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Integrated Care Centre Violet Melchett Centre Good

Inspection Summary


Overall summary & rating

Good

Updated 29 August 2019

This service is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Violet Melchett Centre Integrated Care Centre (GP Hub) on 26 June 2019 as part of our inspection programme. At this inspection we found:

  • There were systems in place to safeguard children and vulnerable adults from abuse and staff we spoke with knew how to identify and report safeguarding concerns. All staff had been trained to a level appropriate to their role.
  • There was an open and transparent approach to safety and systems were in place for recording, reporting and sharing learning from significant events.
  • The service reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • There was a programme of quality improvement including clinical audit which had a positive impact on quality of care and outcomes for patients.
  • Staff had the skills, knowledge and experience to deliver effective care.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • The service took complaints and concerns seriously to improve the quality of care.
  • Leaders demonstrated they had the capacity and skills to deliver high-quality, sustainable care.
  • The provider engaged with patients and staff to improve the service.
  • The provider was aware of the duty of candour and examples we reviewed showed the service complied with these requirements.
  • There was a focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Review current Public Health England (PHE) guidance in relation to immunisation status for staff in direct patient contact.
  • Review guidance and training for non-clinical staff in relation to fridge temperature monitoring and recording in line with best practice.
  • Review staff understanding of the term duty of candour.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 29 August 2019

We rated the service as good for providing safe services.

Safety systems and processes

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

  • The service had appropriate systems to safeguard children and vulnerable adults from abuse. There was a lead member of staff for safeguarding processes and procedures and policies covering adult and child safeguarding which were accessible to staff. All staff had received up-to-date safeguarding training appropriate to their role. We saw that clinicians and the service manager were trained to child safeguarding level 3 and other non-clinical staff were trained to either level 2 or level 1. Staff we spoke with knew how to identify and report concerns.
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, discrimination and breaches of their dignity and respect. Learning from safeguarding incidents was discussed at relevant meetings, which were minuted and available to staff.
  • Notices were displayed to advise patients that a chaperone service was available if required. Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • The service engaged locum GPs and nurses through one locum workforce agency. Non-clinical staff were employed. We saw evidence that there was a system in place to check all relevant employment documentation provided by the agency for GPs and nurses. We saw that the service carried out appropriate staff checks at the time of recruitment and on an ongoing basis. We reviewed six staff files, which included locum staff, and found appropriate checks had been undertaken, which included photo-ID, references, DBS checks and professional registration.
  • The service maintained the hepatitis B status of all clinical staff at the point of recruitment but did not routinely maintain the immunisation status of all staff in direct patient contact in line with the recommendations of Public Health England (PHE).
  • There was an effective system to manage infection prevention and control (IPC) which included a nominated IPC lead, training for all staff relevant to their role and regular audit. We observed the premises to be clean and tidy.
  • The arrangements for managing waste and clinical specimens kept people safe.
  • The service operated from Central London Community Healthcare (CLCH) NHS Trust premises who managed and maintained the facilities. The provider had oversight of maintenance undertaken and had access to records. We saw various risk assessments had been carried out which included legionella and fire.
  • We saw evidence that all staff had undertaken fire awareness training. Staff we spoke with knew the location of the fire evacuation assembly point. We saw evidence that the fire alarm was tested weekly and logged.
  • The provider ensured that medical equipment was safe and maintained according to manufacturers’ instructions. We saw evidence that annual calibration had been undertaken in March 2019.

Risks to patients

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

  • The service provided one GP at each session, one nurse on Tuesday, Wednesday, Thursday, Saturday and Sunday and two receptionists at each session. GP and nurse sessions were filled by some local GPs and locum GPs. Arrangements were in place for planning and monitoring that this requirement was fulfilled and took account of holidays, sickness and busy periods. We saw evidence that rotas were planned ahead.
  • There was an effective induction system for temporary staff tailored to their role. This was supported by a locum pack, which we saw was regularly reviewed and updated.
  • The service was equipped to deal with medical emergencies (including suspected sepsis) and staff were suitably trained in emergency procedures. There was oxygen and a defibrillator on site and systems to ensure these were regularly checked and fit for use. All staff had received basic life support training in line with guidance.
  • The service had access to all the appropriate emergency medicines. We saw there was an emergency medicine box for the location and the provider held an additional supply of emergency medicines for its service. However, we found some medicines were not held by the provider, for example benzylpenicillin (used for suspected bacterial meningitis) but was available in the emergency medicines available at the location. Immediately after the inspection the provider sent an updated risk assessment of the emergency medicines it intended to hold in line with guidance and to avoid confusion in the event of an emergency. The provider also sent evidence that it had updated its emergency medicine stock and check list to reflect the changes.
  • Clinicians we spoke with knew how to identify and manage patients with severe infections including sepsis. We saw that a sepsis update had been included in the October 2018 clinical bulletin.
  • Receptionists we spoke with were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given written guidance on identifying such patients.
  • The service had a comprehensive business continuity plan in place for major incidents such as power failure or building damage. The plan included emergency contact numbers for staff.
  • The provider held a risk register and we saw that all identified risks had been assessed to define the level of risk by considering the category of probability against the category of impact on the service. All risks had been allocated a RAG (red, amber, green) rating based on this assessment. The provider regularly monitored this.

Information to deliver safe care and treatment

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

  • Individual care records, including clinical data, were written and managed securely and in line with current guidance and relevant legislation.
  • There were systems for sharing information with a patient’s GP and other agencies to enable them to deliver safe care and treatment. For example, the service undertook cervical screening for patients registered at all the GP practices covered by the service. The test result was sent directly to a patient’s GP. The service sent notification to the patient’s GP through the clinical system to advise them a cervical smear had been undertaken to enable them to monitor receipt of the result.
  • Referral letters contained specific information to allow appropriate and timely referrals. The service had a system in place to send a notification to a patient’s GP through the clinical system when an urgent two-week wait referral had been undertaken. We saw that the service also had a process in place to monitor urgent two-week wait referrals.
  • The service complied with the Data Protection Act 2018, including General Data Protection Regulation (GDPR). We saw that staff had undertaken data security awareness training.

Appropriate and safe use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • There was a dedicated medicines storage refrigerator with built-in thermometer and an internal portable temperature data logger. It was the responsibility of the nurse to record the daily refrigerator temperatures when at the location. When the nurse was not available this was undertaken by a member of the non-clinical team. We saw evidence that the minimum, maximum and actual temperatures had been recorded by the nurse, but only the actual temperature recorded by the non-clinical team. Immediately after the inspection the service provided evidence that they had undertaken a significant event analysis (SEA) in relation to the potential breach of the cold chain. In line with their cold chain policy they downloaded the temperature data from the data logger to ascertain if there had been a breach of the minimum temperature (2oC) and the maximum temperature (8oC) and sought guidance from the medicines information team at the local trust. The SAE concluded that there had been no significant rise in temperature which would affect the quality or efficacy of the medicines stored in the refrigerator. A recommendation and outcome of the SAE was to retrain non-clinical staff on the cold chain policy.
  • Blank prescriptions were kept securely, and their use monitored in line with national guidance.
  • Staff prescribed and administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The service monitored the prescribing of its clinicians through regular notes reviews.
  • The service had reviewed its antimicrobial prescribing and had taken action to support good antimicrobial stewardship in line with local and national guidance.
  • The service monitored the prescribing of controlled drugs, for example investigation of unusual prescribing, quantities, dose, formulations and strength.
  • Staff we spoke with explained the process in place for the appropriate monitoring and clinical review required ahead of prescribing high-risk medicines, for example warfarin. However, a review of prescribing showed that no high-risk medicines had been prescribed in the last 12 months.
  • The service had the support of the federation pharmacists.

Track record on safety

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

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • The provider demonstrated its system for recording and acting on significant events. There was an incident policy.
  • Staff we spoke with understood their duty to raise concerns and report incidents and near misses and knew how to do this. They told us leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service.
  • The service demonstrated it shared lessons and outcomes through monthly meetings, which were minuted. We reviewed the content of minutes from the last five months and saw several examples of shared learning. For example, the GP locum pack was updated to include the process for community referrals through the clinical system and the referral pathways available.
  • The provider had processes in place to share information with other organisations such as the National Reporting and Learning System (NRLS), the Clinical Commissioning Group (CCG) and the Care Quality Commission (CQC). This role was the responsibility of the managing director who was the provider’s registered manager for the registration with the CQC.
  • We saw evidence that the provider had complied with the Duty of Candour (a set of specific legal requirements that providers of services must follow when things go wrong with care and treatment). Not all staff we spoke with immediately understood the term duty of candour. However, when prompted were able to give examples.
  • The service held a log of all the medicines and safety alerts and actions undertaken for relevant alerts. The service had an effective mechanism in place to disseminate and act on alerts. We saw alerts were included in the monthly bulletin and learning outcomes in monthly meetings, which were minuted. Staff we spoke with confirmed they received the bulletins and had access to minutes of meetings.

Effective

Good

Updated 29 August 2019

We rated the service as good for providing effective services.

Effective needs assessment, care and treatment

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

  • 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. Guidance and updates were communicated to all clinical staff through monthly bulletins, and meetings. The provider held quarterly educational meetings, which included a paediatric update, safeguarding and asthma. Staff we spoke with confirmed this. Locum staff were invited to attend, and remuneration offered.
  • The service monitored that these guidelines were followed through risk assessments, audits and random sample checks of patient records.
  • 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.
  • Reception staff knew to contact clinical staff for any patients presenting with high-risk symptoms, such as chest pain or difficulty in breathing.

Monitoring care and treatment

The service served a patient population of 250,000 registered at 42 GP practices. The service, over both GP hub locations, was commissioned to provide each week 282 GP appointments (five appointments per hour) and 212 practice nurse appointments (four appointments per hour). Appointment capacity can be increased at the request of the commissioners. For example, directly after the Grenfell Tower fire disaster additional GP and nurse appointments were provided.

We saw that appointment utilisation, did not attend (DNA) rates, cervical screening and immunisation uptake were provided to the board and commissioners on a monthly basis.

We reviewed utilisation data for the period June 2018 to June 2019 for this GP hub location and found:

  • 6313 GP appointments were available, of which 4104 were booked (65%). Of the booked appointments we saw that 789 (19%) of patients were recorded as did not attend (DNA).
  • 2140 nurse appointments were available, of which 2669 were booked (85%). Of the booked appointments we saw that 592 (22%) of patients were recorded as did not attend (DNA).
  • The provider was aware of the DNA rates and monitored these. They told us that this had been a challenge, but improvements had been through patient and practice education to cancel appointments not required. The service was looking at providing a text reminder service. We saw that the monthly average DNA rate for GP and nurse appointments at this location had reduced from 21% in May 2018 to 13% in May 2019.

As part of its commissioned services, the GP hubs provided cervical screening to increase uptake by offering the service outside of core GP hours and at weekends. We reviewed data and found that between April 2017 and March 2018 516 cervical smears had been undertaken. For the period April 2018 to March 2019 this had increased to 993.

There was evidence of quality improvement and they routinely reviewed the effectiveness and appropriateness of the care provided.

  • The service undertook monthly antimicrobial prescribing audits to ascertain if antimicrobials were prescribed according to evidence-based guidelines and controlled drug audits. Audit outcomes were discussed with prescribers. We saw clinicians had access to local prescribing guidelines.
  • The service routinely reviewed clinical notes. The provider reviewed 15 patient records for each clinician after each five clinical sessions undertaken at the service. One-to-one feedback was provided to clinicians. Clinicians we spoke with confirmed this.
  • The service undertook other audits which included two-week-wait referrals, safeguarding and cervical screening.

Effective staffing

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

  • Staff had appropriate knowledge for their role.
  • The service understood the learning needs of staff and provided protected time and training to meet them. Up-to-date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The service had a mandatory training schedule for staff which included safeguarding children and adults, chaperoning, mental capacity act (MCA), infection prevention and control, basic life support, data security awareness, fire awareness, health and safety and equality and diversity.
  • The service could demonstrate how they ensured role-specific training and updating for relevant staff. For example, cervical screening competency training.
  • The service provided staff with ongoing support. There was an induction programme for new staff, including locum staff, one-to-one meetings, appraisals and clinical supervision.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The service shared clear and accurate information with relevant professionals
  • Patients received coordinated and person-centred care.

Helping patients to live healthier lives

As a GP Hub, the service was not able to provide continuity of care to support patients to live healthier lives in the way that a GP practice would. However, we saw the service demonstrate their commitment to patient education and promotion of health and well-being advice.

Staff we spoke to demonstrate a good knowledge of local and wider health needs of patient groups who may attend the GP Hub. GPs and nurses told us they offered patients general health advice within the consultation and if required they referred patients to their own GP for further information.

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 make a decision. We saw that Mental Capacity Act (MCA) training was included as part of the mandatory training schedule.

Caring

Good

Updated 29 August 2019

We rated the service as good for caring.

Kindness, respect and compassion

During our inspection we observed that members of staff were courteous and helpful to patients and treated them with kindness, respect and compassion.

  • Staff we spoke with demonstrated they understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • We saw equality and diversity training formed part of the provider’s mandatory training schedule.
  • We received 16 patient Care Quality Commission comment cards, all of which were positive. Comments included excellent service and care, professional and friendly staff and treated with care and respect.
  • The provider also collected patient feedback through the NHS Friends and Family Test. Data for the period July 2018 and April 2019, based on 102 responses showed that 92% would be extremely likely or likely to recommend the service.
  • We did not have the opportunity to speak with any patients during our inspection.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the

Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Interpretation services were available for patients who did not have English as a first language.
  • Information leaflets, including easy read format leaflets 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.

  • We observed that there were arrangements to ensure confidentiality at the reception desk. For example, computer screens could not be seen when standing at the reception desk. Staff we spoke with gave examples of how they maintained confidentiality. For example, patient identifiable information not being visible.
  • Staff we spoke with told us that if patients were distressed or wanted to discuss sensitive issues they would be taken to a private room.

Consultation and treatment room doors were closed during consultations; conversations taking place in these rooms could not be overheard.

Responsive

Good

Updated 29 August 2019

We rated the service as good for providing responsive services.

Responding to and meeting people’s needs

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

  • The service understood the needs of its population and tailored services in response to those needs. The service was intended to avert patients using accident and emergency services (A&E) for non-urgent concerns and to increase the uptake of childhood immunisations and cervical screening.
  • The facilities and premises were appropriate for the services delivered.
  • The service made reasonable adjustments when patients found it hard to access services. Patients had access to interpreter services and there was an induction hearing loop in place in the reception area for patients who had hearing difficulties.
  • The service was advertised through participating GP practices on their websites.

Timely access to care and treatment

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

  • Patients had timely access to initial assessment, diagnosis and treatment. Patient feedback was positive about the convenience of the service.
  • Waiting times and delays were minimal and managed appropriately.
  • The service at this location was open from 6:30pm to 9pm on weekdays, from 8am to 4pm on Saturdays and from 8am to 2pm on Sundays. Patients registered at one of the 42 GP practices served by the service could access appointments through their own GP practice. NHS 111 and urgent care centres had direct access to appointments.

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. Staff treated patients who made complaints compassionately.
  • There had been three written complaints in the past 12 months.
  • The complaint policy and procedures were in line with recognised guidance. The service learned lessons from individual concerns and complaints and from analysis of trends. It acted as a result to improve the quality of care.

Well-led

Good

Updated 29 August 2019

We rated the service 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 service had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

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

  • There was a clear vision and set of values. The service 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 service planned its services to meet the needs of the service population.
  • The service monitored progress against delivery of the strategy.

Culture

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

  • Staff we spoke with stated they felt respected, supported and valued. They were proud to work in the service.
  • Staff told us there were positive relationships between staff, it was a very friendly team and the clinical leads and hub manager were approachable and accessible when needed.
  • The service focused on the needs of patients.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included regular appraisal.
  • The service actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.

Governance arrangements

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

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective.
  • The local management team included a clinical director, GP leads, nurse lead, general manager and hub manager overseen by a general manager and board of directors.

The service held regular meetings, which were minuted. Locum staff were invited to attend meetings and educational events and offered payment.

  • Staff we spoke with were clear on their roles and accountabilities including in respect of safeguarding, significant event reporting and infection prevention and control.
  • Service leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. Staff we spoke with knew how to access these.

Managing risks, issues and performance

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

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The service had processes to manage current and future performance. Service leaders had oversight of safety alerts, incidents, and complaints.
  • Audits 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 service had plans in place and had trained staff to deal with major incidents.
  • The service considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The service 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 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 submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

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

  • The service obtained feedback from patients from a range of sources including the NHS Friends and Family (FFT) test, complaints, comments and suggestions and direct feedback during clinical encounters.
  • The staff we spoke to informed that they were always consulted before making any changes that may affect their work.
  • 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.
  • The service made use of internal and external reviews of incidents and complaints.
  • Learning was shared effectively and used to make improvements.
  • The service was actively promoting and facilitating childhood immunisations and cervical screening for patients from its member practices.