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Inspection Summary


Overall summary & rating

Good

Updated 27 March 2019

This practice is rated as Good overall. (Previous rating 5 June 2018 – Good)

The well-led key question at this inspection is rated as: Good.

We carried out an announced focused inspection at North Park Health Centre on 24 January 2019 to follow up a breach of regulation from our last inspection carried out on 5 June 2018.

The full comprehensive report on the June 2018 inspection can be found by selecting the ‘all reports’ link for North Park Health Centre on our website at .

At the previous inspection of 5 June 2018 we rated the practice as ‘good’ overall but as ‘requires improvement’ in the well-led key question. We identified a breach of Regulation 17 HSCA (RA) Regulations 2014 - Good governance. This was because the systems and processes to support good governance were not always clearly set out and there was not always sufficient leadership oversight of some of the systems and processes in place.

This inspection was a follow up inspection to confirm that the provider had carried out their plan to meet the legal requirements. Our key findings were as follows:

  • The provider had taken action to meet the breach of regulation.
  • The systems and processes in place to ensure good governance had been reviewed and improved.

We also looked at action taken in response to the recommendations we had made to the provider following the last inspection visit. We found:

  • A formalised process had been put in place to demonstrate that staff were provided with appropriate support, training, appraisal and professional development.
  • An up to date record of staff training had been produced to ensure the provider had an overview of the training staff had undergone and to identify any gaps in training.
  • A new system had been introduced to demonstrate the management of complaints and the actions taken following receipt of complaints.
  • Staff had access to regularly reviewed policies and procedures to ensure they were provided with up to date and accurate guidance to support them in their work.
  • Meetings, including clinical and governance were being recorded in greater detail to reflect the discussions and decisions made.
  • A new log for recording/accounting for blank prescriptions had been introduced.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the evidence table for further information.

Inspection areas

Safe

Good

Updated 10 September 2018

We rated the practice as good for providing safe services.

Safety systems and processes

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

  • The practice had systems in place to safeguard children and vulnerable adults from abuse. We were told that staff had received up-to-date safeguarding training appropriate to their role. However, there was no record of this for one of the GPs. The provider submitted confirmation that this had taken place following the inspection. Staff we spoke with knew how to identify and report concerns. Staff told us they took steps to protect patients from abuse, including working with other agencies. However, we found the register of children at risk had not been reviewed and updated for some time. At the time of the inspection visit a piece of work had commenced to address this and the provider confirmed that this had been completed following the inspection.
  • Staff who acted as chaperones were trained for the role and had undergone a Disclosure and Barring Service 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.)
  • We viewed a sample of three staff files to look at the provider’s recruitment process. We found that appropriate pre-employment/recruitment checks had been carried out prior to staff appointments.
  • Procedures were in place to ensure appropriate standards of hygiene were maintained and to prevent the spread of infection. Some environmental factors made infection control practices more difficult to maintain but the provider was working around this whilst awaiting an upgrade to the premises.
  • Arrangements were in place to ensure that facilities and equipment were safe and in good working order.
  • Arrangements were in place for managing waste and clinical specimens.

Risks to patients

There were 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 and busy periods.
  • There was an induction programme for staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention.
  • Staff had been provided with information on how to identify and manage patients with severe infections including sepsis.
  • The provider had a system in place for managing patient safety alerts. Information we were shown at the time of the inspection indicated that the system was not effective. However, following the inspection the provider told us the information we had been given was not accurate and they held this information centrally. They submitted additional information to support the actions taken in response to alerts. A policy outlining the process was also submitted to us following the inspection visit.

Information to deliver safe care and treatment

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

  • Information needed to deliver safe care and treatment was available to staff.
  • 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.
  • There was a documented approach to managing test results.

Appropriate and safe use of medicines

The practice had systems in place for the safe handling of medicines.

  • We looked at the system in place for the authorisations of trained staff to administer vaccines. The file we were shown contained some out of date directives and directives that had not been signed appropriately. Following the inspection visit the provider told us we had been shown the wrong file that was no longer in use. They told us a second file was in place at the time of the visit containing accurate directives.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. However, there was no policy outlining the processes for this. A policy for this was submitted to us following the inspection visit.
  • Records for logging and monitoring prescriptions were not sufficient detailed to account for who and where they had been designated to. This was the case for both computer and hand-written prescription pads.

Track record on safety

The practice had a good track record on safety.

  • A safe working practice risk assessment had been carried out covering aspects of health and safety and this included information on the actions taken to mitigate risks.

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. Staff told us leaders and managers supported them when they did so.
  • There were systems for reviewing and investigating when things went wrong.
  • The practice learned and acted to improve safety in the practice.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 10 September 2018

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

(Please note: Any Quality Outcomes (QOF) data relates to 2016/17. QOF is a system intended to improve the quality of general practice and reward good practice.)

Effective needs assessment, care and treatment

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 assessed. This included their clinical needs and their mental and physical wellbeing.
  • Data form the Quality Outcomes Framework (QOF) showed that the practice had made improvements to outcomes for patients in many aspects of clinical care and they expected to see further improvements by then end of the current reporting year.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • The provider had a designated clinical lead.
  • Prescribing data showed that the practice was performing in line with local and national averages for prescribing medicines. For example, the average daily quantity of hypnotics prescribed per specific therapeutic group was comparable to other practices.
  • Information on how to respond to suspected Sepsis was displayed in treatment rooms and in the reception area. Guidance for recognising and responding to suspected Sepsis was also discussed in a recent clinical meeting.
  • Clinical meetings were used to discuss best practice guidance and to look at the care and treatment provided to patients with more complex needs. A new agenda had recently been introduced to provide greater structure to these meetings as the record of previous meetings were not detailed or informative. The new agenda included discussion and learning in areas such as; the care provided to palliative patients and those with a critical illness, newly diagnosed cancer patients, safeguarding concerns, safety alerts, significant events, complaints, the Quality Outcome Framework and sharing of evidence based guidance.

Older people:

  • The practice kept up to date registers of patients with a range of health conditions (including conditions common in older people) and used this information to plan reviews of health care and to offer services such as vaccinations for flu.
  • Older patients identified as being frail had a clinical review including a review of their medication.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any changes in their needs.
  • The practice used the ‘Gold Standard Framework’ (this is a systematic evidence based approach to improving the support and palliative care of patients nearing the end of their life) to ensure patients received appropriate care.
  • Several staff had been provided with training in dementia awareness to support them in supporting patients with dementia care needs.

People with long-term conditions:

  • The practice held information about the prevalence of specific long-term conditions within its patient population. This included conditions such as diabetes, chronic obstructive pulmonary disease (COPD), cardio vascular disease and hypertension. The information was used to target service provision, for example to ensure patients who required immunisations received these.
  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met.
  • GPs followed up patients who had received treatment in hospital or through the out of hours service.
  • Data as provided by the practice, showed that the practice was performing in comparison with other practices locally and nationally for the care and treatment of people with chronic health conditions.
  • Multi-disciplinary meetings were held to discuss patients with complex needs and patients receiving end of life care.
  • The practice provided an in-house phlebotomy service which was convenient for patients especially those requiring regular blood monitoring.
  • Patients were provided with advice and guidance about prevention and management of their health conditions and were signposted to support services.

Families, children and young people:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates for the vaccines given were below but close to the target percentage of 90%. Opportunistic immunisations were given to encourage uptake. The practice monitored non-attendance of babies and children at vaccination clinics and staff told us they would report any concerns they identified to relevant professionals.
  • The practice had arrangements for following up failed attendance of children for appointments in secondary care.
  • A designated lead was in place for safeguarding. Staff we spoke with had appropriate knowledge about child protection and had ready access to safeguarding policies and procedures. There was no documented record to demonstrate that one of the GPs had undergone safeguarding training.
  • Family planning services were provided.
  • Child health surveillance clinics were provided for 6-8 week olds.

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

  • 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.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances in order to provide the services patients required. For example, a register of people who had a learning disability was maintained to ensure patients were provided with an annual health check and to ensure longer appointments were provided for patients who required these.
  • 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. Staff provided examples of when they had recognised signs of potential abuse in vulnerable adults and how they had acted to report their concerns.
  • The practice provided appropriate access and facilities for people who were disabled.
  • Information and advice was available about how patients could access a range of support groups and voluntary organisations.

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

  • The practice assessed and monitored the physical health of people with mental illness.
  • Data from the QOF indicated that outcomes for patients experiencing poor mental health were similar to local and national averages.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected a referral was made for assessment and diagnosis.
  • A member of staff from the local community mental health team attended the practice one half day per week.
  • The practice hosted a support group for the carers of people living with Alzheimer’s.

Monitoring care and treatment

The practice had a programme of quality improvement activity and reviewed the effectiveness and appropriateness of the care provided.

  • Data from the QOF from April 2017 to March 2018 showed performance in outcomes for patients were comparable to those of the Clinical Commissioning Group (CCG) and national averages.
  • Clinical audits were carried out to improve outcomes for patients. Clinical audit is a way to find out if the care and treatment being provided is in line with best practice and it enables providers to know if the service is doing well and where they could make improvements. The aim is to promote improvements to the quality of outcomes for patients. We viewed a sample of audits that demonstrated that the provider has assessed and made improvements to the treatment provided to patients.

  • An effective system was in place for monitoring patients referred to secondary care for tests or investigations under the two week wait rule.

Effective staffing

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

  • Staff told us they felt encouraged and well supported to develop their skills.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received up to date relevant training.
  • Staff were provided with protected time to undergo training and to meet their professional development. An up to date record of training was not being maintained at the time of the inspection visit. Staff files did not contain up to date information about their training. The provider submitted an overview of the training staff had been provided with following the inspection. This showed that there were some gaps in training in topics such as safeguarding, fire safety and infection control.
  • A system of annual appraisal was in place but staff whose records we looked at were overdue their appraisal.
  • The provider told us that practice ensured the competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing. However, there was no formal documented process to show this.

Coordinating care and treatment

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

  • The practice shared information with relevant professionals as part of their delivery of care and treatment for patients.
  • 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 supported 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.

The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns and tackling obesity.

Health promotion information was available in the reception area.

Information and advice was available about how patients could access a range of support groups and voluntary organisations.

Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.

The provider hosted a local pilot project ‘Living Well Sefton’ once per week. The project was aimed at supporting patients holistically with their health and or social care needs. For example, through supporting or signposting patients for debt advice, exercise, cooking skills and smoking cessation.

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.

Please refer to the Evidence Tables for further information.

Caring

Good

Updated 10 September 2018

We rated the practice as good for providing a caring service.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • We observed that members of staff were courteous and helpful to patients and treated them with dignity and respect.
  • Feedback from patients we spoke with was positive about the way staff treated them.
  • Patients we spoke with told us they received ‘excellent’ and ‘caring’ treatment from the practice.
  • Feedback from patients in the CQC comments cards we received (15 in total), about how they were treated, was positive in the main. However, two patients told us they were not satisfied with their consultations with GPs as they felt they had not been listened to.
  • Feedback from the national GP patient survey showed that the practice had received scores that were similar to local and national average scores for patients feeling they were treated with care and concern.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about their care and treatment.

  • Patients told us they felt listened to and included in decisions about their care and treatment.
  • Staff demonstrated a patient centred approach to their work during our discussions with them.
  • The practice manager was 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.
  • A hearing loop system was in place to support people who wear hearing aids.
  • Some staff had been trained in dementia awareness to support them in supporting patients with dementia care needs.
  • Staff helped patients and their carers find information about local services.
  • Results from the national GP patient survey for questions about patient involvement in planning and making decisions about their care and treatment were comparable to local and national averages.

The practice had coded patients who they knew were carers on the patient record system and there was a range of information available to inform carers of the local support services. A member of staff was designated as a lead to liaise with a carers support service.

Privacy and dignity

The practice respected and promoted patients’ privacy and dignity.

  • Staff recognised the importance of patients’ dignity and respect and they told us how they worked to ensure they maintained patient confidentiality.
  • Reception staff told us they could offer patients a private area if they wanted to discuss sensitive issues or if they appeared uncomfortable or distressed.
  • The practice complied with the Data Protection Act 1998.

Please refer to the Evidence Tables for further information.

Responsive

Good

Updated 10 September 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.
  • Telephone appointments were available and this supported patients who were unable to attend the practice in person.
  • The facilities and premises were appropriate for the services delivered. Reasonable adjustments had been made to accommodate the needs of patients.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was co-ordinated with other services.
  • The clinical team provided home visits for patients with enhanced needs who found it difficult to attend the practice in person.
  • The practice provided primary care to patients who were known to have displayed violent or aggressive behaviour. Risks associated with this were managed.

Older people:

  • 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.

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.
  • Data shared with us by the provider showed that the practice was performing similarly to local and national averages in chronic disease management.
  • Patients with several long-term conditions were offered a single, longer appointment to avoid multiple visits to the surgery.

Families, children and young people:

  • There was a system in place to identify 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.
  • A register of children at risk was in place but this information had not been reviewed or updated.
  • Babies and young children were offered an appointment as a priority and appointments were available outside of school hours.
  • The premises were suitable for children and babies and baby changing facilities were available.

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.
  • Telephone consultations were provided and patients therefore did not always have to attend the practice in person.
  • The practice was proactive in offering online services including the booking of appointments and requests for repeat prescriptions. Electronic prescribing was also provided.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances for example those with a learning disability.
  • Same day appointments supported patients whose circumstances made them vulnerable.
  • 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.
  • The practice provided appropriate access and facilities for people who were disabled.
  • Longer appointments were available for patients with enhanced needs.

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

  • The practice identified patients who experienced poor mental health in order to be responsive to their needs, for example by the provision of regular health checks.
  • The practice was performing comparably to local and national averages for the treatment of patients experiencing poor mental health.
  • Patients experiencing poor mental health were referred to appropriate services such as psychiatry and counselling services and were informed about how to access various support groups and voluntary organisations.
  • A number of staff had been provided with training in supporting patients who have dementia care needs.

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.

Patients with the most urgent needs had their care and treatment prioritised.

Waiting times, delays and cancellations were minimal and managed appropriately.

The majority of patients we spoke with said their experience of getting through to the practice and getting an appointment had improved significantly. However, a small number of patients told us they still found getting an appointment difficult.

The practice provided a ‘walk in’ service each morning for appointments with the nurse clinician. Feedback from patients was that this was a very valuable service. The provider was therefore looking to introduce this in some of their other practices.

Patients and staff told us that patients regularly queued outside of the building early in the morning to try to secure an appointment for that day. Patients could book appointments in advance but the majority of GP appointments were kept for ‘book on the day’ appointments. The provider told us they had introduced this in an attempt to reduce the number of patients who failed to attend their appointments. They told us the current system had been effective in reducing the problem of non-attendance.

The provider had extended the appointment time for patients from 10 minutes to 15 minutes. Patient feedback was positive about the extended consultation time.

Results from the national patient survey showed that the practice had received scores that were lower than Clinical Commissioning Group (CCG) or national averages for questions about access and people’s experience of making an appointment. The survey was carried out between January and March 2017. This therefore may not fully reflect patient’s current experiences. However, the provider had not surveyed patients since these results were made available. Following the inspection the provider submitted information to support the actions they had taken in response to the patient survey. These included; the introduction of a nurse clinician led walk in service and on-line booking of appointments.

Listening and learning from concerns and complaints

  • A complaints policy and procedure was in place.
  • A complaints information leaflet was available to help patients understand the complaints procedure and how they could expect their complaint to be dealt with. This did not contain information about the different stages of a complaint.
  • We viewed a sample of complaints. The initial complaint had been documented as received and the practice manager told us they had dealt with each complaint verbally and to the satisfaction of the patients concerned. However, the complaints had been made in writing and there was no evidence on the complaints file of how they had been investigated, what the outcome of the investigation was and whether there had been any learning from the complaints. A form was in place to document this information but this had not been used. Following the inspection the provider submitted information that complaints information was held centrally. The information they shared with us indicted that complaints had been investigated and action had been taken in response to the complaints but we did not see the evidence supporting this at the time of the inspection visit.
  • Complaints had been added to the agenda for discussion and dissemination of learning at practice meetings.

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