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Old Road West Surgery Requires improvement

The provider of this service changed - see old profile

Inspection Summary


Overall summary & rating

Requires improvement

Updated 16 January 2019

This practice is rated as requires improvement overall. (Previous rating August 2017 – Inadequate)

The key questions are rated as:

Are services safe? – Requires improvement

Are services effective? – Good

Are services caring? – Requires improvement

Are services responsive? – Requires improvement

Are services well-led? - Good

We previously carried out an announced comprehensive inspection at Old Road West Surgery on 15 August 2017. Overall the practice was rated as inadequate and was placed into special measures.

We issued warning notices in respect of identified issues and found arrangements had significantly improved when we undertook a follow up inspection of the service on 5 February 2018. The details of these can be found by selecting the ‘all reports’ link for Old Road West Surgery on our website at

Following this inspection, the provider appointed a new Partner and made an application to CQC to change their CQC registration from a registered individual to a registered partnership. The application was supported by the CCG and was in transit when the newly appointed Partner resigned and the provider reverted to their previous legal entity.

We therefore conducted an announced comprehensive inspection on 29 November 2018 to check the practice has met the requirements of the regulations and re-evaluate the decision for placement into special measures.

At this inspection we found:

  • The practice had significantly improved its formal systems to underpin how significant events, incidents and concerns were monitored, reported and recorded.
  • The practice had made significant improvements and had clear systems to manage risk so that safety incidents were less likely to happen. For example, infection prevention and control and fire safety procedures.
  • The practice had significantly improved its systems for the appropriate and safe handling of medicines.

  • The practice's disease registers had been embedded and now contained all the relevant patients presenting with the clinical condition.
  • The practice had systems for sharing information with staff and other agencies. However, care plans were not always accessible.
  • Patient records for those requiring mental health checks, did not always contain evidence of physical health checks documented.
  • Care and treatment was planned and delivered in a coordinated way.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Planned changes had been conducted to their appointment system to ensure it was meeting patients’ needs.
  • The practice had improved its system for handling complaints and concerns. However, acknowledgment response times when the practice manager was absent needed addressing.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Most patients we spoke with found the appointment system easy to use and reported that they could access care when they needed it. However, national GP patient survey results did not reflect this.
  • Governance arrangements had significantly improved to ensure they were always sufficient and effectively implemented.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Ensure that care and treatment is provided in a safe way for service users.

The areas where the provider should make improvements are:

  • Continue to monitor and ensure the system for recording the use of local anaesthetic is effective.
  • Continue with their plan to improve how carers are identified and offered support.
  • Improve the system for acknowledging the receipt of complaints in the practice managers absence.
  • Continue to monitor and carry out their plan to address low national GP patient survey results.

I am taking this service out of special measures. This recognises the significant improvements made to the quality of care provided by this service.

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

Inspection areas

Safe

Requires improvement

Updated 16 January 2019

At a previous inspection on 15 August 2017, we rated the practice as inadequate for providing safe services because:

  • Where significant incidents had been recorded centrally we found evidence they had been investigated. However, only some learning had been identified and shared with the staff team.
  • There was no established and effective system to ensure the safe management of medicines.
  • Some clinical equipment required repair. The practice had not conducted an annual infection prevention control audit. There were no detailed cleaning schedules to demonstrate where, when and how items were cleaned.
  • There were insufficient procedures in place for assessing, monitoring and managing risks to patient and staff safety.
  • The practice had insufficient arrangements in place to respond to emergencies and major incidents.
  • Best practice guidance had not been followed.

We issued notices in respect of these issues and found arrangements had improved when we undertook a follow up inspection of the service on 5 February 2018, but further improvements were still required. The details of these can be found by selecting the ‘all reports’ link for Old Road West Surgery on our website at www.cqc.org.uk.

At this inspection we rated the practice as requires improvement for providing safe services.

Safety systems and processes

The practice had made significant improvements to ensure they had clear systems to keep people safe.

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Reports and learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a DBS check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • The system to manage infection prevention and control had been improved and effectively embedded.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

Systems to assess, monitor and manage risks to patient safety had been improved.

  • There were arrangements for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was an effective induction system for temporary staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures. Routine checking of equipment and medicines used in an emergency had been improved and embedded effectively.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

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

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff. There was a documented approach to managing test results.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver care and treatment. However, care plans were not always consistently accessible and patient records (for those requiring mental health checks), did not always have evidence of physical health checks having been recorded.
  • The practice now ensured that locum clinicians made timely referrals in line with protocols. For example, two week wait referrals (this is when there is a suspicion of cancer that requires a more urgent response) were not always monitored appropriately and in accordance with protocols.

Appropriate and safe use of medicines

The practice had improved its systems for the appropriate and safe handling of medicines.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks. Routine records for checks of vaccine fridges had significantly improved.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.
  • Arrangements for dispensing medicines at the practice kept patients safe. Patient specific prescriptions or directions (PSD's) were now scanned in a timely manner in order to ensure they were maintained appropriately on the patients’ medical records. Additionally, blank prescriptions were now being stored and monitored appropriately.
  • Systems and processes for the recording of the use of local anaesthetic in minor operations had recently been implemented.

Track record on safety

The practice had significantly improved its systems and processes for maintaining safety.

  • There were risk assessments which had now been implemented effectively. For example, recording of fire safety and Legionella.
  • The practice monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture of safety that led to safety improvements.

Lessons learned and improvements made

The practice had significantly improved how they learnt and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • The practice had improved their systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice now had effective systems to ensure they acted on and learnt from external safety events, as well as patient and medicine safety alerts. We saw that all safety alerts had been acted upon.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 16 January 2019

At a previous inspection on 15 August 2017, we rated the practice as inadequate for providing effective services because:

  • There was no system in place to ensure staff knew and adhered to current evidence based guidance.
  • We found some of the practice’s disease registers had not been validated. Therefore, the Quality and Outcome Framework data was not representative of the care and treatment provided to some of the practice’s patients.
  • The practice did not provide evidence of clinical audits having been conducted to inform quality improvement.
  • There was no induction pack for locum GPs defining roles and responsibilities, signposting policies and procedures and referral pathways.
  • There were inconsistencies in the quality of the care plans.
  • The practice had not shared patient records including end of life care plans with their out of hours provider.
  • Some clinical staff had not received annual appraisals, but we found evidence of them accessing appropriate training and personal development opportunities.

We issued notices in respect of these issues and found arrangements had improved when we undertook a follow up inspection of the service on 5 February 2018 but further improvements were still required. The details of these can be found by selecting the ‘all reports’ link for Old Road West Surgery on our website at www.cqc.org.uk.

At this inspection we rated the practice as good for providing effective services and as requires improvement across all population groups (as the practice is rated as requires improvement overall, this impacted across all population groups).

Effective needs assessment, care and treatment

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

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.
  • The practice provided GP services to patients living in one of two care homes.

People with long-term conditions:

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions. For example, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension).
  • The practice’s performance on quality indicators for long term conditions was in line with both the local and national averages, with the exception of diabetes.

Families, children and young people:

  • Childhood immunisation uptake rates were above the target percentage of 90%.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.

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

  • The practice’s uptake for cervical screening was 77%, which was below the 80% coverage target for the national screening programme but comparable to other local practices.
  • The practice’s uptake for breast and bowel cancer screening were in line with the national average.

  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable. End of life care plans had been shared with their out of hours provider.
  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
  • The practice provided GP services to patients with a learning disability, who lived in a care home.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

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

  • The practice told us they assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. However, records were not consistently being maintained in patients notes, to reflect what staff told us. There was a system for following up patients who failed to attend for administration of long term medication.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements to help them to remain safe.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • The practice offered annual health checks to patients with a learning disability.
  • The practices performance on quality indicators for mental health were in line with the local and national averages.

Monitoring care and treatment

The practice had improved its systems to ensure there was a comprehensive programme of quality improvement activity. They routinely reviewed the effectiveness and appropriateness of the care provided.

  • Quality Outcome Framework (QOF) results for Old Road West Surgery were either comparable with or higher than both local and national averages. The practice's disease registers had been further embedded to ensure that QoF targets would be achieved.
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity and a programme of audits had been fully embedded.

Effective staffing

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

  • Staff had appropriate knowledge for their role. For example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. Improvements had been made to ensure there was an induction pack for clinical staff defining roles and responsibilities, signposting policies and procedures and referral pathways. Policies in the induction pack were now up to date and aligned with those on the practices computer system.
  • Induction training included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.
  • Staff appraisals had now been conducted and we saw records to confirm this.
  • 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 practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health. For example, through care navigation (directing patients to alternative care and treatment providers. For example, the pharmacy).
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health. For example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

At our inspection on 5 February 2018, we found that consent to care and treatment was not always obtained in line with legislation and guidance.

At this inspection we found:

  • Patient's consent for minor surgery was now being obtained in accordance with the General Medical Council guidance on Consent: Patient and doctors making decisions together (2008).
  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.

Caring

Requires improvement

Updated 16 January 2019

At a previous inspection on 15 August 2017, we rated the practice as requires improvement for providing caring services because:

  • Patients were not routinely offered the convenience of choose and book services.
  • The practice had identified 0.5% of their patient list to be carers.
  • The practice told us they contacted bereaved families but could not provide evidence of this.

We issued notices in respect of these issues and found arrangements had improved when we undertook a follow up inspection of the service on 5 February 2018 but further improvements were still required. The details of these can be found by selecting the ‘all reports’ link for Old Road West Surgery on our website at www.cqc.org.uk.

At this inspection we rated the practice as

requires improvement

for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • Entries to support the GP having contacted bereaved families and carers were now being made.
  • The practices GP patient survey results were below the local and national averages for questions relating to kindness, respect and compassion. The practice had an action plan to monitor and address these.

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.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice were continuing to identify carers and ways in which to support them. Leaflets were being prepared to advise carers how to find further information and there was information included on the practices’ website.
  • The practices GP patient survey results were in line with both the local and national averages for questions relating to involvement in decisions about care and treatment. Patients were now routinely offered the convenience of choose and book services.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues or appeared distressed, reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.

Responsive

Requires improvement

Updated 16 January 2019

At a previous inspection on 15 August 2017, we rated the practice as inadequate for providing effective services because:

  • The practice did not demonstrate an understanding of their population profile and had not conducted an assessment of their appointment system and whether it was meeting their patients’ needs.
  • Patients reported difficulties making an appointment. The practice offered limited pre-bookable appointments. The majority of appointments were on the day appointments with the GPs. This presented difficulties for patients who worked or needed to plan ahead.
  • Information about how to complain was available.
  • We found no evidence to support that learning or sharing of outcomes took place, from complaints investigated, with staff and other stakeholders.

We issued notices in respect of these issues and found arrangements had improved when we undertook a follow up inspection of the service on 5 February 2018 but further improvements were still required. The details of these can be found by selecting the ‘all reports’ link for Old Road West Surgery on our website at www.cqc.org.uk.

At this inspection we rated the practice, and all of the population groups, as

requires improvement

.

Responding to and meeting people’s needs

The practice had improved how it organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The practice now understood the needs of its population and tailored services in response to those needs.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours. Along with the introduction of appointments accessible within The Hub.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GP and paramedic practitioner also provided home visits for those who had difficulties getting to the practice.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

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

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, appointments accessible within The Hub (up to 8pm Monday to Friday and including Saturday).

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.
  • The paramedic practitioner conducted welfare checks and home visits on patients in vulnerable circumstances.

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

  • Staff interviewed understood how to support patients with mental health needs and those patients living with dementia.

Timely access to care and treatment

Patients were not always able to access care and treatment from the practice within an acceptable timescale for their needs.

  • The practice had assessed their appointment system and whether it was meeting their patient needs. The appointment system had been updated and feedback about this was positive from patients we spoke with and the majority of cards completed.
  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • The majority of patients reported that the appointment system was easy to use. However, five patients commented in cards that booking of appointments was difficult.
  • The practices GP patient survey results were below the local and national averages for questions relating to access to care and treatment. The practice had an action plan to monitor and address these.

Listening and learning from concerns and complaints

The practice had significantly improved their systems to ensure complaints and concerns were taken seriously and responded to them appropriately, to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available.
  • All complaints we saw had been appropriately investigated and outcome letters completed. However, acknowledgement response times when the practice manager was absent needed addressing.
  • Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 16 January 2019

At a previous inspection on 15 August 2017, we rated the practice as inadequate for providing caring services because:

  • Changes to personnel had left roles vacant and the risks associated with this had not been addressed. For example, the practice had failed to validate their disease registers to ensure the integrity of their clinical data assessed as part of the Quality and Outcome Framework.
  • Policies were incomplete, not adhered to and recommendations not followed.
  • We found only one meeting had been held so far, in July 2017.
  • We found no identification or evidence of quality improvements.
  • There was no induction pack for locum GPs; members of the clinical team had not received annual appraisals.
  • We found the practice did not have an established or effective system for being aware of notifiable safety incidents and sharing the information with staff and ensuring appropriate action was taken.
  • We found formal mechanisms to inform patients about changes were limited. For example, the reduced opening hours at the branch surgery.

We issued notices in respect of these issues and found arrangements had improved when we undertook a follow up inspection of the service on 5 February 2018 but further improvements were still required. The details of these can be found by selecting the ‘all reports’ link for Old Road West Surgery on our website at www.cqc.org.uk.

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

Leadership capacity and capability

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

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.
  • Improvements had been made and sustained due to practice management and staff being focussed on continually improving the quality of services provided. There was clear evidence to support this.

Vision and strategy

The practice had a credible strategy to deliver quality, sustainable care.

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

Culture

The practice had a culture of quality sustainable care.

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • The practice focused on the needs of patients. For example, changing the appointment system and recruiting new clinical staff to fill previously vacant roles.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and now 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 had now received regular annual appraisals. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

Significant improvements had been made to ensure there were clear responsibilities, roles and systems of accountability to support good governance and management. Systems and processes were now embedded and had been implemented effectively.

  • Structures, processes and systems to support good governance and management were clearly set out and understood. They had been improved to ensure identified issues regarding the reporting of significant events, patient safety alerts, infection control, fire safety procedures and complaints information were addressed and routinely monitored.
  • The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care, with the exception of care plans not always being accessible and physical health checks being recorded in patients’ notes when a mental health review had been conducted.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Practice leaders had established, implemented and embedded policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

Significant improvements had been made to ensure there were clear processes for managing risks, issues and performance.

There was now a process to identify, understand, monitor and address current and future risks including risks to patient safety.

  • There was now a programme of audit or understanding of the benefits of employing such an approach to identifying, addressing and reducing risks and improving patient outcomes.
  • Formal arrangements for monitoring safety, using information from audits, risk assessments and routine checks had been embedded.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had significantly improved and had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice 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 practice involved patients, the public, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group who supported the practice in informing patients about changes occurring.
  • Practice meetings had been held on a monthly basis. Records of meetings viewed and staff we spoke with confirmed this.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • The practice made use of internal and external reviews of teaching and mentorship for the registrars and students they supported.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Older people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement