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Inspection Summary


Overall summary & rating

Good

Updated 15 February 2019

We carried out an announced focused inspection at King Street Health Centre on 31 January 2019 as part of our inspection programme.

At the last inspection in June 2018 we rated the practice as good overall, with a rating of requires improvement for providing safe services. The full comprehensive report regarding the June 2018 inspection can be found by selecting the ‘all reports’ link for King Street Health Centre on our website at www.cqc.org.uk.

The practice was rated as requires improvement for providing safe services because:

  • The provider was not able to give full assurance that all Patient Group Directions and updates had been fully authorised.
  • The provider had not checked or recorded the immunity status of applicable staff with regard to measles, mumps and rubella, and chickenpox.
  • There was only limited assurance regarding the system for checking emergency medicines and equipment.
  • All relevant staff were not aware of the symptoms of sepsis.

In addition to the areas for improvement identified under the key question of providing safe services, at the inspection in June 2018 we also said the practice should consider improving the following area:

  • Review and improve communication activities with staff.

At this inspection, we found that the provider had satisfactorily addressed these areas.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information from the provider and other organisations.

Overall the practice is now rated as good overall, with the practice rated as good for providing safe services.

Our key findings were as follows:

  • The provider had adopted practices and processes which ensured Patient Group Directions had been fully authorised, and that staff were fully competent to deliver vaccinations and immunisations.
  • The provider had made, or was in the process of making, the necessary checks to assure themselves of the immunity status of all relevant staff members. This included status checks in relation the measles, mumps and rubella, and chickenpox.
  • We saw that the provider had developed and implemented processes for the checking of emergency medicines and equipment.
  • Staff had introduced processes and procedures, and raised staff awareness, to enable them to identify and manage patients with severe infections including sepsis.
  • The provider had improved communication with staff members. We saw for example, that staff bulletins were circulated and there were mechanisms in place for staff to cascade feedback to managers.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 15 February 2019

Effective

Good

Updated 25 July 2018

  • 84% of people who arrived at the service completed their treatment within 1 hour.
  • 15% of people who arrived at the service completed their treatment between 1 and 2 hours.
  • 1% of people who arrived at the service completed their treatment between 2 and 3 hours.

In addition, the provider shared with us information which reinforced this data and showed patient outcomes which demonstrated that since May 2018:

  • The service had given treatment to over 2,500 patients who had not required any subsequent follow up.
  • Referred and supported over 500 patients to another more appropriate service.
  • Referred around 200 patients to accident and emergency/999.

  • The service used information about care and treatment to make improvements. For example, to ensure patients received appropriate care they had introduced a streaming system if identify patients where care needed to be prioritised.
  • The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality. For example, an audit of patients presenting with a sore throat carried out in December 2017 showed that 14 of 20 consultations had been classified as high-quality consultations. Where deficiencies had been highlighted there was some evidence that this had been discussed with individual clinicians. Such audits were regularly repeated and formed part of the staff annual appraisal process.

Effective staffing

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

  • All staff were appropriately qualified. The provider had a two-day mandatory induction programme for all newly appointed staff. This covered such topics as health and safety, safeguarding, incident reporting and work specific instruction support.
  • The provider ensured that all staff worked within their scope of practice and had access to clinical support when required.
  • Staffing numbers at the time of inspection were adequate.
  • However, in light of some previous recruitment and capacity issues the provider had used funding derived from Health Education England Yorkshire and the Humber and worked with others to establish posts for five trainee advanced clinical practitioners within the health centre. These were recruited from allied health professionals (who included pharmacists and paramedics) and were being supported to attain an Advanced Care Practitioner Masters programme at an accredited university. This was achieved via a mix of attendance at a local university, work experience and personal development at the health centre and other medical settings. The programme had oversight from GP clinical supervisors and appropriately qualified advanced nurse practitioners. Candidates were appointed in May 2018, and the provider had recently been informed that they had been awarded a further five trainee posts to commence in January 2019.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop. We saw that at the time of inspection 93% of all mandatory training requirements had been achieved and the provider had in place processes to track training compliance.
  • The provider gave staff ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The provider could demonstrate how it ensured the competence of staff employed in advanced roles by audit of their clinical decision making.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.
  • The provider had developed a procedure to manage throughput of patients. This contained details of appropriate escalation routes and actions to be taken should demand begin to exceed capacity or actually exceeded capacity. For example, action included the redeployment of other staff to the health centre from other sites operated by the provider.

Coordinating care and treatment

Staff worked together, and worked well with other organisations when required to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment.
  • Patients received coordinated and person-centred care. This included when they moved between services or when they were referred to other organisations. Staff communicated promptly with patient's registered GP’s so that the GP was aware of the need for further action. Staff also referred patients back to their own GP to ensure continuity of care, where necessary.
  • Patient information was shared appropriately, and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way.
  • The service had formalised systems with the NHS 111 service with specific referral protocols for patients referred to the service. An electronic record of all consultations was sent to patients’ own GPs. The provider reported some minor issues with regard to sharing patient record information, but that this was not serious.
  • The service ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those who may be vulnerable because of their circumstances.
  • There were clear and effective arrangements for booking appointments, and transfers to other services. Staff were empowered to make direct referrals and/or appointments for patients with other services.
  • The provider told us that they were working with both the extended and out of hours services to enable patients to be seen by the most appropriate service. In addition, the provider was also working with local service commissioners to offer a consistent model of assessment/triage irrespective of where the patient attends or calls. This supported achievement of the NHS target of ensuring 50%5 of NHS 111 contact are in receipt of clinical triage.

Helping patients to live healthier lives

Staff were consistent and proactive in empowering patients, and supporting them to manage their own health and maximise their independence.

  • The service identified patients who may be in need of extra support.
  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors, where identified, were highlighted to patients and their normal care providers so additional support could be given.
  • Where a patient’s need could not be met by the service, staff redirected and supported them to access services appropriate to their needs.

Consent to care and treatment

The service obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The provider monitored the process for seeking consent appropriately.

Caring

Good

Updated 25 July 2018

We rated the service as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information. Reception staff gave patients clear information and kept them updated with regard to ongoing issues such as extended waiting times. There were arrangements and systems in place to support staff to respond to people with specific health care needs such as end of life care and those who had mental health needs. We saw that staff training was generally up to date and this ensured staff could deal with these specific needs. Staff could also call on support from the wider organisation for clinical advice and support when this was required.
  • All of the 14 patient Care Quality Commission comment cards we received were positive about the service experienced, although two of the comment cards also included a less positive comment with regard to the confidentiality at the reception desk and another comment related to the perceived poor attitude of a staff member. Results from the NHS Friends and Family Test showed that from November 2017 to the date of inspection 81% of service users would be either extremely likely or likely to recommend the service to others. The provider had recently introduced a patient survey and whilst this was in it’s very early days of operation, feedback viewed during the inspection was positive.
  • We saw that the provider supported patients to access more appropriate services when they were outside the scope for being treated by the service. To support this, the provider had developed clinical presentation guidance to advise staff how these patients should be assisted. This guidance included that patients would be informed of this but that they would still be offered a basic assessment so that they could be properly referred and supported to access the most appropriate service.

Involvement in decisions about care and treatment

Staff helped patients be involved in decisions about their care and were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information they are given):

  • Interpretation services were available for patients who did not have English as a first language. Information leaflets were available in easy read formats, to help patients be involved in decisions about their care.
  • Patients told us through comment cards, that in general they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • For patients with learning disabilities or complex social needs family, carers or social workers would be appropriately involved.
  • Staff communicated with people in a way that they could understand, for example, the provider had worked with an organisation which supported people who had a visual impairment and as a result of this changes had been made to literature used to advise patients. At the time of inspection the provider was in consultation with an organisation which supported people who had a hearing impairment on how best to deliver and make improvements to the service on offer to these patients.
  • Staff helped patients and their carers find further information and access community and advocacy services.

Privacy and dignity

The service respected and promoted patients’ privacy and dignity.

  • Staff informed us that they respected confidentiality at all times.
  • Staff understood the requirements of legislation and guidance when considering consent and decision making.
  • Staff supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The service monitored the process for seeking consent appropriately.
  • It was noted during the inspection that confidentiality at the reception area was poor and that private discussions could be overheard. The provider acted on our comments regarding confidentiality and after the inspection told us they had taken action to improve this. Actions included placing a privacy screen in reception and/or placing a line in front of the queuing area which marked a minimum distance other patients should wait behind, and also asking patients if they would rather write what their problem was rather than discussing it at reception.

Responsive

Good

Updated 25 July 2018

Well-led

Good

Updated 25 July 2018

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

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders had the experience, capacity and skills to deliver the service strategy and address risks to it.
  • They were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges in developing the new service, aligning capacity and demand and managing patients who presented to them but were out of the scope of the service. We saw that the provider had worked on approaches to address these issues. For example, they had developed guidance for staff on how to deal with patients who presented themselves at the health centre but were outside the scope of the service.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • Senior management was accessible throughout the operational period, with an effective on-call system that staff were able to use.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.
  • Staff we spoke to on the day said that they felt supported by the leadership team and they felt comfortable raising issues with them.
  • During the inspection it was noted that a member of the clinical team with management responsibilities had limited capacity and time allocated to deliver all these duties.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The service developed its vision, values and strategy jointly with staff and stakeholders.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The provider planned the service to meet the needs of the local population and to meet contractual obligations.
  • The provider monitored progress against delivery of the strategy and key performance indicators.

Culture

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

  • Staff felt respected, supported and valued. Frequently during the inspection staff told us how proud they were to work for the provider and at the health centre.
  • The service focused on meeting the needs of the patients who attended the service.
  • 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, and we saw that apologies had been made and explanations given to patients with respect to past 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.
  • Staff communication via team meetings was limited and periods of time between meetings had become extended. For example, team meetings were meant to be held on a quarterly basis, however the period of time between meetings had extended to four to five months. Minutes of team meetings whilst detailed, showed limited evidence of staff input. After the inspection we were sent details by the provider of actions implemented to improve communication with staff, this included:

    • Creation of a communications folder on the shared drive of the IT system and holding a paper copy on reception for staff to access.
    • Weekly bulletins for staff asking them to raise suggestions, concerns or other issues.
    • Establishing a buddy system at meetings to ensure important messages could be cascaded on to staff who cannot attend meetings.
    • Provide more regular meetings and make minutes more detailed.

  • Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff and staff were able to access occupational health support and other wellbeing services when required.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

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

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were 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 provider had processes to manage current and future performance of the service. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of MHRA alerts, incidents, and complaints. Leaders also had a good understanding of service performance against the national and local key performance indicators. Performance was regularly discussed at senior management and board level. Performance was shared with staff and the local CCG as part of contract monitoring arrangements.

Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality.

The providers had plans in place and had trained staff for major incidents.

The provider implemented service developments and where efficiency changes were made this was with input from clinicians to understand their impact on the quality of care.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. The provider had just begun to carry out patient satisfaction surveys and combined this with performance data to improve performance.
  • Quality, sustainability and improvement were discussed in relevant meetings.
  • The service used performance information which was reported and monitored, and management and staff were held to account. When necessary staff were supported to improve performance.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses. For example, the provider had recently updated it’s IT system to improve performance monitoring and reporting.
  • The service used information technology systems to monitor and improve the quality of care.
  • The service submitted data or notifications to external organisations as required.
  • There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

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

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. For example, the provider sought patient feedback on the trial of the patient streaming service and used this in part during the decision to expand this service.
  • Staff were able to describe to us the systems in place to give feedback. However, it was noted that feedback via staff meetings appeared limited. Since the inspection we have been informed of methods which will be introduced by the provider to improve this, such as via more frequent meetings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement at all levels within the service. For example, the provider made detailed use of clinical audits and performance monitoring to continual track service improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The service made use of reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There was a strong culture of innovation evidenced by the number of pilot schemes the provider was involved in. These included:

    • The recently introduced patient streaming system used to manage periods of high demand.
    • The introduction and support of the trainee advanced clinical practitioner programme to develop skills and ease capacity and recruitment issues.

Checks on specific services

People with long term conditions

Good

Updated 19 August 2016

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

  • Staff had lead roles in chronic disease management, which included diabetes, chronic obstructive pulmonary disease (COPD) and asthma, and patients at risk of hospital admission were identified as a priority.

  • Longer appointments and home visits were available when needed.

  • Patients had a named GP and 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 multidisciplinary packages of care.

  • The practice offered 24 hour blood pressure monitoring and in-house spirometry.

Families, children and young people

Good

Updated 19 August 2016

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

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk.

  • We were told by the practice that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

  • The practice uptake for the cervical screening programme was 76%, which was below the CCG average of 84% and the national average of 82%.

  • Child immunisation rates were significantly below the Clinical Commissioning Group average for five year olds.

  • Appointments were available outside of school hours and the premises were suitable for children and babies. Additionally, patients could access the walk-in centre out of the practice core hours.

  • All staff had received safeguarding training and were aware how to follow up concerns.

Older people

Good

Updated 19 August 2016

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

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

  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. For example, practice nurses made home visits to administer flu vaccinations to older patients who struggled to attend the surgery.

  • Care plans had been developed for older patients who were identified as being at risk.

Working age people (including those recently retired and students)

Good

Updated 19 August 2016

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

  • The practice was proactive in offering online services, which included appointment booking and repeat prescription requests.

  • A range of health promotion and screening was offered that reflected the needs for this age group, this included weight management advice and smoking cessation support.

  • Telephone consultations were available to those unable to attend the surgery.

People experiencing poor mental health (including people with dementia)

Good

Updated 19 August 2016

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

  • The practice regularly worked closely with other health professionals in the case management of patients experiencing poor mental health, including those with dementia. Practice staff told us they also worked closely with relatives of patients who had poor mental health including dementia when this was appropriate.

  • The practice told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

  • Staff had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 19 August 2016

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 and used this information to coordinate services. For example, it used the mental health register to recall patients for regular reviews and a carers register to offer winter flu immunisations.

  • The practice and walk-in centre provided regular services for members of the nearby traveller community.

  • The practice offered longer appointments for patients with enhanced needs such as those with a learning disability or the frail elderly, and offered health checks and care planning.

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

  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

  • Staff knew how to recognise signs of abuse in vulnerable adults. Staff 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.