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Inspection Summary


Overall summary & rating

Good

Updated 22 July 2019

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at GP Healthcare Alliance as part of our inspection programme.

At this inspection we found:

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

  • The service 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 people with compassion, kindness, dignity and respect.

  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 22 July 2019

We rated the service as good for providing safe services.

Safety systems and processes

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

  • The provider conducted safety risk assessments. It had safety policies, including Control of Substances Hazardous to Health and Health & Safety policies specific to the host location which GPHA held copies of. Staff received safety information from the provider as part of their induction and refresher training.
  • The provider also had systems to safeguard children and vulnerable adults from abuse. These were regularly reviewed and communicated to staff. A file containing all the information was kept at each host location and accessible to all the staff who worked during the weekend service. The weekend staff also had access to a drop box where all the information was held. The information outlined clearly who to go to for further guidance and gave details of who to contact at the weekends in the event of any safeguarding concerns.
  • The service worked with other agencies to support patients and protect them from neglect and abuse . Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (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 knew how to identify and report safeguarding concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • Since the inspection we were provided with evidence of a training matrix. This matrix listed all staff who worked for the service with details of their current training and when this was due to expire. This offered assurance that all their staff were trained appropriately.
  • There was an effective system to manage infection prevention and control.
  • The provider ensured that facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions. There were systems for safely managing healthcare waste for each host site which were reviewed often by the extended access service.

Risks to patients

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

  • There were arrangements for planning and monitoring the number and mix of staff needed. There was an effective system in place for dealing with surges in demand and any shortages of staff. If any staff were unable to attend work, then a dedicated member of staff would be contacted, and they would then contact other staff members to try and ensure the weekend service was fully staffed.
  • There was an effective induction system for temporary staff tailored to their role with a new starter checklist.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. In line with available guidance, patients were prioritised appropriately for care and treatment, in accordance with their clinical need.
  • Staff told patients when to seek further help. They advised patients what to do if their condition got worse.

Information to deliver safe care and treatment

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

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.

Appropriate and safe use of medicines

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

  • Checks of controlled drugs and emergency equipment were carried out by the practice staff at the host locations during the week however these were not routinely checked by GPHA staff at the weekends. We raised this with the service and they implemented a protocol to ensure the staff working at the weekend were assured that controlled drugs and emergency equipment was available and in full working order if it was required.
  • The service kept prescription stationery securely and monitored its use.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing. On the day of the inspection we were provided with evidence of audits relating to the prescribing of antifungal medications, contraception, opioids, antibiotics and high-risk medications (e.g. Warfarin).
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. The service had audited antimicrobial prescribing. There was evidence of actions taken to support good antimicrobial stewardship and learning was disseminated.
  • Palliative care patients were able to receive prompt access to pain relief and other medication required to control their symptoms until an appointment with their regular GP was made.

Track record on safety

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.
  • There was a system for receiving and acting on safety alerts.
  • Joint reviews of incidents were carried out with partner organisations such as the GP practices that GPHA provided services for. Any complaints were discussed at meetings held between all services involved.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events and incidents. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • On the day of the inspection we looked at significant events. Three events had been reported in the last three years and evidence showed that the service was responsive to significant events and that learning was disseminated.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service.
  • The service learned from external safety events and patient safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including locum staff.

Effective

Good

Updated 22 July 2019

We rated the service as good for providing effective services.

Effective needs assessment, care and treatment

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

  • Clinical staff had access to guidelines from the National Institute for Health and Care Excellence (NICE) and used this information to help ensure that people’s needs were met. The provider monitored that these guidelines were followed.
  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • Arrangements were in place to deal with repeat patients. There was a system in place to identify frequent callers and patients with particular needs, for example palliative care patients, and care plans, guidance and protocols were in place to provide the appropriate support. We saw no evidence of discrimination when making care and treatment decisions.
  • When staff were not able to make a direct appointment on behalf of the patient clear referral processes were in place. These were agreed with senior staff and clear explanation was given to the patient or person calling on their behalf.
  • Staff assessed and managed patients’ pain where appropriate.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • The provider ensured that all staff worked within their scope of practice and had access to clinical support when required.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills and qualifications were maintained. Staff were encouraged and given opportunities to develop.
  • The provider provided staff with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The provider could demonstrate how it ensured the competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing.
  • 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 worked well with other organisations to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment.
  • Staff communicated promptly with the patient's registered GP so that the GP was aware of the need for further action. Staff also referred patients back to their own GP to ensure continuity of care, where necessary.
  • Patient information was shared appropriately, and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way.
  • The service ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those who may be vulnerable because of their circumstances.
  • There were clear and effective arrangements for booking appointments. Appointments could be booked one week in advance via the patient’s own GP or up to one month in advance directly with the weekend service.
  • The service had appointments that were released on the day.

Helping patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • The service identified patients who may be in need of extra support.
  • Where appropriate, staff gave people advice so they could self-care. Systems were available to facilitate this.
  • Risk factors, where identified, were highlighted to patients and their normal care providers so additional support could be given.
  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

The service 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 provider monitored the process for seeking consent appropriately.
  • The provider had a consent policy in place which was accessible to all staff via a drop box facility.

Caring

Good

Updated 22 July 2019

We rated the service as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • Staff were able to advise patients that a separate room was available should they wish to discuss something private.
  • We received 48 patient Care Quality Commission comment cards. 44 of these were positive, with patients praising the care and treatment provided by the clinical and non-clinical staff. The remaining four comment cards were mixed and did not identify any themes or trends.
  • When we visited the weekend service we spoke with seven patients from both host locations. Feedback was positive from all, with five patients stating that they had received a time for their appointment that same day.
  • The provider did not partake in the NHS Friends and Family Test as they did not have a relevant code to enable them to report this data; however, the provider completed their own survey which commenced in April 2019. 33 responses were received. All patients were satisfied or extremely satisfied with the care delivered by reception and clinical staff.

Involvement in decisions about care and treatment

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

  • Interpretation services were available for patients who did not have English as a first language, although the practice had identified that a majority of patients spoke English. As the provider used buildings used by other practices during their contracted hours, we saw notices displayed in the reception area when the service was operational. This provided a greeting in various languages and contact details for local services.
  • When practices booked their patients in for a weekend appointment with GP Healthcare Alliance, they wrote in the booking whether the patients had any communication needs or preferences. The service was looking to formalise this system in the near future.
  • Patients told us through comment cards that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • If it was identified during a consultation that the patient needed the support of the local care co-ordinator, the patient’s usual GP was notified who would then make a referral.

Privacy and dignity

The service respected and promoted patients’ privacy and dignity.

  • Staff respected confidentiality. The provider had privacy and consent policies which were available to all staff.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Responsive

Good

Updated 22 July 2019

We rated the service as good for providing responsive services.

Responding to and meeting people’s needs

The provider organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of its population and tailored services in response to those needs.
  • The provider improved services where possible in response to unmet needs. For example the service now has appointments which open up on the day whereby previously all appointments were bookable in advance only.
  • The facilities and premises were appropriate for the services delivered.
  • The service was responsive to the needs of people in vulnerable circumstances.
  • There were separate rooms available for patients who appeared distressed to sit and wait if they preferred not to be sat in the main waiting area.

Timely access to the service

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

  • The service operated on a Saturday and a Sunday from 9am – 3pm.
  • The service engaged with people who are in vulnerable circumstances and took actions to remove barriers when people found it hard to access or use services.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • The appointment system was easy to use. Patients were able to obtain an appointment by ringing their own GP practice during normal working hours or they could phone one of the host GP practices on the day. NHS 111 were also able to sign post patients to the extended hours service and provide the details of who to contact for an appointment.
  • The service did not directly refer to other services however a protocol was implemented whereby the clinical staff on duty at the weekends would task the patients surgery to ask them to refer the patient onward. The clinician would also task the administrator for GP Healthcare Alliance asking them to follow up with the patient’s surgery to confirm that the task had been completed.

Listening and learning from concerns and complaints

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

  • Information about how to make a complaint or raise concerns was available via a leaflet relating to the weekend service. Staff would hand these to patients if required. Staff also treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. Eight complaints had been received in the last year.
  • Evidence showed that the service learned lessons from individual concerns and complaints. It acted as a result to improve the quality of care, for example, if the patients regular GP is notified by the weekend service that the patient requires a referral then the service administrator would also be notified so they can follow up with the GP on Monday to ensure this has been done.

Well-led

Good

Updated 22 July 2019

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

Leadership capacity and capability

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

  • Leaders had the experience, capacity and skills to deliver the service strategy and address risks to it. Board members were from both the locality and externally, whilst clinical leads were appointed from each locality.

  • They were knowledgeable about issues and priorities relating to the quality and future of services, such as primary care networks. 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 operations manager was contactable throughout the operational period. In the event that they were not contactable, there was another member of the board allocated to be available.

  • The provider had effective processes to develop leadership capacity and skills, including planning for the future of the service, for example they were currently in discussions with other primary care networks to deliver the extended access service and were looking to recruit more staff as a support package.

  • They have also applied for public health funding to locate a wellness table in practices to provide a holistic approach to patient care working alongside the voluntary sector.

  • The service held bimonthly locality meetings which included attendance from the services management team, GPs and practice managers who worked at individual practices across the locality. Minutes observed from these meetings showed that discussions around recruitment and current staffing were discussed.

  • Evidence of staff 1:1 clinical feedback sessions were provided to us. These feedback sessions were held on a monthly basis between staff members and a GP and lasted for approx. 20-30minutes. These feedback sessions provided time for the GP’s to give feedback to the clinician and also for the clinician to discuss any issues with them. Feedback sessions between the service and clinician were also held on a monthly basis, this gave the clinician an opportunity to discuss any issues that arose from the clinical feedback sessions.

    Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The provider advocated patient-focused services which were well managed,efficient, convenient and accessible for patients. Staff and patient feedback evidenced that these values were being delivered by the service.
  • Part of the vision included keeping referring GPs informed. The provider evidenced this through their system for referrals. Member practices had requested that they would prefer to manage patient referrals themselves, including 2 week wait referrals, and therefore, the provider changed their systems to task the relevant practice with the referral request, which would be carried out by the patient’s usual GP. The provider would contact the practice on a Monday morning to ensure the task had been received.
  • The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with patients, staff and external partners. The vision was initially decided at the initial shareholder meeting where GPs and practice managers presented these their vison to the board.