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Suffolk GP Federation C.I.C. - Head Office Requires improvement

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Inspection Summary


Overall summary & rating

Requires improvement

Updated 15 March 2019

This service is rated as Requires improvement overall. (Previous inspection October 2013, the provider was compliant with the regulations but was not rated at this inspection.)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Requires improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Requires Improvement

  • We carried out an announced comprehensive inspection at the Suffolk GP Federation C.I.C. as part of our inspection programme on 21, 22, and 29 January 2019. Suffolk GP Federation C.I.C is a community interest company and is the registered provider of three other locations and services are provided from various sites across Suffolk and North East Essex. Suffolk GP Federation C.I.C. holds contracts with Ipswich and East Suffolk, West Suffolk and North-East Essex Clinical Commissioning Groups (CCGs).

At this inspection we found:

  • The Suffolk GP Federation C.I.C was a clinically led organisation and leaders had the capacity and skills to deliver high-quality, sustainable care. We found at senior level the leadership was clear, organised and proactive but this did not always ensure that the leadership at local levels was effective for example we identified risks to patients at the minor injuries unit.
  • We found the records of some patients seen at the minor injuries unit did not contain sufficient detail to evidence that patients had been fully assessed. The management team took immediate action and reviewed the records, contacted patients as appropriate and told us they would implement new systems to address this issue.
  • The service had 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 used various ways to communicate with both regular and sessional staff such as regular emails, newsletter and electronic notifications and staff were responsible for reading communications issued to them. However, not all staff we spoke with during our inspection were aware of the learning shared.
  • We found the service had systems and processes to manage risks to patients but not all of these were fully known or understood by staff working in the local sites where services were delivered. For example, not all staff working at the various locations we inspected were clear about the IPC process and their responsibilities.
  • Although the provider had risked assessed the provision of emergency medicines to ensure they were easily available to staff in the event of a medical emergency, the medicines in stock were not in line with the current guidelines and the mitigation of risk for some medicines was insufficient to ensure patients would receive emergency treatment in a timely manner. The Suffolk GP Federation C.I.C. reviewed their assessment immediately and updated to provide additional medicines.
  • The emergency department streaming service provided care and treatment within service guidelines and timescales. The provider worked closely with emergency department partners to continually evaluate and improve the service, including effective safety protocols in place to manage patients who needed to be referred back into the emergency department.
  • The GP+ service provided patients with timely access to evidence based care and treatment based on their needs. Staff felt well supported and there was good cross site working to effectively manage capacity and demand.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided; however, we found in the minor injuries unit these reviews did not always address issues in the way care and treatment was recorded.
  • We found that staff were knowledgeable about their service but the provider did not have clear and easy oversight that all staff were competent to do their role. We found in some areas such as the minor injuries unit and the cardiology clinic there was a lack of oversight to be assured that all staff had been fully assessed as competent to do their roles.
  • 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.
  • Patients we spoke with and the results from the friends and family test gave positive feedback about the care and treatment they had received.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation. We saw examples of clinical and non- clinical staff having access to further development including leadership programmes.

We saw areas of outstanding practice:

  • In October 2018, the north-east Essex diabetes services (NEEDS) had won a national award in recognition of its clinical excellence at the recent Quality in Care Diabetes award, winning the category for the best adult diabetes education programme. The Suffolk GP Federation C.I.C was also highly commended in the ‘Best Practice and Sustainability’ category for their integrated approach which had improved patient outcomes. The provider continuously and proactively monitored the diabetic service they offered. Regular reports and audits were shared with the North Essex CCG who confirmed they had no concerns about the high level of service offered. Regular audits had been completed such as the number of patients completing the patient education programmes and the monitoring of patients’ blood test results. The CCG analysed the progress of the diabetes quality and outcome (QOF) indicators for the North-East Essex practices comparing 2015/2016 data to 2016/2017 data. This concluded an improvement was seen in eight of the ten QOF indicators. The service saw an average of 1000 patients per month through the year January to December 2018.
  • The falls and fragility service is a small service offered by specialist’s nurses in the community. It was set up six years ago to ensure patients across West Suffolk had equitable access to advice and support. The service gave patients a personalised service with a long term aim to reduce fractures in the age group of over 60 years old. CCG data showed that from April 2018 to November 2018 the service had seen 332 patients. Nationally published data showed that as a result of their approach and follow up the patients they saw were more compliant with their medicines with an 80% compliance compared with the national average of 32%.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure care and treatment is provided in a safe way to patients.
  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas

Safe

Requires improvement

Updated 15 March 2019

We rated the service as requires improvement for providing safe services.

We rated the service as requires improvement for providing safe services because,

  • We found the records of some patients seen at the minor injuries unit did not contain sufficient detail to evidence that patients had been fully assessed to ensure they were kept safe.
  • We found the service had systems and processes to manage risks to patients but not all of these were fully known or understood by staff working the local sites were services were delivered. For example, not all staff working at the various locations we inspected were clear about the IPC process and their responsibilities.

  • Although the provider had risked assessed the provision of emergency medicines to ensure they were easily available to staff in the event of a medical emergency. The medicines in stock were not in line with the current guidelines and the mitigation of risk for some medicines was insufficient to ensure patients would receive emergency treatment in a timely manner. The Suffolk GP Federation C.I.C. reviewed their assessment immediately and updated to provide additional medicines.
  • We found in the minor injuries unit that prescription stationary use was not monitored in line with current guidelines.

Safety systems and processes

The service had some 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, which were regularly reviewed and communicated to staff. Staff received safety information from the provider as part of their induction and refresher training.
  • There was an overarching system to manage infection prevention and control (IPC) and the sites we visited were clean and tidy. The Suffolk GP Federation C.I.C governance team undertook comprehensive audits and developed action plans; however, we found that not all staff working at the various locations we inspected were clear about the IPC process and their responsibilities. There were systems for managing healthcare waste.
  • The provider had systems to safeguard children and vulnerable adults from abuse. Most staff we spoke with were clear about their responsibilities and could outline who to report to both in and out of hours.
  • 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 had a comprehensive system for ensuring staff were recruited safely. They 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 received up-to-date safeguarding and safety training appropriate to their role; however, the system did not record additional training such as sepsis awareness. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • The provider had systems and processes to ensure facilities and equipment were safe and that equipment was maintained according to manufacturers’ instructions, however, we found the system was not wholly effective. For example, staff we spoke with at the GP+ service told us they were encouraged/required to provide some of their own equipment but there was not a clear system for checking and calibrating these.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety but some of these were not effective.

  • 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.
  • There was an induction system for staff tailored to their role. Staff we spoke with told us they had been fully supported by the management team and at a local community site level.
  • We found most staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention; however, staff had not received training in sepsis awareness. In line with available guidance, patients were prioritised appropriately for care and treatment, in accordance with their clinical need. However, we reviewed records of patients seen in the minor injuries service which did not contain sufficient detail to evidence that patients had always received an appropriate initial assessment including a record of basic clinical observations. The service had undertaken regular audits of record keeping but these had failed to identify the problem. We identified this to the management team who took immediate action, reviewed the medical records and told us they would put new measures in place to ensure staff completed and document all appropriate checks.
  • Systems were in place to manage people who experienced long waits.
  • Generally, staff told patients when to seek further help and advised patients what to do if their condition got worse. However, there was a lack of detail in the medical records at the minor injuries unit to be assured that this always happened.
  • When there were changes to services or staff, the service assessed and monitored the impact on safety.

Information to deliver safe care and treatment

We found in the minor injuries unit, the information needed to deliver safe care and treatment to patient needed to be improved. However, across the other services we found staff had appropriate information to deliver safe care and treatment.

  • Most 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. However, we reviewed records of patients seen in the minor injuries service which did not contain sufficient detail to evidence that patients had always received an appropriate initial assessment including a record of basic clinical observations. We highlighted this to the provider who took immediate actions to address this issue.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. Some of these systems were paper based due to the lack of electronic systems to transfer medical information.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance. The service had implemented second checks on referrals made by clinical staff to ensure there was no delay in these being processed.

Appropriate and safe use of medicines

The service had systems for safe handling of medicines however these needed to be improved.

  • The provider did not hold medicines, apart from some emergency medicines, or vaccines as these were not required in the services they delivered.
  • Although the provider had risked assessed the provision of emergency medicines to ensure they were easily available to staff in the event of a medical emergency, the medicines in stock were not in line with the current guidelines and the mitigation of risk for some medicines was insufficient to ensure patients would receive emergency treatment in a timely manner. The Suffolk GP Federation C.I.C. reviewed their assessment immediately and updated to provide additional medicines.
  • The service issued prescriptions at the minor injuries unit. The prescription stationery was kept securely but they did not monitor its use.
  • The prescribing support service offered to GP practices across Suffolk carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed 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.
  • Within the community services and where appropriate, 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.

Track record on safety

  • There were comprehensive risk assessments in relation to safety issues. The provider undertook annual health and safety audits of the locations they used. Audits we reviewed of the sites we visited were detailed and contain action plans where issues had been identified.
  • The service monitored and reviewed activity. This helped it to understand risks which led to safety improvements; however, the reviews undertaken in the minor injuries unit did not always identify safety issues relating to the care and treatment delivered to patients.
  • There was a system for receiving and acting on safety alerts at the head office and evidence that they had been cascaded; however, some staff told us they did not receive the alerts or the learning outcomes from any reviews and staff were aware of their responsibility to read them.
  • Joint reviews of incidents were carried out with partner organisations, including GP practices that were members of the Suffolk GP Federation C.I.C.

Lessons learned and improvements made

  • 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. The provider used an electronic system (Datix) to record and monitor all significant events. The system gave a comprehensive overview of the event, clear audit trail of actions taken. They had recorded for all their services 409 incidence over the past 12 months. The provider used various ways to communicate to all staff including emails and newsletters but did not have a system to check that all staff had read or acted on these.
  • There were systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and acted to improve safety in the service. For example, there were shortfalls in the electronic system to transmit scans for processing. The sonographers had to transcribe patient’s details including their NHS numbers. Following identified errors, the provider implemented a system for an administrator to undertake a second check to ensure all details had been transcribed correctly thus preventing any delays.
  • The service learned from external safety events and patient safety alerts. The service had a mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.

Effective

Requires improvement

Updated 15 March 2019

We rated the service as requires improvement for providing effective services.

We have rated the services as requires improvement because,

  • We found in the minor injuries unit that clinical records had been audited but this process had not identified where staff had not recorded a full assessment of the patient including a set of baseline clinical observations.  

  • The provider did not have clear and easy oversight that all staff were competent to do their role. We found in some areas such as the minor injuries unit and the cardiology clinic there was a lack of oversight to be assured that all staff had been fully assessed as competent to do their roles.
  • 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 but some staff told us they did not read them.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice but these were not all effective.

  • We saw evidence that generally, clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols. We found in the minor injuries unit that clinical records had been audited but this process had not identified where staff had not recorded a full assessment of the patient including a set of baseline clinical observations.  Following our inspection, the provider took immediate action, reviewed the consultation records and implemented systems and processes to address the issues. The provider told us they had cascaded the learning and reminded staff to use the record template to ensure all essential information was recorded and had arranged a meeting to ensure adherence.
  • 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 but some staff told us they did not receive them. The provider showed that they used various modes of communicating this information but did not have a system in place to ensure all staff read them.
  • Except for the minor injuries unit, we found patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing. Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable. For example, patients who were housebound had access to services such as falls and fragility by having clinicians visit patients in their homes.
  • We saw no evidence of discrimination when making care and treatment decisions in the records we viewed.
  • The CCG confirmed that the service data on the performance met the contract standards.
  • For the GP+, minor injuries unit, arrangements were in place to deal with repeat patients. The service alerted the patient’s own GP. There was a system in place to identify frequent callers and patients with particular needs, for example palliative care patients, and care plans/guidance/protocols were in place to provide the appropriate support.
  • When staff were not able to make a direct appointment on behalf of the patient clear referral processes were in place. The GP+ and minor injuries unit had fail systems in place to ensure all referrals were dealt with in a timely manner.
  • Some technology and equipment was used to improve treatment and to support patients’ independence. However, the provider identified some limitations and challenges due to lack of integrated IT systems for example the patient information flow within the minor injuries unit was paper based.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided; however, this had not identified issues with patients records in the minor injuries unit. Some examples include:

Emergency department streaming:

  • Data from the CCG performance team confirmed the service had performed at 100% in relation to time spent in A+E department, time to initial assessment time to treatment and patients waiting less than four hours.

The minor injuries:

  • Data from the CCG showed from April 2018 to December 2018, 4230 patients between were treated in the minor injuries unit.

GP+ service:

  • Data from the CCG showed from April 2018 to December 2018, 43000 patients were seen across the 9 sites where GP+ was offered.

The non-obstetric ultrasound service:

  • CCG data showed waiting times from referral to treatment showed that in April 2018 and August 2018 all patients were seen within the six-week target; since the transition to a new clinical system there had been some delays that resulted in approximately 1% of patients waiting longer that six weeks. Since December 2018, there was a reorganisation of the service which, along with the intelligence gained from the clinical system, optimised the transformation of ultrasound scheduling to be more predictive and reduce the potential longer waiting times. From April 2018 to November 2018 the service saw 9,824 patients.

The diabetes service:

  • The diabetes services (NEEDS) which was delivered in North East Essex had won a national award which recognised its clinical excellence at the recent Quality in Care Diabetes award, winning the category for the best adult diabetes education programme. The Suffolk GP Federation C.I.C was also highly commended in the ‘Best Practice and Sustainability’ category for their integrated approach which had improved patient outcomes. The provider continuously and proactively monitored the diabetic service they offered. Regular reports and audits were shared with the North Essex CCG who confirmed they had no concerns about the high level of service offered. Regular audits had been completed such as the number of patients completing the patient education programmes and the monitoring of patients’ blood test results. The CCG analgised the progress of the diabetes quality and outcome (QOF) indicators for the North-East Essex practices comparing 2015/2016 data to 2016/2017 data. This concluded an improvement was seen in eight of the ten QOF indicators. The service saw an average of 55 patients per month in 2018.

The falls and fragility service:

  • CCG data showed that from April 2018 to November 2018 the service had seen 332 patients. Staff we spoke with told us that as a result of their approach and follow up the patients that they saw were more compliant with their medicines and said their compliance percentage was 80% compared with the national percentage of 32%.

The bowel and bladder service:

  • Data from the CCG showed from April to December 2018 the service saw 2787 patients and 100% of patients were seen within 18 weeks of referral.

The stoma care service:

  • Data from the CCG showed from April 2018 to December 2018 108 patients were treated and 100% of patients were seen within the 18 weeks of referral. From April 2018 to December 2018 the longest wait was 12 weeks.

The service made improvements through the use of completed, full cycle audits. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality. For example, the first cycle of an audit in relation to the prescribing of an antibiotic was undertaken in the GP+ service which showed 46% of the prescribing was in line with guidance. All the clinical staff were sent a letter with advice and guidance to ensure they were prescribing safely and within the guidelines. The second cycle undertaken in December 2018 showed this had increased to 68%. Further actions had been taken including a pop up message within the clinical system and to implement regular reporting. A further audit was programmed for June 2019.

  • The service was actively involved in quality improvement activity. For example, the diabetes service and the falls and friability service both contribute to the national audit programmes and share good practice across the wider health teams.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles however the service did not monitor all staff to ensure they maintained their skills in line with evidence based guidance.

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff. This covered such topics as fire safety and safeguarding training. The provider did not have clear and easy oversight that all staff were competent to do their role. We found in some areas such as the minor injuries unit and the cardiology clinic there was a lack of oversight to be assured that all staff had been fully assessed as competent to do their roles.
  • The provider 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. Staff we spoke with told us they were supported to undertake further training; some members of the non- clinical management team had been enrolled on to leadership courses. Several GPs from the member practices had been supported to undertake leadership training and qualifications and were using these skills to further the primary care at scale work.
  • The provider provided staff with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation.
  • There was a lack of oversight and the provider could not easily demonstrate how it ensured the competency of all staff employed.
  • There were systems and processes to ensure staff were supported and managed 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 found staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment.
  • 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. Care and treatment for patients in vulnerable circumstances was coordinated with other services. For example, patients with diabetes care was shared between the service and their GP practice and in some cases the hospital. Staff communicated promptly with patient's registered GP’s 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. There were established pathways for staff to follow to ensure callers were referred to other services for support as needed. The service worked with patients to develop personal care plans that were shared with relevant agencies.
  • 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 considered the needs of different patients, including those who may be vulnerable because of their circumstances.
  • There were clear and effective arrangements for booking appointments, transfers to other services. Staff were empowered to make direct referrals and/or appointments for patients with other services.

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 patient’s 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 decide.
  • The provider monitored the process for seeking consent appropriately.

Caring

Good

Updated 15 March 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.
  • The service gave patients timely support and information. Staff gave people referred into the service clear information. There were arrangements and systems in place to support staff to respond to people with specific health care needs such as those who had mental health needs.
  • The provider sought constant feedback from the patients and this showed patients felt they had received good care from the staff. All the patients we spoke with told us that had received kind and care treatment.

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. We saw notices in the reception areas, including in languages other than English, informing patients this service was available. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.
  • Patients told us, 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.
  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.
  • 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.

Privacy and dignity

The service respected and promoted patients’ privacy and dignity.

  • Staff respected confidentiality at all times.
  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Responsive

Good

Updated 15 March 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. For example, the community clinics were held in many locations, often in GP practices across Suffolk enabling patients to be seen in a convenient place they knew.

  • The provider engaged with commissioners to secure improvements to services where these were identified. For example, they identified that following the transition to an electronic clinical system there had been a small number of patients who had experienced a delay to being seen within the 18 weeks target for ultrasound scans. Working with the CCG, the service made changes and optimised the electronic system to be more predictive and reduce the potential for delays.
  • The provider improved services where possible in response to unmet needs. For example, the diabetes services which operated in North East Essex actively sought patients who did not regularly attend health checks. They offered support and education to ensure patients had greater awareness of and the skills to promote self-management their diabetes.
  • The service made reasonable adjustments when people found it hard to access the service and had a system in place that alerted staff to any specific safety or clinical needs of a person using the service. In particular, patients who required home visits were assessed to ensure staff were aware of anything they needed to consider. For example, patients with poor mobility or hearing difficulties who may live alone and needed extra time to answer the door or telephone.
  • Care pathways were appropriate for patients with specific needs, for example those at the end of their life, babies, children and young people.
  • The facilities and premises were appropriate for the services delivered.
  • The service was responsive to the needs of people in vulnerable circumstances. For example, patients who may have dementia or a learning disability were given additional time and appointments were arranged at time that were convenient for their carers or relatives.

Timely access to the service

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

  • Patients could access care and treatment at a time to suit them. Each service operated a variety of times for example the GP+ service saw patients who had appointments booked through their GP practice each evening from 6.30pm to 9pm and at the weekends. Patients requiring minor injuries services were able to attend with an appointment, the service was open from 7am to 10pm every day.
  • Patients had timely access to initial assessment, test results, diagnosis and treatment. We saw the most recent CCG results for the services (April to December 2018) which showed the provider was meeting the standards set in the performance contract.

For all services, except for ultrasound, the provider had performed at 100% and the performance for ultrasound was 99%. This meant that all patients referred to the service had been seen and treated within the agreed times frames from the time of referral.

  • Waiting times, delays and cancellations were minimal and managed appropriately; for example, in the stoma 100% of patients were seen with 12 weeks.
  • The service engaged with people who were in vulnerable circumstances and took actions to remove barriers when people found it hard to access or use services. The service offered the clinics in a significant number of places across Suffolk giving easy access to patients and in surroundings that were familiar to them. Home visits were arranged for those services where patients were housebound including the falls and frailty service.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Referrals and transfers to other services were undertaken in a timely way. For example, in the cardiology clinic each patient assessed by the GP with special interest was discussed with the consultant. If needed, a direct booking could be made with secondary care.

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 and it was easy to do. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. 26 complaints were received in the last year, these were recorded on the electronic Datix system. The provider had clear oversight of the complaint, the service it was regarding, the timeliness of the actions taken and response to the patient. We reviewed three complaints and found they were well manged and completed in a timely way.
  • Issues were investigated across relevant services and staff were able to feedback to other parts of the patient pathway where relevant.
  • The service learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care. They sent regular newsletters and emails sharing the learning across the services. Each service verbally discussed complaints amongst the team at their local level.

Well-led

Requires improvement

Updated 15 March 2019

We rated the service as requires improvement for leadership.

We rated the service as requires improvement for well led services because,

  • In some areas the provider had not ensured care and treatment was provided in a safe way to patients or that governance systems were always effective and some legal requirements were not met.

Leadership capacity and capability

The Suffolk GP Federation C.I.C was a clinically led organisation and leaders had the capacity and skills to deliver high-quality, sustainable care. However; we found at senior level the leadership was clear, organised and proactive but this did not always ensure that the leadership at local levels was effective for example we identified risks to patients at the minor injuries unit.

  • Leaders had the experience, capacity and skills to deliver the service strategy and address risks to it. We found the board and management team of the Suffolk GP Federation C.I.C had a wide range of experience, knowledge and skills both in clinical and non- clinical remits, however this was not always replicated at local levels.
  • The senior management team were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them. The Suffolk GP Federation C.I.C. had been proactive in working with other organisations such as the CCGs, local county councils and mental health trust to develop new models of care and at scale working to provide alternative ways to deliver care to patients.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • Senior management was accessible throughout the operational period, with an effective on-call system that staff were able to use.
  • The provider had processes to develop leadership capacity and skills, including planning for the future leadership of the service. The Suffolk GP Federation C.I.C.had been proactive and had supported a number of GPs to undertake a future leaders programme giving them the skills and confidence to lead the federation and to help other organisations such as the local medical committee and the Suffolk Primary Care (SPC) partnership. Leadership programmes were offered to non-clinical staff and we spoke with staff members who had started the course.
  • Shortly after the inspection and due to the concerns we identified, we asked the provider to establish what immediate action they proposed to take to reduce that risk. The provider responded with an action plan for improvement in the short term. Additional senior managers had been employed to oversee the identified improvements that were needed and support for the clinical lead had been identified and put into place. The Clinical Commissioning Group also agreed to provide support to the provider.

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 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.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them. Staff were passionate about the service they delivered and how they had contributed to the design of the services.
  • The strategy was in line with health and social priorities across the region. The provider planned the service to meet the needs of the local population.
  • The provider monitored progress against delivery of the strategy.
  • The provider ensured that staff who worked away from the main base felt engaged in the delivery of the provider’s vision and values.

Culture

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

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. We saw that patients received detailed responses to incidences and complaints including investigation, outcomes and learning identified and actions taken. 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 staff development opportunities. This included appraisal and career development conversations. All staff received regular annual appraisals. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff. Staff we spoke with reported positively about their experience of working within the Suffolk GP Federation C.I.C Where staff were concerned, they told us that they addressed these with the management team.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. 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 at senior level. However, for some risk management such as calibration of equipment this did not always ensure that actions required were understood and undertaken by the staff at local levels.

  • Structures, processes and systems to support good governance and management were clearly set out, but these were not always understood or effective. For example, we found that the consultation records of clinical staff in the minor injuries unit did not contain sufficient detail to be assured that patients had been assessed fully. There were systems in place to audit these records however, these audits had not identified the shortfall in the documentation and the risk to patients.
  • The management team held regular meetings to discuss the services they operated. These meetings were held monthly with detailed agenda and minutes. The agendas included regulatory and contractual compliance, finance, information governance, risk management workforce, patient safety and patient experience quality assurance, clinical effectiveness and service development. We reviewed the minutes of meetings held in November 2018 which were detailed, with clear actions and progress mapping.
  • The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care. We saw many examples of this throughout all the community clinics.
  • We found across all services and sites that some staff were not clear on their roles and accountabilities in respect of safeguarding and there was a lack of awareness of other processes and responsibilities such as infection prevention and control and ensuring equipment was safe to use.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were processes for managing risks, issues and performance at senior level but there was a lack of systems and process to ensure these were monitored and changes made at service and site level.

  • There was a process to identify, understand, monitor and address current and future risks including risks to patient safety but this was not always effective.
  • The provider had processes to manage current and future performance of the service. The provider worked with other stakeholders such as the CCGs to identify trends and ensure the service was delivering the care and treatment that was needed in the right place for patients to have easy access.
  • The provider showed evidence that performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions but this was not always effective. We found in the minor injuries unit that audits had been completed however, they had not highlighted the lack of detail in some consultation notes.
  • The provider did not have clear and easy oversight that all staff were competent to do their role. We found in some areas such as the minor injuries unit and the cardiology clinic there was a lack of oversight to be assured that all staff had been fully assessed as competent to do their roles. The processes used to review performance were not always effective.
  • Leaders had oversight of patient safety alerts, incidents, and complaints; however, learning was not always shared with staff. Leaders also had a good understanding of service performance against local key performance indicators. Performance was regularly discussed at senior management and board level. Performance was shared with staff and the local CCG as part of contract monitoring arrangements.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality.
  • The providers had plans in place and had trained staff for major incidents.
  • The provider implemented service developments and where efficiency changes were made, this was with input from clinicians to understand their impact on the quality of care.

Appropriate and accurate information

The service generally acted on appropriate and accurate information

  • Quality and operational information was used to ensure and improve performance but in the minor injuries unit we found evidence that poor quality of record keeping had not been identified and addressed to keep patients safe.
  • 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 service 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 service used information technology systems to monitor and improve the quality of care.
  • The service submitted data or notifications to external organisations as required.
  • There were effective 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 service 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. For example, we spoke with patients who had been seen at the various community clinics and all the patients were complimentary about the care and treatment they had received.
  • The provider actively encouraged patients to give their feedback after every contact at each service. Data for the past 2 years, from the friends and family test, showed they had consistently high performance with scores ranging from 84% to 100% for patients extremely likely/likely to recommend the service to their family and friends.
  • Staff were able to describe to us the systems in place to give feedback which included verbal feedback, via the family and friends test or by a paper questionnaire.
  • We saw evidence of the most recent staff survey and how the findings were Suffolk GP Federation C.I.C back to staff. The Suffolk GP Federation C.I.C had a staff council whose purpose was to engage with staff and provide a two-way platform for communication through the organisation. It provided all staff with the opportunity to feed into the strategic plans and decisions. The staff council had members including a representative from the board, operations and human resource director, human resource manager and 12 staff representatives from all the services.
  • Results from the staff survey showed 83% of staff who responded would recommend the Suffolk GP Federation C.I.C as a good place to work. 76% of staff who responded said they felt involved in deciding changes that affected their work. The management team had compiled an action plan to address areas for improvement based on staff feedback.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement at all levels within the service.
  • Staff knew about improvement methods and had the skills to use them.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There was a strong culture of innovation evidenced by the number of pilot schemes the provider was involved in. There were systems to support improvement and innovation work. For example, engagement with Integrated Neighbourhood Teams to ensure that integrated services can be delivered locally.