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Inspection Summary


Overall summary & rating

Good

Updated 18 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Lime Tree Surgery on 9 May 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.
  • Data showed that practice achievement for cervical cytology, immunisations for five year olds and bowel screening was below the CCG and national averages.
  • Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
  • All staff had completed mandatory training in line with their role; this included safeguarding children, fire training and chaperoning.
  • Results from the national GP patient survey showed patients were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day, however results from the GP Patient Survey did not support this and were low in relation to making and obtaining an appointment.
  • 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 patient participation group was active and they purchased a defibrillator for the practice from monies they raised from fundraising.

The areas where the provider should make improvement are:

  • Continue to work to improve patient satisfaction with access to services including getting through to the practice by telephone and obtaining an appointment.
  • Continue to work to increase the uptake of cervical cytology, childhood immunisations and bowel screening.

Review the process for recalling patients with mental health illnesses to increase the uptake of annual reviews.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 18 July 2017

The practice is rated as good for providing safe services.

  • From the sample of documented examples we reviewed, we found there was an effective system for reporting and recording significant events; 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, received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.
  • The practice held regular meetings where learning from significant events and patient safety alerts were discussed and shared.
  • 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 18 July 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework showed patient outcomes were mostly comparable to the CCG and the national averages.
  • Data showed that cervical cytology, immunisation rates for five year olds and bowel screening rates were lower than the CCG and national averages.
  • Staff 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 involved.

Caring

Good

Updated 18 July 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice comparably to the CCG and national averages for several aspects of care.
  • Survey information we reviewed showed that patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
  • The practice had identified less than 1% of its patient as being a carer.

Responsive

Good

Updated 18 July 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, including patients with a condition other than cancer and patients living with dementia.
  • Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. However results from the GP patient survey did not support this view.
  • The practice had extended hours appointments on two evenings a week and was a part of the local HUB which provided appointments on weekday evenings and weekends when the practice was closed.
  • 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 two examples reviewed showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 18 July 2017

The practice 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 held regular governance meetings.
  • An overarching governance framework supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • Staff had received inductions, annual performance reviews and attended staff meetings and training opportunities.
  • The provider was aware of the requirements of the duty of candour. In one example we reviewed we saw evidence the practice complied with these requirements.
  • The partners encouraged a culture of openness and honesty. The practice had systems for being aware of notifiable safety incidents and sharing the information with staff and ensuring appropriate action was taken.
  • The practice proactively sought feedback from staff and patients and we saw examples where feedback had been acted on. The practice engaged with the patient participation group, which was very active.
  • There was a focus on continuous learning and improvement at all levels. Staff training was a priority and was built into staff rotas.
  • GPs who were skilled in specialist areas used their expertise to offer additional services to patients.

Checks on specific services

People with long term conditions

Good

Updated 18 July 2017

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

  • Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.
  • 78% of patients with diabetes had a record of a foot examination and risk classification documented in their records compared to the CCG average of 80% and the national average of 88%. The practice had an exception reporting rate of 4%, which was lower than the CCG average of 6% and the national average of 8%.
  • 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 emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.
  • All these patients had a named GP and 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 named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
  • The practice held health promotion events for these patients.

Families, children and young people

Good

Updated 18 July 2017

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

  • From the sample of two documented examples we reviewed 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.
  • Immunisation rates were relatively low for immunisations for five year olds.
  • The practice provided support for premature babies and their families following discharge from hospital.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal, post-natal and child health surveillance clinics.
  • The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications.
  • There was a GP with a specialist interest in womens health who carried out six week baby checks.
  • The practice had a dedicated room for breastfeeding.

Older people

Good

Updated 18 July 2017

The practice is rated as good for the care of older people.

  • Staff were able 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.
  • These patients were offered an annual review and had a named GP.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
  • The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.
  • The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.
  • Where older patients had complex needs, the practice shared summary care records with local care services.
  • Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible.

Working age people (including those recently retired and students)

Good

Updated 18 July 2017

The practice is rated as good for the care of working age people (including those recently retired and students).

  • The needs of these populations had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.
  • Telephone consultations were available each day.
  • The practice was signed up to the local HUB which provided appointments on weekday evenings and weekends when the practice was closed.
  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group. 

People experiencing poor mental health (including people with dementia)

Good

Updated 18 July 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.
  • 76% of with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive agreed care plan documented in the record compared to the CCG average of 91% and the national average of 89%.The practice had an exception reporting rate of 3%, which was lower than the CCG average of 7% and the national average of 13%.
  • The practice had a policy to not exception report these patients unless there were extenuating circumstances.
  • The practice specifically considered the physical health needs of patients with poor mental health and dementia and gave these patients longer appointments to give enough time to discuss their complex needs.
  • The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.
  • 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 about 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 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 18 July 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 homeless people, refugees and those 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.
  • These patients were offered an annual review.
  • 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 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 in normal working hours and out of hours.