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Inspection Summary


Overall summary & rating

Good

Updated 21 January 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Castle Healthcare Practice on 22 September 2015. Overall the practice is rated as good.

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

  • We inspected the practice within 11 months of being registered with the Care Quality Commission and found significant achievements had been made within a short time to provide a responsive and patient focused service.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. All opportunities for learning from internal and external incidents were maximised.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • The practice used proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, they had a robust and patient focussed approach to reviewing the health needs of older people, patients on high risk medicines and people experiencing poor mental health.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet people’s needs.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Urgent appointments were usually available on the day they were requested. However, patient feedback was mixed in respect of telephone access, availability of routine appointments and waiting times.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.
  • The practice had excellent facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand.
  • The practice had a clear vision which had quality and safety as its top priority. The strategy and business plans to deliver this vision were regularly reviewed and discussed with staff.
  • There was a clear leadership structure and staff felt supported by management. High standards were promoted across all roles.

An area of outstanding practice:

  • The patient participation group promoted short walks on most Tuesdays leaving the surgery waiting area at 10.30am and again at 11.30am. This was aimed at promoting activity for people who may not otherwise go out for a walk alone and to create friendship opportunities.

However there were areas where the provider should make improvements:

  • Improve multi-disciplinary working and communication to ensure patients receive timely and well-coordinated care.
  • Improve processes for making appointments including the availability of non-urgent appointments and reducing waiting times.
  • Take steps to improve the number of annual health checks undertaken for people with learning disabilities.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 21 January 2016

The practice is rated as good for providing safe services.

The practice had an open and transparent culture towards safety and an effective system for reporting and recording significant events. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Information about safety was highly valued and used to promote learning and improvement.

There were suitable arrangements in place to keep people safe and safeguarded from abuse. Medicines were well managed and the monitoring of high risk drugs was a strong feature. Risks to people using the service were assessed and well managed. The practice had procedures in place for dealing with emergencies, including dedicated rooms for medical emergencies.

Effective

Good

Updated 21 January 2016

The practice is rated as good for providing effective services.

Systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines. We saw evidence to confirm that these guidelines and clinical audits were positively influencing and improving patient outcomes and practice performance.

The 2014/15 data showed mixed patient outcomes, with most clinical indicators at or above average for the locality. The practice had action plans in place to address areas where performance was not in line with national or local figures.

The practice worked in collaboration with other health and social care professionals. However improvements were required to ensure effective multi-disciplinary working, communication and the regular review of patients’ needs.

A strong feature of the practice was the strategic and proactive engagement to address the health and well-being of patients within the community. For example, one of the GP partners had contributed to the establishment of the weight management service and the design of referral forms which are used by GP’s within the local area. The practice had referred 120 patients to date and 368 patients were receiving support in weight management within Nottinghamshire.

The patient participation group also promoted short walks on most Tuesdays leaving the surgery waiting area at 10.30am and at 11.30am.  This was an outstanding feature which promoted activity for people who may not otherwise go out for a walk alone and created friendship opportunities.

Caring

Good

Updated 21 January 2016

The practice is rated as good for providing caring services.

Most patients said they were treated with compassion, dignity and respect and were involved in decisions about their care and treatment. Some patients gave specific positive examples to demonstrate how their choices and preferences were valued and acted on.

This was aligned with patient survey data which showed the practice had comparable rates to the local and national averages for its consultations with GP and nurses.

We observed a patient-centred culture with staff committed to improving patient’s experience of the service. The practice had systems in place to support patients cope with their care and treatment. This included a clinical commissioning group (CCG) led bespoke carers service and information relating to support groups and bereavement.

Responsive

Good

Updated 21 January 2016

The practice is rated as good for providing responsive services.

The practice was actively engaged work with the local community in planning and developing innovative approaches to ensure integrated and person-centred care. This included care for older people living in care homes and those considered frail; and patients experiencing poor mental health. This was led by the GP partners who held strategic roles within the clinical commissioning group.

Patient feedback about access to the service was mixed. For example urgent appointments were usually available on the day they were requested. However, patients said that they sometimes had to wait a long time for non-urgent appointments and access to a named GP.

This was aligned with the national patient survey results published in July 2015 which showed:

  • 74% of respondents described their experience of making an appointment as good compared to a local average of 80% and national average of 73%.

  • 39% of respondents did not find it easy to get through by phone compared to a local average of 19% and national average of 27%.

The practice had implemented improvements to monitor telephone access, availability of appointments and waiting times as a consequence of patient feedback.

The practice had excellent facilities and was well equipped to treat patients and meet their needs. Information about how to complain was available and the practice responded appropriately when issues were raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 21 January 2016

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

The practice had a clear vision with quality and safety as its top priority. The strategy to deliver this vision had been produced with patients, 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. High standards were promoted and owned by all practice staff and teams worked together across all roles. There was an overarching governance framework which supported the delivery of the strategy and good quality care.

Governance and performance management arrangements were proactively reviewed and took account of current models of best practice. There was a strong focus on continuous learning, innovation and improvement at all levels.

Checks on specific services

People with long term conditions

Good

Updated 21 January 2016

The practice is rated as good for the care of people with long-term conditions.

Nationally reported data showed outcomes for patients with long term conditions were mostly in line with and or above the local and national averages. This was achieved through:

  • Effective systems in place to assess, review and monitor the outcomes for patients. The GPs and nursing staff had lead roles in chronic disease management and the monitoring of patient outcomes.

  • Patients at risk of hospital admission were identified as a priority and suitable care planning arrangements were in place to reduce avoidable admissions.

  • Regular and structured reviews were undertaken to check that patient’s health and needs were met and their medicines remain suitable. The named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care for people with the most complex needs. However, improvements to multi-disciplinary arrangements were required to ensure all patients received timely and coordinated care.

  • Longer appointments and home visits were available when needed.

Families, children and young people

Good

Updated 21 January 2016

The practice is rated as good for the care of families, children and young people.

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.

There were systems in place to safeguard children from abuse and to follow up children living in disadvantaged circumstances. Joint working arrangements were in place with midwives, health visitors and school nurses. However these needed to be strengthened to ensure effective communication and coordination of patients care. Immunisation rates were relatively high for all standard childhood immunisations.

The practice offered responsive services to young people. This included engagement with sixth form students at a local school, teenage immunisations and being signed up to the C-Card scheme. This scheme offers one to one consultation for young people aged 13 –24 to get free condoms and advice about sex and relationships.

One of the GPs also had a special interest in teenage health and worked as a school doctor and shared their expertise with staff. Another GP had initiated the Public Health adolescent strategy within the local area; and this included reducing obesity.

Older people

Good

Updated 21 January 2016

The practice is rated as good for the care of older people.

The leadership of the practice had a thorough understanding of the needs of older people and were engaging this patient group and other stakeholders to improve the service. Specifically,

  • One of the GP leads was the clinical commission group (CCG) lead for the enhanced care home service provision which aimed to improve the quality of care for older people by reducing unplanned admissions, ambulance transfers, length of inpatient stays and falls. Data reviewed showed positive outcomes had been achieved and this included reduced hospital admissions from nursing homes within the local area.

  • The practice offered proactive, personalised care to meet the needs of the older people in its population. Weekly visits were carried out by dedicated GPs for three local care homes to ensure continuity of care. Joint visits were also undertaken with a pharmacist advisor to review the medication of the residents.

  • Another GP was the CCG lead for frail elderly persons and within their role they had facilitated the implementation of the carer support service offered within the local area and joint working arrangements with the community geriatrician.

The practice offered proactive and personalised care to meet the needs of the older people in its population. Home visits and urgent appointments for patients with enhanced needs were available when needed. Patients aged 75 and over had a named GP.

Some areas requiring strengthening included:

  • Outcomes for patients diagnosed with Osteoporosis. For example, 66.7% of people aged over 75 with a fragility fracture were being treated with a bone-sparing agent compared to a CCG average of 78.6% and national average of 79.3%.

Working age people (including those recently retired and students)

Good

Updated 21 January 2016

The practice is rated as good for the care of working-age people (including those recently retired and students).

A strong feature of the practice was the strategic work related to health and well-being. For example, one of the GP executive partners was the clinical commissioning group (CCG) lead for the health and wellbeing board and a member of the obesity steering group. They had contributed to the design of referral forms for patients to receive support with weight management; and these were used by GPs within the CCG area.

The practice was instrumental in the establishment of this service which is commissioned by Public Health. The practice had referred 120 patients to date and 368 patients were receiving the weight management services within Nottinghamshire.

The patient participation group (PPG) also promoted short walks on most Tuesdays leaving the surgery waiting area at 10.30am and again at 11.30am. This was aimed at promoting activity for people who may not otherwise go out for a walk alone and to create friendship opportunities.

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. For example,

  • patients could access appointments and telephone consultations between 8am and 8pm Monday to Friday; and urgent appointments on a Saturday and Sunday morning from another local practice.

  • engagement with patients via text messaging with their consent and

  • access to both female and male GPs.

The practice was proactive in offering online services and this included booking appointments and ordering repeat prescriptions. A full range of health checks, screening programmes and health promotion advice was offered.

People experiencing poor mental health (including people with dementia)

Good

Updated 21 January 2016

The practice is rated as good 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 and care planning of people experiencing poor mental health and those with dementia. Patients and or their carers were informed about how to access various support groups and voluntary organisations.

The practice had 148 patients listed on their dementia register. Data showed 85.2% of people had their care reviewed in a face to face meeting within the last 12 months.

A system was in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

Robust systems were in place for the in house drug monitoring of high risk medicines such as lithium and clozapine. The practice had lower than local average rates for anti-depressant prescribing.

Staff had a good understanding of how to support people with mental health needs and dementia. They were supported by one of the GP partners who was the clinical commissioning group lead for mental health. They had a strategic overview of local mental health service provision and led on development work to improve patient care.

People whose circumstances may make them vulnerable

Good

Updated 21 January 2016

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

Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours. The practice worked with multi-disciplinary teams in the case management of vulnerable people; and improvements were needed to improve communication and coordination of care.

The practice held a register of patients living in vulnerable circumstances including those with a learning disability and patients receiving palliative care. It offered annual health checks for people with a learning disability. However, follow-up of these patients needed strengthening to ensure attendance.

The practice premises were new and purpose built with reasonable adjustments made for people with disabilities and impairments. For example, braille signage, hearing loop; automated doors and adjustable beds. Vulnerable patients had access to information on various support groups and voluntary organisations.