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Archived: Shannon Court Surgery Good

This service was previously registered at a different address - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 1 November 2018

This practice is rated as good overall.


The key questions are rated as:

Are services safe? – Requires Improvement

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 Shannon Court Surgery on 18 September 2018 as part of our comprehensive inspection programme.

At this inspection we found:

  • We found communication with the practice required strengthening as staff were aware of where policies were kept, but unsure of what policies were available.
  • The practice was unable to demonstrate that an infection control audit had been completed and we found some of the staff had not completed the appropriate training for infection control relevant to their role.
  • 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.
  • Clinical staff immunisation status was not recorded for some of the clinical team and no risk assessments had been completed to identify duties undertaken, risks and actions to minimise the risk to staff and patients.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use, but some patients commented on difficulties in getting routine appointments.
  • Patients commented positively on the care received by the practice.
  • Staff involved and treated patients with compassion, kindness, dignity and respect. Results from the August 2018 national GP patient survey showed that the practice scored above local and national averages in a number of areas.

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

The areas where the provider should make improvements are:

  • Continue to review process to identify carers.
  • Review and monitor staff training to ensure staff have completed training updates appropriate to their role.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas

Safe

Requires improvement

Updated 1 November 2018

We rated the practice as requires improvement for providing safe services as no risk assessments had been completed in the absence of staff immunisation and legionella. The practice was unable to demonstrate infection control audits had been undertaken an, staff had not received the appropriate training updates relevant to their role.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse, however there was some confusion on speaking with staff on who the safeguarding lead was.

  • 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. Reports and learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a 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, harassment, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • The practice told us there was a system to manage infection prevention and control, however the practice was unable to demonstrate that an infection control audit had been undertaken and on reviewing a selection of staff files we found no evidence that infection control training had been completed.
  • 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.

Risks to patients

There some 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.
  • On reviewing staff personnel files, we found staff immunisation status was not recorded for some of the clinical team and no risk assessments had been completed to identify duties undertaken, risks and actions to minimise the risk to staff.
  • 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, however some of the administration staff were unaware of red flags for 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.

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff. There was a documented approach to managing test results.
  • 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.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed, administered or supplied 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 stewardship in line with local and national guidance.
  • 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.
  • Arrangements for dispensing medicines at the practice kept patients safe.

Track record on safety

The practice had a good track record on safety, however we did identify a lack of risk assessments in relation to staff immunisation,

  • There were some comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed activity, however we identified gaps in the effectiveness of their systems. For example: the practice was unable to demonstrate that an effective legionella assessment had been completed.
  • Some of the systems in place helps the practice understand risks and gave a clear, accurate and current picture of safety that led to safety improvements.

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.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 1 November 2018

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

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.

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. This 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 mental health, psychological and communication needs.

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.
  • 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 ran a diabetes clinic with the support of a diabetes specialist nurse.

Families, children and young people:

  • Childhood immunisation uptake rates were in line with the target percentage of 90% or above.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.
  • The practice had arrangements to identify and review the treatment of newly pregnant women on long-term medicines. Health checks for babies between six and eight week were carried out by the clinical team; and other routine checks were carried out by the health visitors.
  • The practice offered contraceptive advice and services to patients aged 16 and over. Clinical staff demonstrated competencies in the principles use to judge capacity in children to consent to medical treatment and understood the importance of involving them in the decision-making process as far as possible.

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

  • The practice’s uptake for cervical screening was 77%, which was above the local average of 74%, but below the 80% coverage target for the national screening programme.
  • The practice’s uptake for breast and bowel cancer screening was above 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 homeless people, travellers and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.
  • Clinicians screen for drug and alcohol misuse; patients in need of support were referred appropriately.

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.
  • The practice offered annual health checks to patients with a learning disability.

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. The practice had undertaken a range of medicine audits with the support of the clinical commissioning group (CCG) prescribing advisor. The audits identified patients that required medicine reviews and changes to medicines where appropriate.

Data taken from the 2016/17 QOF year showed that results were significantly better than local and national averages in a number of clinical areas. For example, patients diagnosed with respiratory diseases such as asthma and chronic obstructive pulmonary disease (COPD).

  • Where appropriate, clinicians took part in local and national improvement initiatives.
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

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 and qualifications were maintained, however we found gaps in training updates for some staff. 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, coaching and mentoring, clinical supervision and revalidation.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.
  • Dispensary staff were appropriately qualified and their competence was assessed regularly. They could demonstrate how they kept up to date.

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 and when coordinating healthcare for care home residents. 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.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

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 1 November 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The 2018 national GP patient survey published in August 2018 indicated that patient satisfaction regarding how they were treated was positive.

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, 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 had identified carers and offered some support, however the practice was unable to demonstrate an effective approach to encouraging carers to identify themselves. We found no evidence of services or support groups available to carers on display in the practice.
  • The national GP patient survey results published in August 2018 showed patients responded positively to questions relating to involvement in decisions about care and treatment with the practice achieving scores in line with local and national averages.

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 1 November 2018

We rated the practice and 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 allocated appointments daily for the duty doctor who would triage patients who were unable to get an appointment to assess if they were required to be seen urgently.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered. The practice had moved to the current premises in April 2018 after the previous facilities became unsuitable to deliver for the services delivered. The new premises had been renovated to ensure they met the requirements of the practice and the practice population.
  • The practice had made some reasonable adjustments when patients found it hard to access services. For example, all the consulting rooms were on the second floor of the premises, however, a room on the ground floor had been allocated as a consulting room to support patients who were unable to access the lift in the building.
  • The practice did not have a hearing loop in place. We were told that an alert would be added to the patients’ clinical record if a difficulty was noted by staff for the patient to access the practice and services available.
  • 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 provided dispensary services for people who needed additional support with their medicines, for example a delivery service, weekly or monthly blister packs.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GP and practice nurse also accommodated home visits for those who had difficulties getting to the practice.
  • The practice offered an electronic prescription service which enabled prescriptions to be sent electronically from the GP practice to a patient’s chosen pharmacy for patient convenience and to support patients who were unable to leave their home.

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 held regular meetings with the local community nursing teams to discuss and manage the needs of patients with complex medical issues.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life were coordinated with other services.

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 under the age of five were offered a same day appointment when necessary.
  • Late appointments were available with the nursing team to accommodate school age children.

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 were offered two mornings a week from 7am to 8am.
  • Telephone GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The practice website gave patients access to online services, including appointment bookings and ordering of repeat medicines.
  • The practice carried out healthy lifestyle checks for patients over the age of 45 years and offered advice and support with lifestyle changes.
  • Meningitis vaccines for 18-year olds and students going to university were available at the practice

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.
  • The practice was proactive in understanding the needs of the patients, such as people who may be approaching the end of their life and people who may have complex needs, such as housebound patients. Staff had received training in Gold Standards Framework (GSF) (an evidence based guideline to deliver high quality end of life care), and were using GFS to coordinate end of life care with other health care professionals.

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

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • A mental health nurse attended the practice once a week to support patients with complex mental health needs.
  • Clinicians carried out dementia screening including annual blood tests. There were referral processes in place where identified patients were referred to secondary care memory clinics.

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.
  • A duty doctor was available each day to deal with emergencies and triage calls when appointments were no longer available.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • The 2018 national GP patient survey indicated that patients were not entirely satisfied with appointment times or the types of appointment they were offered; however, patients responded positively to getting through to the practice by phone.

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 1 November 2018

We rated the practice as good for providing a well-led service.

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.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

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

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.

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.
  • The practice 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. 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 received regular 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, however comments from staff highlighted a divide between the management team and administration staff on occasions,

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 set out, but on speaking with staff with found communication required strengthening to ensure all were aware and the processes were effective. The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities in respect of safeguarding, however the management team had not monitored staff training in infection prevention and we found some staff had not received updates relevant to their role.
  • Practice leaders had established policies, procedures and activities to ensure safety and was operating as intended. On speaking with staff, they were aware of where the polices were held, but unsure what policies were available and the information they contained.

Managing risks, issues and performance

There were processes for managing risks, issues and performance, however these were not embedded within the practice.

  • There was a process to identify, understand, monitor and address current and future risks including risks to patient safety, however there was no oversight in the management of risk in the absence of appropriate staff training.
  • 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 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 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.

Continuous improvement and innovation

There were 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.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

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

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