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Inspection Summary


Overall summary & rating

Good

Updated 8 August 2018

This practice was previously inspected in October 2017 and rated as Requires improvement overall.

This practice is now rated as Good overall.

The key questions at this inspection 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 Baldwins Lane Surgery on 4 July 2018 to follow up on breaches of regulations we identified during our previous inspection in October 2017.

At this inspection we found:

  • The practice had taken appropriate action following our previous inspection in October 2017 to ensure they were complying with regulations where we had previously identified breaches.
  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice 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 patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels.

We saw one area of outstanding practice:

The practice had discussed as a team they would like to improve their numbers of patients attending screening for Abdominal aortic aneurysm (AAA). The practice invited all male patients registered with them, over the age of 65, who had previously not been invited, or had been invited and not attended, for screening of Abdominal aortic aneurysm (AAA). In total the practice invited 228 male patients to attend. Of the patients invited, 79 attended and five were diagnosed with an abnormal aorta. All identified patients were followed up appropriately. The practice was contacted by the screening team at a local NHS trust and asked if they would share the letter they had used to invite patients as it was felt that other GP practices who struggled with patients attending screening appointments would benefit from using the letter.

The areas where the provider should make improvements are:

  • The provider should ensure all actions from their fire risk assessment are completed as planned.
  • The provider should continue to improve processes to ensure all safety checks are documented in line with practice policies and procedures.
  • The provider should ensure all relevant staff are aware of the practice’s policy for patient specific directives, and take action to ensure it is adhered to and operated effectively when a healthcare assistant is employed.
  • The provider should continue to take action to improve uptake of children’s’ vaccinations.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Safe

Good

Updated 8 August 2018

At our previous inspection on 3 October 2017, we rated the practice as requires improvement for providing safe services. We found that the arrangements for

monitoring of patients on some high risk medicines, recruitment processes and storage of emergency medicines and equipment needed improving.

These arrangements had significantly improved when we undertook a follow up comprehensive inspection on 4 July 2018.

Safety systems and processes

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

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. (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 took steps, including working with other agencies, to protect patients from abuse, neglect, discrimination and breaches of their dignity and respect.
  • Since our October 2017 inspection, the practice had improved their recruitment processes and we saw the practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.
  • We found the practice had actions outstanding from their fire risk assessment in 2016. The provider told us they had a programme of work in place and had taken action to mitigate risk in the meantime.

Risks to patients

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

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was an effective induction system for temporary staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

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

  • All of the care records we saw, except for one showed that information needed to deliver safe care and treatment was available to staff.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

The practice had reliable systems for appropriate and safe handling of medicines. With the exception of systems to support effective use of Patient Specific Directives (PSD).

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial prescribing in line with local and national guidance. The lead GP informed us they monitored antibiotic prescribing closely and would take action if staff were not following guidelines and prescribing appropriately.
  • Since our previous inspection, the practice had reviewed their storage of emergency medicines and equipment. We saw these were stored in one location and easily accessible to staff.
  • The practice had also improved their processes for reviewing patients on high risk medicines.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.
  • The practice’s policy for patient specific directives (a PSD is an instruction to administer a medicine to a list of individually named patients where each patient on the list has been individually assessed by that prescriber) was not effective and staff were unclear on their roles and responsibilities. At the time of the inspection, the practice did not employ a healthcare assistant and was not using PSDs, so there was no risk to patients. Following our inspection, the practice sent us a revised protocol for PSDs which included clear roles and responsibilities ensuring the safe administration of vaccines by a healthcare assistant.

Track record on safety

The practice had a good track record on environmental safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed safety using information from a range of sources.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.
  • The practice shared learning from safety events with other local GP practices.
  • The practice sent us evidence after the inspection, to show they had discussed the concerns we had raised during the inspection regarding the use of PSDs, and had taken appropriate action.

Please refer to the evidence tables for further information.

Effective

Good

Updated 8 August 2018

We rated the practice and all of the population groups as good for providing effective services overall.

Effective needs assessment, care and treatment

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

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.
  • The practice used technology and equipment to improve treatment and to support patients’ independence. We saw the practice was using a health monitoring machine, which patients could use independently without the need for an appointment to monitor certain health measures including blood pressure and weight.
  • The practice were also trialling the use of an App (a computer application that can be used on a computer, mobile phone or tablet device), that gave patients access to their records, allowed patients to book appointments, order repeat prescription, and gave patients access to lifestyle advice.

Older people:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.
  • The practice had carried out an audit of male patients on their patient list above the age of 65 who were eligible for screening for Abdominal aortic aneurysm, to see how many had attended their screening appointment (a screening to detect swelling of the main blood vessel that runs from the heart, down through the abdomen to the rest of the body). Those patients that had previously not been invited, or had not attended their screening appointment, were invited for screening at a local screening facility. In total, 228 patients were contacted. 79 of these patients attended for screening. Five of these patients were found to have an abnormal aorta as a result of the audit and were followed up appropriately.

People with long-term conditions:

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension)
  • The practice’s performance on quality indicators for long term conditions was in line with local and national averages.

Families, children and young people:

  • Childhood immunisation uptake rates were below the target percentage of 90%. The practice was aware of this and had taken action to improve immunisation uptake.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.

Working age people (including those recently retired and students):

  • The practice’s uptake for cervical screening was 73%, which was below the 80% coverage target for the national screening programme. The practice was aware of this and had taken appropriate action to improve screening rates.
  • The practice’s uptake for breast and bowel cancer screening was in line with the national average.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

  • 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 held a register of patients living in vulnerable circumstances including those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

People experiencing poor mental health (including people with dementia):

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medication.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • At the time of the inspection, the practice told us they had 12 patients registered with them who were living with dementia. The practice gave us unverified data to show all 10 patients had been reviewed in the past year and all 12 had medication reviews.
  • The practice offered annual health checks to patients with a learning disability.
  • The practices performance on quality indicators for mental health was in line with national averages.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

The practice used information about care and treatment to make improvements. We saw the practice discussed QOF performance during practice meetings with clinical and non-clinical staff. The practice had taken action following 2016/2017 QOF results to improve exception reporting levels, childhood vaccination rates and cervical screening rates.

Effective staffing

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

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, clinical supervision and revalidation.
  • 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 with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.
  • The practice had displayed examples of unit glasses of alcohol in the waiting area to highlight recommended units for men and women.
  • The practice had a health monitoring machine in the waiting area, which patients could use to monitor blood pressure, pulse, height, weight, body mass index (BMI). The machine produced a receipt which patients placed into a secure box, and the nursing staff would enter the details on to the patients record. If the patients receipt indicated the patient needed a review this was arranged.

Consent to care and treatment

The practice 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 practice monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.

Caring

Good

Updated 8 August 2018

At our previous inspection on 3 October 2017, we rated the practice as requires improvement for providing caring services. We found that the arrangements for responding to patient feedback to improve patient experience needed improving.

These arrangements had improved when we undertook a follow up comprehensive inspection on 4 July 2018. The practice are now rated as good for providing caring services.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • We saw staff treating patients with kindness and respect.
  • CQC comment cards were mostly positive about the way staff treated patients.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The practice’s 2017 GP patient survey results were below local and national averages for questions relating to kindness, respect and compassion. In particular, for questions relating to consultations with the GP. Staff told us they had reviewed results from the survey and had made changes to staffing. Staff had also received appropriate training to improve communication with patients.
  • Since our October 2017 inspection, the practice had carried out their own patient survey to help them determine the cause of patient dissatisfaction and help identify further training needs.
  • The practice had found following their own survey, patient satisfaction with GP consultations had improved.
  • Staff told us they had reviewed the use of locum GPs and felt this had contributed to increased patient satisfaction. They also told us they would be repeating their own survey to monitor patient satisfaction.

Involvement in decisions about care and treatment

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

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them.
  • The practice’s 2017 GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment. The provider’s own patient survey (January to March 2018) showed patients were satisfied with how well the GP explained tests and treatments.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues or appeared distressed reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.

Responsive

Good

Updated 8 August 2018

At our previous inspection on 3 October 2017, we rated the practice as requires improvement for providing responsive services. We found that the arrangements for responding to patient’s mobility needs needed improving.

These arrangements had improved when we undertook a follow up comprehensive inspection on 4 July 2018. The practice are now rated as good for providing responsive services.

We rated all of the population groups, as good for providing responsive services.

Responding to and meeting people’s needs

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

  • The practice understood the needs of its population and tailored services in response to those needs.
  • The practice offered extended opening hours on a Thursday evening which supported patients who were unable to attend the practice during normal working hours.
  • The practice offered phlebotomy appointments at the practice.
  • The practice offered online services such as booking appointments and ordering repeat prescriptions.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services. The practice had made changes to one of their clinical rooms, to ensure patients who could not access the minor operations room, could receive their treatment in a suitable room.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.
  • The practice supported patients who were housebound (permanently or temporarily). The practice nurses had six dedicated home visit appointment slots assigned to their weekly schedule.
  • The lead GP used his gynaecology specialist skills to reduce referrals to secondary care where appropriate. The practice provided data to show between April 2017 and March 2018, five patients who would normally have been referred for a hospital appointment had been seen at the practice for a gynaecological biopsy procedure.

Older people:

  • All patients had a named GP who supported them.
  • The practice were part of a group of GP practices (Hall Green Collaborative Group) that had come together to provide additional services for patients. As part of this group they had employed a nurse and a medicines management person to review any patients over 75 years old that had been discharged from hospital to ensure they had been discharged safely and address any additional needs they may have.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice communicated with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • 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. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child received a telephone call back from the GP or were offered a same day appointment when necessary.
  • Pregnant and post natal women were able to access a midwife at the practice one day a week.

Working age people (including those recently retired and students):

  • The needs of this population group 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.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability. At the time of the inspection the practice did not have any homeless or traveller patients registered with them.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

People experiencing poor mental health (including people living with dementia):

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.

Timely access to care and treatment

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

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • The practice’s 2017 national GP patient survey results were in line with local and national averages for questions relating to access to care and treatment.
  • Staff told us they were encouraging patients to use the health monitoring machine for checking blood pressure or height and weight measurements as an alternative to booking an appointment where appropriate. This meant the patient could visit the surgery when it suited them and it meant the practice could make more effective use of its appointments. Results were printed and passed to a practice nurse to arrange follow up where appropriate

Listening and learning from concerns and complaints

The practice 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. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 8 August 2018

At our previous inspection on 3 October 2017, we rated the practice as requires improvement for providing Well-led services. We found that the arrangements for management of governance processes required improvement including monitoring and improving quality, identifying and establishing actions to mitigate risk, and systems for monitoring and responding to training needs.

These arrangements had significantly improved when we undertook a follow up comprehensive inspection on 4 July 2018. The practice are now rated as good for providing Well-led services .

Leadership capacity and capability

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

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. 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.
  • Staff told us since our last inspection, roles and responsibilities of leaders was clearer, leading to better outcomes for patients and the practice.

Vision and strategy

The practice had a vision and credible strategy to deliver high quality, sustainable care.

  • The practice did not have a documented vision and set of values. However, all staff we spoke with spoke of similar goals and values.
  • The practice did not have a documented strategy and supporting business plan. However, staff spoke of plans to federate with other GP practices in the future to deliver additional services. We saw the practice were already engaging with other practices within the Hall Green Collaborative Group to plan additional services that would meet the needs of the practice population.

Culture

The practice had a culture of high-quality sustainable care.

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice. We saw the practice had a low turnover in staff. Staff told us since the last inspection they felt communication was better between teams which resulted in greater job satisfaction and a better outcome for patients.
  • The practice focused on the needs of patients.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff had received annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care.
  • The practice had taken action since our inspection in October 2017 to improve their governance processes. During this inspection we found all staff were clear on their roles and accountabilities in respect of infection prevention and control.
  • The practice had made appropriate improvements to their policies for obtaining satisfactory references and to the management of high risk medications.
  • We saw the practice had established policies, procedures and activities to ensure safety however, we did find gaps in the management of patient specific directives.. Following the inspection, the practice sent us evidence they had discussed their processes around the use of PSDs and had amended their PSD policy.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved patients, the public, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The service was transparent, collaborative and open with stakeholders about performance..
  • We saw the practice had displayed in reception an action plan of how they had responded to the concerns raised in our previous report.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • One of the practice nurses was being supported to complete a prescribing course which would lead to benefits for staff and patients.
  • The practice had identified and invited patients at risk of Abdominal aortic aneurysm (AAA) for screening. Clinical audits demonstrated an improvement in the identification and treatment of AAA. The practice shared the letter they had devised to invite patients for screening with the screening team from a local NHS trust who then shared the letter with local GP practices.
  • The practice had been using a health monitoring machine for seven months, to measure patients weight, height, body mass index, blood pressure and pulse. The practice provided evidence to show in seven months, the machine had been used 697 times. The practice were monitoring use of the machine and its impact on the practice for example if there was a positive effect on appointments. Staff told us the machine was benefiting patients as it prompted recalls if measurements indicated the need for a full health review. Results from the machine were printed and left securely for the practice nurses to review.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good