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Inspection Summary


Overall summary & rating

Good

Updated 13 September 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Norheads Lane Surgery on 2 August 2017. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety.
  • Clinical staff were aware of current evidence based guidance and had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and felt involved in their care and decisions about their treatment. The practice was rated above average for consultations with the nurse but comparable to or below the national average in some areas for consultations with a GP.

  • Information about services and how to complain was available. Improvements were made as a result of learning from complaints and concerns.
  • A patient participation group (PPG) had been in operation in the practice since 2011. However, there were now only six members of the group and as they no longer held meetings, communication was carried out by email only.

  • Most patients we spoke with said they were usually able to make an appointment with a GP when they wanted one and urgent appointments were usually available the same day through the practice walk-in service.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvement are:

  • The provider should continue to monitor patient satisfaction rates regarding consultations with GPs and implement improvements as appropriate.
  • The provider should consider strategies to encourage patients to join the patient participation group (PPG) and establish regular communication with group members.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 13 September 2017

The

practice is rated as good for providing safe services.

  • There was a system in place for reporting, recording and investigating significant events and lessons were shared to make sure action was taken to improve safety in the practice.

  • When things went wrong, patients were informed as soon as practicable and  received reasonable support, truthful information and a written apology. They were told about any actions taken to improve processes to prevent the same thing happening again.

  • The practice had clearly defined and embedded systems, processes and practices to minimise risks to patient safety.

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

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

Effective

Good

Updated 13 September 2017

The practice is ra

ted as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed that patient outcomes for all indicators were above or comparable to the local and national averages.

  • The overall clinical Exception Reporting rate was comparable to the local and national average.

  • Clinical staff had access to and were aware of current evidence based guidance.

  • Clinical audits demonstrated quality improvement.

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

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

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

  • End of life care was coordinated with other services.

Caring

Good

Updated 13 September 2017

The practice is rat

ed as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for consultations with the nurse and comparable to or below the national average for consultations with a GP.

  • Information for patients about the services available was accessible.

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

Responsive

Good

Updated 13 September 2017

The practice is rated as good for providing responsive services.

  • The practice understood its population profile and had used this understanding to meet the needs of its population.
  • The practice took account of the needs and preferences of patients with life-limiting conditions and patients living with dementia.
  • Patients we spoke with said they were usually able to make an appointment with a GP and urgent appointments were usually available the same day through the practice morning walk-in service.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and evidence from the complaints we reviewed showed the practice responded quickly to issues raised and learning from complaints was shared with staff.

Well-led

Good

Updated 13 September 2017

The p

ractice is rated as good for being well-led.

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

  • There was a clear leadership structure and staff felt supported by management. The practice had policies and procedures to govern activity and these were readily available to staff and reviewed regularly.

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

  • Staff had received an induction, annual performance review and attended staff meetings and training opportunities.

  • The provider was aware of the requirements of the duty of candour. In examples of incidents and complaints we reviewed we saw evidence that the practice complied with these requirements.

  • The provider encouraged a culture of openness and honesty.

    The practice had systems for managing safety incidents and sharing the information with staff and ensuring appropriate action was taken.

  • The practice proactively sought feedback from staff and patients. We saw examples where feedback had been acted on.

  • The practice engaged with the patient participation group via email.

  • There was a focus on continuous learning and improvement at all levels. Staff training was encouraged.

Checks on specific services

People with long term conditions

Good

Updated 13 September 2017

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

  • The Practice Nurse and GP worked collaboratively in the management of patients with long-term conditions.
  • The practice performance rates for the Quality and Outcomes Framework (QOF)diabetes related indicators were above the local and national average.
  • The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.
  • There were processes in place for patients with long-term conditions who experienced a sudden deterioration in health.
  • There was a system to recall patients for a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Good

Updated 13 September 2017

The

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

  • From the sample of records we reviewed we found there were systems to identify and follow up children who were at risk, for example, children and young people who had a high number of accident and emergency attendances.

  • Immunisation rates were below the national target for some standard childhood immunisations but the practice were aware of this and continued to work towards improving uptake rates.

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

  • The practice worked with midwives and health visitors to support this population group in the provision of ante-natal, post-natal and child health surveillance clinics. Quarterly meetings were held with the health visitor to discuss children and families of concern.

  • The practice had processes in place for managing appointments for acutely ill children and for acute pregnancy complications.

Older people

Good

Updated 13 September 2017

The practice is rated as

good for the care of older people.

  • Staff had received training to enable them to recognise the signs of abuse in older patients and knew how to escalate any concerns.

  • The practice offered proactive, personalised care to meet the needs of the older patients in its population.

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

  • Patients were involved in planning and making decisions about their care, including their end of life care.

  • The practice followed up older vulnerable patients when discharged from hospital to ensure care plans were updated to reflect any additional needs.

  • Where older patients had complex needs, the practice shared summary care records with local care services following consent from patients.

  • Older patients were provided with health promotional advice and support to help them maintain their health and independence for as long as possible.

Working age people (including those recently retired and students)

Good

Updated 13 September 2017

The practice is rated as good for the care of 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 and flexible.
  • The practice was proactive in offering online services.
  • A full range of health promotion and screening services were provided that reflects the needs for this age group.

People experiencing poor mental health (including people with dementia)

Good

Updated 13 September 2017

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

  • The practice carried out advance care planning for patients living with dementia.
  • 92% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the preceding 12 months. This was above the local average of 82% and national average of 84%.

  • The practice monitored the physical health needs of patients with poor mental health and dementia.

  • The practice monitored repeat prescribing for patients receiving medicines for mental health needs.
  • 100% of patients diagnosed with a mental health disorder had a comprehensive agreed care plan documented in the preceding 12 months. This was above the local average of 83% and national average of 89%.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those living with dementia.
  • Patients at risk of dementia were identified and offered an assessment.
  • The practice had information available for patients experiencing poor mental health regarding how they could access various support groups and voluntary organisations.
  • The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff we interviewed had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 13 September 2017

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

  • The practice held a register of patients living in vulnerable circumstances including those patients with a learning disability.

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

  • The practice offered longer appointments for patients with a learning disability.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.

  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.

  • Staff we interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies.