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Inspection Summary


Overall summary & rating

Good

Updated 27 December 2018

This practice is rated as Good overall. (Previous rating 02 May 2018 – Overall Good – requires improvement in safe)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Not inspected on this occasion

Are services caring? – Not inspected on this occasion

Are services responsive? – Not inspected on this occasion

Are services well-led? - Not inspected on this occasion

We carried out an announced comprehensive inspection at Sedlescombe House on 02 May 2018. The overall rating for the practice was good. The practice was also rated good for the effective, caring, responsive and well-led domains and all the population groups. It was however rated as requires improvement for providing safe services. The full comprehensive report on the May 2018 inspection can be found by selecting the ‘all reports’ link for Sedlescombe House on our website at: www.cqc.org.uk

After the inspection in May 2018 the practice wrote to us with an action plan outlining how they would make the necessary improvements to comply with the regulations.

At this inspection our key findings were:

There was an effective system for managing and actioning safety alerts appropriately. Actions in relation to safety alerts were recorded.

Prescriptions were tracked to specific printers and their numbers recorded.

Checks on emergency equipment were recorded.

Appropriate checks were carried out and recorded when recruiting locum staff.

Systems and protocols for the monitoring of high risk medicines were followed. However a potential weakness in the new monitoring system for a medicine, whose management was shared with the hospital, was identified.

Additionally, we saw that the practice had:

Provided awareness training for all staff on the ‘red flag’ sepsis symptoms that might be reported by patients and how to respond.

Reviewed and improved systems for ensuring sharps boxes were disposed of within their expiry date.

Reviewed and improved systems for identifying and recording carers.

The areas where the provider should make improvements are:

Continue to review, improve and audit the new system for monitoring high risk medicines.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Safe

Good

Updated 27 December 2018

At our previous inspection on 02 May 2018, we rated the practice as requires improvement for providing safe services because:

Actions in relation to safety alerts were not always recorded.

Prescriptions were not tracked to specific printers and their numbers recorded.

Checks on emergency equipment were not always recorded.

Appropriate checks were not always carried out and recorded when recruiting locum staff.

Systems and protocols for the monitoring of high risk medicines were not followed in all cases.

These arrangements had improved when we undertook a follow up inspection on 02 November 2018. The practice is now rated as good for providing safe services.

Safety systems and processes

The practice had clear systems to keep people safe.

  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis. This included the recruitment of locum staff.
  • All sharps boxes were in date. This was checked and recorded monthly .

Appropriate and safe use of medicines

The practice had systems for the handling of medicines.

  • The systems for managing and storing emergency equipment, minimised risks. Emergency equipment was checked regularly and we saw these checks were recorded.
  • The practice stored prescriptions securely and recorded the numbers as they came into the practice. Rooms were always locked when not in use. Identification numbers of prescriptions were recorded and tracked to specific printers.

Patients on high risk medicines were monitored appropriately. However, a potential weakness in the new monitoring system for one specific medicine, whose management was shared with the hospital, was identified. The practice immediately suggested ways to improve the system and subsequently implemented them.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts. The practice had a system to receive, action and save safety alerts to a central digital file and could demonstrate that they had taken appropriate action as a result.

Please refer to the evidence tables for further information.

Effective

Good

Updated 22 June 2018

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

.

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.

The previous partner left the practice in April 2016. The practice was re-registered with CQC as an individual provider in April 2017. However the leadership was unchanged from April 2016 to the date of the inspection which included the period that the QOF data refers to and we therefore refer to this data set in the report and evidence table.

Effective needs assessment, care and treatment

The practice 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 used appropriate tools to assess the level of pain in patients.
  • 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 worked with a community pharmacist who carried out medicines reviews for patients in care homes.
  • 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.
  • Vulnerable patients held separate care plans.

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.
  • The practice had arrangements for adults with newly diagnosed cardiovascular disease including the offer of statins for secondary prevention, 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 they identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension.
  • The practice held monthly multi-disciplinary team (MDT) meetings.

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 above the target percentage of 90% or above and in three out of four categories showed a significant positive variation.

  • The practice had arrangements to identify and review the treatment of newly pregnant women on long-term medicines. These patients were provided with advice and post-natal support in accordance with best practice guidance.
  • 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 75.9%, which was in line with the local and England averages. The target for the national screening programme was 80%. 
  • The practices’ uptake for breast cancer screening was above the national average. Bowel cancer screening was in line with the national average.

  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • 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.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, people dependant on drugs/alcohol, immigrants and those with a learning disability.
  • Patients were referred to appropriate local support services.
  • Reception staff knew the vulnerable patients and would alert the clinicians so that opportunistic care could be offered immediately.
  • 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 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.

The practice was aware of patients on long term medication that needed to be administered at the practice and would follow them up if they failed to attend.

  • 88% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the previous 12 months. This was comparable to the national average
  • 75% of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the previous 12 months. This was comparable to the national average.
  • The practice specifically considered the physical health needs of patients with poor mental health and those living with dementia. For example 91% of patients experiencing poor mental health had received discussion and advice about alcohol consumption. This was comparable to the national average.
  • 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.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. For example, as a result of an audit of cervical smear samples taken the practice implemented improvements which reduced the number of inadequate smear samples taken from post-menopausal women.

  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

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. This included an induction process, one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The induction process for healthcare assistants included the requirements of the Care Certificate.
  • 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 deciding care delivery for people with long term conditions and when coordinating healthcare for care home residents. The shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services.
  • 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 the diabetes year of care scheme and also through referral to a local service that advised patients on lifestyle changes.
  • 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

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.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the Evidence Tables for further information.

Caring

Good

Updated 22 June 2018

We rated the practice as good for caring.

The previous partner left the practice in April 2016. The practice was re-registered with CQC as an individual provider in April 2017. However the leadership was unchanged from April 2016 to the date of the inspection which included the period that the GP National Survey data refers to and we therefore refer to this data set in the report and evidence table.

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.

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 were available.
  • Staff helped patients and their carers find further information and access community and advocacy services.
  • The practice proactively identified carers and supported them. The practice had identified and recorded 27 carers which is 0.7% of the practice population and less than they may have expected.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • Reception staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer 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

Good

Updated 22 June 2018

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

The previous partner left the practice in April 2016. The practice was re-registered with CQC as an individual provider in April 2017. However the leadership was unchanged from April 2016 to the date of the inspection which included the period that the GP National Survey data refers to and we therefore refer to this data set in the report and evidence table.

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 GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • 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 although they could be seen by whichever GP they wished. The GPs 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. The GP also accommodated home visits for those who had difficulties getting to the practice where appropriate.

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. The practice was working towards reviewing patients with multiple conditions at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held meetings with the local district nursing team when they were available 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. The lead GP followed up children who failed to attend appointments for secondary care.
  • All parents or guardians calling with concerns about a child 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 make these accessible, flexible and offered continuity of care.

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 able to register with the practice, including those with no fixed abode

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

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • Where appropriate patients were referred to a local counselling service.

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.
  • Longer waiting times and delays sometimes occurred, but the practice was aware and took steps to minimise them.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also 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 22 June 2018

We rated the practice and all of the population groups 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.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high 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. The practice developed its vision, values and strategy jointly with patients, staff and external partners.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social 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 high-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.

  • 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 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.

  • Clinical staff were considered valued members of the practice 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.

  • 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

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

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.

  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control

  • Practice 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 processes for managing risks, issues and performance.

  • There was a process to identify, understand, monitor and address risks including risks to patient safety however in some areas such as recording actions taken on MHRA alerts, a clear audit trail was not always established.

  • The practice had processes to manage current and future performance. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Practice leaders had oversight of national and local safety alerts, incidents, and complaints.

  • Clinical audit 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 in place and had trained staff for major incidents.

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

  • Although systems were in place to manage risks, issues and performance, in some areas actions were not always recorded for example monthly checks on emergency equipment and references for locum staff.

    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.
  • 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.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal 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.

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

Older 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