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Inspection Summary


Overall summary & rating

Good

Updated 2 August 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at the Old Mill Surgery on 14 June. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events, including dispensary significant events.
  • The practice had clearly defined and embedded systems to manage safeguarding concerns.
  • The practice needed to carry out fire alarm testing as detailed in the fire risk assessment.
  • The dispensary did not monitor room temperatures and the system in place for the tracking of prescription pads required review.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • The practice were performing in line with local and national averages. Unverified data for the Quality and Outcomes Framework showed improvements from 2015/16 to 2016/17.
  • The practice held regular meetings with a variety of multidisciplinary teams.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • The practice had identified less than 1% of their patient population as carers; however they had an action plan in place to increase this number.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was 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.
  • The practice had completed numerous surveys to gather patient feedback and had acted upon these.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

We saw areas of outstanding practice:

  • The practice had completed a survey for housebound patients to ensure they were meeting their needs. As a result of this survey, each patient had an individualised action plan to make access to and the provision of healthcare easier. For example, some patients relied on family members to book appointments and pick up medications. The practice had ensured they knew which family members were involved and liaised with them, as well as ensuring this was documented in the patient’s notes.
  • The practice had completed a survey to get patient feedback about a walking group. The response was positive and as a result, the practice worked with a local Norfolk scheme to devise a route for patients to encourage 30 minutes of activity per day. Feedback from the group was positive in relation to health and social factors, including reducing loneliness in the older population. The practice also offered to weigh patients and take blood pressure measurements to monitor the benefits of this walking group and were able to evidence a reduction in blood pressure and weight for some of the group.
  • The practice worked closely with the patient participation group (PPG) and had set up open evenings with the aim of educating patients. These were held twice per year and were open to all of the community, including those patients not registered with the practice. Topics included dementia, stroke, diabetes and heart disease. The turnout for these events had been positive, with 85 people attending one of the events. The practice engaged with external stakeholders to provide information, such as University of East Anglia lecturers, medical consultants, the Alzheimer’s Society and the Clinical Commissioning Group. The feedback from the open evenings was positive.

The areas where the provider should make improvements are:

  • Continue to identify and offer support to carers.

  • Embed a system to carry out actions detailed in the fire risk assessment on a regular basis.
  • Embed a system to track blank prescription pads.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 2 August 2017

The practice is rated as good for providing safe services.

  • From the sample of documented examples we reviewed, we found there was an effective system for reporting and recording significant events; lessons were shared to make sure action was taken to improve safety in the practice. When things went wrong patients were informed as soon as practicable, received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice did not effectively monitor the tracking of prescription pads.

  • The practice had clearly defined and embedded systems, processes and practices to minimise risks to patient safety. The practice needed to embed a system to complete the actions from the fire risk assessment on a regular basis.

  • Staff demonstrated that they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role.

  • The practice had adequate arrangements to respond to emergencies and major incidents.

Effective

Good

Updated 2 August 2017

The practice is rated as good for providing effective services.

  • The practice were performing in line with local and national averages. Unverified data from the Quality and Outcomes Framework for 2016/17 showed patient outcomes had improved from 2015/16.

  • Staff were aware of current evidence based guidance and this was discussed at meetings.

  • Clinical audits demonstrated quality improvement such as a decrease in antibiotic prescribing.

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

  • There was evidence of appraisals and personal development plans for all staff.

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs. This included the heart failure nurse, health visitor and district nurses.

  • End of life care was coordinated with other services involved such as the palliative care nurse.

Caring

Good

Updated 2 August 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey, published in July 2017, showed patients rated the practice in line with and above local and national averages for several aspects of care.

  • Survey information we reviewed showed that patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • Information for patients about the services available was accessible. The practice had a hearing loop and translation services were available.

  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

  • We received 37 comment cards and all 37 were positive about the standard of care received from the practice.

Responsive

Outstanding

Updated 2 August 2017

The practice is rated as outstanding for providing responsive services.

  • The practice understood its population profile and had used this understanding to meet the needs of its population. The practice had completed a survey for housebound patients and had produced an action plan as a result of the survey.

  • The practice had set up, with help from a local group, a walking group for patients. This had resulted in patients reporting improvements in physical, mental and social health as well as a reduction in weight and blood pressure for some patients.

  • The practice took account of the needs and preferences of patients with life-limiting conditions, including patients with a condition other than cancer and patients living with dementia. The practice had a dementia champion and all staff had completed dementia awareness training.

  • The practice had completed domestic abuse training and had implemented a strategy to get helplines numbers to patients in a discreet manner.

  • The practice worked proactively with the PPG to set up education events twice per year. These were well attended and feedback was positive.

  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

  • The practice had taken part in an NHS England programme and had reviewed access to services. As a result, the practice had started to utilise staff skills and educate patients of appropriateness of appointments. This included signposting patients to relevant services.

  • The practice had good facilities and was well equipped to treat patients and meet their needs. The practice had a room where mothers could breastfeed and offered this room to midwives to hold breastfeeding teaching groups.

  • Information about how to complain was available and evidence from two examples reviewed showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 2 August 2017

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

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it and had helped to develop this.

  • There was a clear leadership structure and staff felt supported by management. The practice had policies and procedures to govern activity and held regular governance meetings.

  • An overarching governance framework supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.

  • Staff had received inductions, annual performance reviews and attended staff meetings and training opportunities.

  • The provider was aware of the requirements of the duty of candour. In two examples we reviewed we saw evidence the practice complied with these requirements.
  • The partners encouraged a culture of openness and honesty. The practice had systems for being aware of notifiable safety incidents and sharing the information with staff and ensuring appropriate action was taken.

  • The practice proactively sought feedback from staff and patients and we saw examples where feedback had been acted on. The practice engaged with the patient participation group. The practice had completed multiple patient surveys and acted upon results.

  • There was a focus on continuous learning and improvement at all levels. Staff training was deemed to be a priority and was built into staff rotas.
Checks on specific services

People with long term conditions

Good

Updated 2 August 2017

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

  • Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.

  • Performance for diabetes indicators from the Quality and Outcomes Framework was 75%, this was 16% below the Clinical Commissioning Group (CCG) average and 15% below the England average. The exception reporting rate was 4%, which was lower than the CCG excepting reporting rate of 15% and the England exception reporting rate of 12%. The prevalence of diabetes was 6%, which was equal to the CCG and national averages of 6%. However, unverified data submitted for 2016/17 showed diabetes related indicators had improved to 97%.

  • There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.

  • All these patients had a named GP and there was a system to recall patients for a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care, such as community nurses.

  • The practice hosted an annual eye screening service for diabetics and undertook diabetic foot screening at the practice.

  • The diabetic specialist nurse attended the practice once per month.

  • The practice offered a weekly dedicated anticoagulation clinic at both sites which offered a full dosing service.

Families, children and young people

Good

Updated 2 August 2017

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

  • From the sample of documented examples we reviewed 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. The practice also held a register of vulnerable children and followed up children who did not attend appointments.

  • Immunisation rates were high for all standard childhood immunisations.

  • Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals.

  • The practice provided support for women that had given birth. For example, the practice made contact after childbirth and offered support to the family, as well as six week mother and baby checks.

  • Appointments were available outside of school hours and the premises were suitable for children and babies, including a play area in the waiting room.

  • The practice worked with midwives and health visitors support this population group.

  • The practice held seasonal flu clinics in the school holidays for children to improve the uptake. The nurses were trained to offer sexual health advice.

  • The practice had an active social media page to encourage young people to engage with the service. The practice also had chlamydia screening kits in patient toilets.

  • The practice had completed a charity event and proceeds went to a local charity. This was an annual event and this year’s proceeds were going to a local charity that supported children’s hospices in the area.

Older people

Good

Updated 2 August 2017

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

  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs, and also for annual diabetic reviews.

  • The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care. The practice also met regularly with the hospice nurse. Patients at the end of life were provided with the GPs out of hours contact details.

  • The practice followed up on older patients discharged from hospital via a telephone call and ensured their care plans were updated to reflect any extra needs.

  • Where older patients had complex needs, the practice shared summary care records with local care services. For example, a nurse who specialised in dementia care held regular clinics at the practice once a month and the practice worked closely with them.

  • Older patients were provided with health promotion advice and support to help them to maintain their health and independence for as long as possible. For example, Age UK attended the most recent flu clinic to advise older people on several aspects of care.

  • The practice work with the PPG to deliver educational sessions on numerous educational topics. For example, dementia, diabetes and medicines management. These were well attended, for example 85 people attended the dementia evening. The PPG also assisted at flu clinics.

  • The practice had a system in place to follow up patients that did not attend for bowel and breast screening and encouraged patients to attend the screening. As a result, the outcomes for these screenings were above local and national averages.

  • The practice also helped to set up a walking group to improve health outcomes such as lower blood pressure and social outcomes such as decrease loneliness. The outcomes from health, social and patient feedback had all been positive.

Working age people (including those recently retired and students)

Good

Updated 2 August 2017

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

  • The needs of these populations 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, the practice offered extended opening hours on a Monday and Tuesday. The practice also offered telephone consultations.

  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group, including health checks for 40 to 70 year olds.

  • The practice offered text message reminders for appointments and communicated with patients via email if this was preferred.

  • The practice offered a secure WIFI network in the surgery for patients’ use, so working patients could access this while waiting for appointments.

People experiencing poor mental health (including people with dementia)

Good

Updated 2 August 2017

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia).

  • The practice carried out advance care planning for patients living with dementia.

  • 89% of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the last 12 months, which was comparable to the national average of 84% and local average of 84%.

  • The practice specifically considered the physical health needs of patients with poor mental health and dementia. For example, the practice had a dementia champion and had completed dementia awareness training for all staff.

  • The practice had worked with the patient participation group to carry out a dementia opening evening to educate patients on the condition. The event was attended by 85 people and feedback was positive. In the previous year the practice had held a charity event which raised money for a local dementia café.

  • Patients at risk of dementia were identified and offered an assessment. The practice also had a dementia champion.

  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia. For example, the practice liaised with the admiral nurse.

  • The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.

  • The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations. For example, the practice offered a ‘wellbeing’ service.

  • The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health. These patients were also discussed at monthly multidisciplinary team meetings.

People whose circumstances may make them vulnerable

Good

Updated 2 August 2017

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

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability and those registered as carers. The practice offered an annual review for patients with a learning disability; all patients were offered a check and 23 out of 43 patients had attended these checks in the past year. Longer appointments were available for patients with a learning disability as standard. The practice supported two local learning disabilities care homes and offered home visits to them as required.

  • The practice offered a carers information package that included information of local services and helpful numbers, such as social services. The practice completed carers health checks.

  • The practice had completed a survey of housebound patients to assess if they were meeting their needs and had compiled personalised action plans for each of the patients.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients such as community nurses, social services and admiral nurses. The practice held monthly gold standard framework meetings to ensure they met the needs of patients and liaised with the appropriate teams.

  • Staff had undertaken domestic abuse and dementia awareness training and had implemented strategies to offer support to patients suffering from domestic abuse. This included signposting patients in a discreet manner.

  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations. There was also an alert on the records of vulnerable patients.

  • Reception staff contacted vulnerable patients by telephone to check on their welfare if it had been a long time since they were seen, or if they did not use the text message service.

  • The practice had a system in place to follow up patients who did not attend their appointment. The practice also printed off appointments for vulnerable patients.

  • The practice had implemented a recall system for vulnerable patients. This was completed monthly to ensure vulnerable patients had appropriate follow up after testing. This was included as the practice recognised that vulnerable patients may not always attend the practice and this further strengthened follow up of this group.

  • The practice actively promoted the Accessible Information Standards in the waiting room and information was available in an easy read format.