in the development of wider community services. This included practice staff becoming members of the local Health and Wellbeing Group.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.

Culture

The practice had a culture of high-quality sustainable care.

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • The practice focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. Staff were supported to meet the requirements of professional revalidation where necessary.
  • The practice was in the process of introducing a new process for doing staff annual appraisals and external consultants had been engaged to support the process this year. We saw that some appraisals were overdue although all staff appraisals were scheduled to be completed by the end of November 2018.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care.
  • The practice told us that in the past year they had reorganised the practice to support the development of specialist teams and skills. For example, the partners had been assigned to sub-groups focussing on different area such as; staffing, finance and quality. Each sub-group had clear terms of reference and responsibilities. The Registered Manager sat on all the sub-groups. A survey had been carried out to assess the specialist knowledge the sub-groups required and a series of presentations had been provided to these groups to help ensure the GPs had the knowledge required.
  • The administration staff had been divided into specialist groups such as call handlers and front of house receptionists. A recent review of these arrangements had identified a few areas where some routine tasks were not being done to the appropriate standard and the practice had taken action to improve these areas. For example, the review had identified they practice system for recording staff training was not fully effective and letters to patients following a complaint did not always included all the necessary information. We saw evidence the practice was taking appropriate action to address these issues.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved patients, the public, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The service was transparent, collaborative and open with stakeholders about performance.
  • The practice produced monthly staff newsletters.
  • The practice led the development and delivery of some services in partnership with other GP practices in Wiltshire, such as care to the elderly through an elderly care team, group consultations for patients with diabetes, social model leg club, some out of hours appointments and some dermatology services.
  • Since the last inspection, the practice had provided medical care for 10 intermediate care beds in the area as part of the elderly care team. However, this service is has been suspended since April 2018 until a new community geriatrician is appointed.

Continuous improvement and innovation

There was clear evidence of a long-standing and on-going drive to continuous improvement and seeking new and innovative ways to achieve this. Targets were set which were later reviewed to ensure the new development was achieving the anticipated benefits.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • The practice took opportunities to learn and develop the practice. For example, they volunteered to participate in a learning disability quality check run by people with learning disabilities working with the local HealthWatch group. We saw evidence the recommendations made had been discussed at a staff away day and action taken to improve their service.
  • The practice was a primary care research centre and participates in research programmes in collaboration with two other local surgeries.
  • The practice actively sought to develop its services. For example, we saw evidence the practice was seeking to start a dermatology service in partnership with another local practice. A pilot had been agreed and was due to be started.
  • Following the inspection, the provider told us innovation was celebrated through the practice newsletter and team meetings. We have been unable to verify this evidence.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Good

Older people

Outstanding

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Outstanding

People whose circumstances may make them vulnerable

Good