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Inspection Summary


Overall summary & rating

Outstanding

Updated 18 June 2015

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Cuckoo Lane Practice on 28 January 2015. Overall the practice is rated as outstanding.

Specifically, we found the practice to be outstanding for being well-led and providing responsive and effective services. We found they were good for providing safe and caring services. It was also outstanding for the care provided to older people, people with long term conditions, families, children and young people, people living in vulnerable circumstances and people experiencing poor mental health (including people with dementia). They were good for the care and treatment they offered working aged people (including those recently retired) and people whose circumstances make them vulnerable.

Our key findings were as follows:

  • Arrangements were in place to ensure patients were kept safe. The practice learnt when things went wrong and shared learning with all staff to minimise the risk of reoccurrence
  • Patients’ needs were appropriately assessed and care and treatment was delivered in line with current legislation and best practice.
  • We saw from our observations and heard from patients that they were treated with dignity and respect.
  • The practice understood the needs of their patients and provided services that met their needs.
  • The practice was well-led, had a defined leadership structure and staff felt supported in their roles.

We saw areas of outstanding practice including:

  • One nurse practitioner at the practice carried out spirometry tests and also provided a weekly clinic for patients registered at other local practices. All COPD patients are given a self-management plan with particular reference to rescue medication. This has led improved symptom control and less hospital admissions for 25% of patients in this group over the last year.

  • The practice took part in the ‘shifting settings of care’ program which supported patients with mental illness access better, more integrated care outside of hospital and transfer the care of people with ‘common mental illness’ or stable ‘severe and enduring mental illness’ from mental health services into primary care. One impact being 19 patients who would have previously received care in Secondary care setting in the past are now receiving their support and treatment from their GP surgery.

  • An example of integrated care for older people is that an Age UK support worker attended the practice three days a week, to support older patients who live on their own. The practice also provided transport to improve access for those patients who are house bound or find it difficult to get to the surgery. Patients reported satisfaction and liked being able to attend the surgery. This improves socialisation and reduced the amount of home visits by 20 during its first month.

  • The practice was instrumental in establishing an Ealing wide approach to the three tier model of shared care for diabetes. This pilot project was part of a major redesign of diabetes care across Ealing and led to more diabetic nurse specialist being appointed including a Diabetic nurse consultant for the borough and weekly satellite clinics.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 18 June 2015

The practice is rated as good for providing safe services. Staff understood and fulfilled their responsibilities to raise concerns, and report incidents and near misses. Lessons were learned and communicated widely to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed. Risks to patients were assessed and well managed and staff told us there were enough staff to keep people safe. A slot for significant events was on the monthly practice meeting agenda and a review of actions from past significant events and complaints was carried out annually. All staff had received child protection and adult safeguarding training. Appropriate recruitment checks had been undertaken prior to employment for all staff which included checks with the Disclosure and Barring Service (DBS). The infection control lead had carried out audits during the last year and improvements that had been identified for action were completed on time.

Effective

Outstanding

Updated 18 June 2015

The practice is rated as outstanding for effective. Data showed patient outcomes were at or above average for the locality. The practice had developed clinical templates so that the links to NICE and other bodies were embedded in the templates. People’s needs were assessed and care was planned and delivered in line with current legislation. This included assessment of a patient’s capacity to make decisions and the promotion of good health. Staff had received training appropriate to their roles and further training needs had been identified and planned. The practice had carried out staff appraisals and had established personal development plans for all staff. There was evidence of multidisciplinary working to discuss the needs of complex patients especially those with care plans. These meetings were attended by district nurses, social workers, palliative care nurses and decisions about care planning were documented in a shared care record. The practice offered a full range of immunisations for children, travel vaccines and flu vaccinations in line with current national guidance.

Caring

Good

Updated 18 June 2015

The practice is rated as good for caring. Data showed patients rated the practice higher than others in the borough for several aspects of care. Patients said they were treated with compassion, dignity and respect and they were involved in care and treatment decisions. Accessible information was provided to help patients understand the care available to them. Patients who had care plans had annual reviews or more frequently where needed.

We saw that staff treated patients with kindness and compassion ensuring confidentiality was maintained. Patients told us the care was excellent and had sufficient time during consultations to make an informed decision about the choice of treatment they wished to receive. Patient feedback from the CQC patient comment cards we received was also positive and aligned with these views. Clinicians told us they would make phone calls to families who had suffered bereavement and offer to refer them to appropriate services for support.

Responsive

Outstanding

Updated 18 June 2015

The practice is rated as outstanding for responsive. The practice reviewed the needs of their local population and engaged with the Clinical Commissioning Group (CCG) to secure service improvements where these were identified. The practice used a risk stratification tool designed to identify patients at highest risk of attending A&E or being admitted to hospital, and also to enable the GPs to have peer to peer discussions regarding patients with similar health concerns. One nurse practitioner at the practice carried out spirometry tests and liaised regularly with the GP that managed the care of patients diagnosed with chronic obstructive pulmonary disease (COPD). They also provided a weekly clinic for patients registered at other local practices.

The practice took part in the ‘shifting settings of care’ program which supported patients with mental illness transition from secondary care to primary care to ensure a safe discharge process. A mental health worker, employed by the CCG, would attend the practice every two weeks to meet with people recently discharged from hospital. An Age UK support worker attended the practice three days a week, to support older patients who live on their own. They also provided transport to improve access for those patients who are house bound or find it difficult to get to the surgery. The practice also registered patients who had ‘no fixed abode’ such as travellers and homeless people.

Patients reported good access to the practice and a named GP and 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. There was an accessible complaints system with evidence demonstrating that the practice responded quickly to issues raised. There was evidence of shared learning from complaints with staff and other stakeholders. The practice reviewed complaints on an annual basis to identify any themes or trends. We looked at the report for the last review and no themes had been identified, however lessons learnt from individual complaints had been acted upon. The practice used a telephone translation service and the automated checking in machine located in the waiting room was in five different languages. The premises were accessible to patients with disabilities, for example there was street level access to the practice, lift access to the first floor and the toilets were accessible to wheelchair users.

Well-led

Outstanding

Updated 18 June 2015

The practice is rated as outstanding for well-led. The practice had a clear vision and strategy to deliver this. 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. The practice had a number of policies and procedures to govern activity and regular governance meeting had taken place. There were systems in place to monitor and improve quality and identify risk. We saw that the risk log was regularly discussed at team meetings and updated in a timely way. The practice proactively sought feedback from staff and patients and this had been acted upon. Staff told us that there was an open culture within the practice and they had the opportunity and were happy to raise issues at team meetings. The practice had an active patient participation group (PPG) and we saw that they discussed issues such as electronic prescriptions, practice/patient communication, patient survey and the re-launch of the group. Staff had received inductions, annual performance appraisals and attended staff meetings and events.

Checks on specific services

People with long term conditions

Outstanding

Updated 18 June 2015

The practice is rated as outstanding for the population group of people with long term conditions. Emergency processes were in place and referrals made for patients in this population group that had a sudden deterioration in health. Where needed, longer appointments and home visits were available. Patients with a long term condition had a named clinician, a care plan and structured annual reviews to check their health and medication needs were being met. For those people with the most complex needs the named clinician worked with relevant health and care professionals to deliver a multidisciplinary package of care. Nursing staff had received appropriate training to manage and support patients with long term conditions such as spirometry. The practice had GP leads for a variety of chronic conditions including diabetes, chronic obstructive pulmonary disease (COPD) and asthma. The practice carried out spirometry tests and liaised regularly with the respiratory consultant that managed the care of patients diagnosed with chronic obstructive pulmonary disease (COPD). They also provided a weekly clinic for patients registered at other local practices. The practice was instrumental in setting up an Ealing wide approach to the three tier model of shared care for diabetes. We saw the practice had scored 100% of their QOF target in most of the long term conditions indicators.

Families, children and young people

Outstanding

Updated 18 June 2015

The practice is rated as outstanding for the population group of families, children and young people. Systems were in place for identifying and following-up children living in disadvantaged circumstances and who were at risk such as children subject to child protection plans. The safeguarding lead attended child protection case conferences and reviews where appropriate and reports were sent if staff were unable to attend. There were weekly immunisation baby clinics and immunisation rates were high in comparison to other practices in the CCG, for all standard childhood immunisations. Patients told us and we saw evidence that children and young people were treated in an age appropriate way and recognised as individuals. Appointments were available outside of school hours and the premises were suitable for children and babies. Emergency processes were in place and referrals made for children and pregnant women who had a sudden deterioration in health. The clinicians offered family planning advice, fitted IUDs and prescribed the contraceptive pill

Older people

Outstanding

Updated 18 June 2015

Patients over 75 years had a named GP to co-ordinate their care. The named GP held regular meetings with other health care professionals to provide multidisciplinary care for older patients and liaised with appropriate health care professionals when required to ensure older patients received effective care. The practice had a list of older people who were housebound whom they would visit regularly, particularly frail older patients. They used a risk stratification tool designed to identify patients at highest risk of attending A&E or being admitted to hospital, and also to enable the GPs to have peer to peer discussions regarding patients with similar health concerns

An Age UK support worker attended the practice three days a week, to support older patients who live on their own. Their role included befriending, attended patients’ homes to carry out small repairs like replacing light bulbs and changing plugs, liaising with social services and acting as advocates. The practice also provided transport to improve access for those patients who are house bound or find it difficult to get to the surgery. Patients report satisfaction and report liking being able to attend the surgery. This improves socialisation and reduced the amount of home visits by 20 during its first month.

The practice had achieved and implemented the gold standards framework for end of life care. It had a palliative care register and had regular internal as well as multidisciplinary meetings to discuss the care and support needs of patients and their families

Working age people (including those recently retired and students)

Good

Updated 18 June 2015

The practice is rated as good for the population group of the 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. They had extended opening for one hour one day a week, offered phone consultations and online services for ordering repeat prescriptions, booking appointments and getting test results were available. The practice offered a full range of health promotion information and invited patients over 40 years of age to have an NHS health check.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 18 June 2015

The practice took part in the ‘shifting settings of care’ program which supported patients with mental illness transition from secondary care to primary care to ensure a safe discharge process. A mental health worker, employed by the secondary care trust, would attend the practice every two weeks to meet with people recently discharged from hospital. The support offered was holistic which included information and advice about housing, income, social and general health. One impact being 19 patients who would have previously received care in Secondary care setting in the past are now receiving their support and treatment in their GP surgery.

The GP’s also had access to consultant psychiatrists help line at Ealing hospital where they would discuss concerns such as medication swaps and co-morbidities. Patients who experienced poor mental health were kept on a register and invited for annual reviews with extended appointments. Reception staff we spoke with were aware of signs to recognise for patients in crisis and to have them urgently assessed by a GP if they presented at the practice. The practice scored 100%of their QOF target for dementia

People whose circumstances may make them vulnerable

Good

Updated 18 June 2015

The practice is rated as good for the population group 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 learning disabilities. There was a system to highlight vulnerable patients on the practice’s electronic patient records. The practice had carried out annual health checks for people with learning disabilities and 95% of these patients had received health checks last year. The practice offered longer appointments for people with learning disabilities.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. The practice had sign-posted vulnerable patients to various support groups and third sector 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 and out of hours.

The practice used a telephone translation service and the automated checking in machine located in the waiting room was in five different languages.