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Dr Htun Nay Lin, Mattock Lane Health Centre Good

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 10 August 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Htun Nay Lin, Mattock Lane Health Centre on 5 July 2017. 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.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety; however they did not include all areas for example not recording checks on oxygen.
  • Staff were aware of current evidence based guidance.
  • Some of the staff had not undertaken essential training relevant to their role; however most staff had completed these training the day following the inspection and the practice sent us evidence to support this.
  • 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 only identified a low number of patients as carers.
  • 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.
  • 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 practice met with the Patient Participation Group only once a year.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

  • Review practice procedures to ensure medical oxygen is regularly checked and recorded and ensure confidentiality agreements are in place for all clinical staff.
  • Review practice procedures to ensure systems are in place to identify when staff training needed to be updated.
  • Review how patients with caring responsibilities are identified to ensure information, advice and support can be made available to them.
  • Consider frequent Patient Participation Group (PPG) Meetings and review practice procedures to ensure PPG is patient led.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 10 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 had clearly defined and embedded systems, processes and practices to minimise risks to patient safety; however they did not include all areas for example not recording checks on oxygen.
  • 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.
  • The practice did not have signed confidentiality agreements for clinical staff.

Effective

Good

Updated 10 August 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework showed patient outcomes were at or above average compared to the national average.
  • Staff were aware of current evidence based guidance.
  • Two out of 13 staff had not undertaken safeguarding children training; five out of 13 staff had not undertaken fire safety training; three out of 13 staff had not undertaken information governance training; two out of five clinical staff had not undertaken Mental Capacity Act training. However the day following the inspection the practice sent us evidence of completion of training for these staff.
  • Five out of 13 staff had not undertaken infection control training; the day following the inspection the practice sent us evidence of completion of training for three members of staff.
  • Clinical audits demonstrated quality improvement.
  • 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.
  • End of life care was coordinated with other services involved.

Caring

Good

Updated 10 August 2017

  • The practice is rated as good for providing caring services.
  • Data from the national GP patient survey showed patients rated the practice higher than others 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.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
  • The practice had only identified 13 patients as carers (approximately 0.5% of the practice list).

Responsive

Good

Updated 10 August 2017

The practice is rated as good for providing responsive services.

  • The practice understood its population profile and had used this understanding to meet the needs of its population.
  • 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.
  • 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.
  • Information about how to complain was available and evidence from the examples reviewed showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 10 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.
  • 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 had training opportunities.
  • The provider was aware of the requirements of the duty of candour. In the examples we reviewed we saw evidence the practice complied with these requirements.
  • The lead GP 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 (PPG); however the practice only had PPG meetings once a year.
Checks on specific services

People with long term conditions

Good

Updated 10 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.
  • The practice performed multiple reviews in one appointment which they said improved patient compliance in attending appointments.
  • The national Quality and Outcomes Framework (QOF) data showed that 81% of patients had well-controlled diabetes, indicated by specific blood test results, compared to the Clinical Commissioning Group (CCG) average of 77% and the national average of 78%. 94% of patients with diabetes had received a foot examination in the preceding 12 months compared to the CCG average of 92% and national average of 89%.
  • The national QOF data showed that 88% of patients with asthma on the register had an annual review, compared to the CCG average of 78% and the national average of 76%.
  • The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.
  • 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.
  • The practice patients had access to electrocardiography, spirometry and phlebotomy which helped them to monitor patients with long-term conditions.

Families, children and young people

Good

Updated 10 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.
  • Immunisation rates were relatively 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’s uptake for the cervical screening programme was 82%, which was in line with the Clinical Commissioning Group (CCG) average of 79% and the national average of 82%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.
  • The practice patients had access to family planning clinics in the health centre where the practice is located.

Older people

Good

Updated 10 August 2017

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

  • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.
  • The practice offered proactive, personalised care to meet the needs of the older patients in its population.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
  • 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 followed up on older patients discharged from hospital and ensured that 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.
  • Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible.

Working age people (including those recently retired and students)

Good

Updated 10 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, extended opening hours on Mondays and Tuesdays.
  • 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.

People experiencing poor mental health (including people with dementia)

Good

Updated 10 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.
  • All the patients with dementia had received an annual review which was above the Clinical Commissioning Group (CCG) average of 73% and national average of 84%.
  • 93% of 38 patients with severe mental health conditions had a comprehensive agreed care plan in the last 12 months which was above the CCG average of 90% and national average of 89%
  • The practice offered out of hospital mental health shared care and provided care for patients discharged from secondary care to the community.
  • The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
  • Patients at risk of dementia were identified and offered an assessment.
  • The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.
  • The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 10 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 homeless people, travellers and those with a learning disability.
  • 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 offered longer appointments for patients with a learning disability. We saw that all the 11 patients with a learning disability had received a health check in the last year.
  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.
  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.
  • Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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.