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Riverlyn Medical Centre Good

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Inspection Summary


Overall summary & rating

Good

Updated 29 November 2019

We carried out an announced comprehensive inspection at Riverlyn Medical Centre on 13 November 2018 as part of our inspection programme. The overall rating for the practice was ‘good’, however, the practice was rated as ‘requires improvement’ for providing safe services.

The full comprehensive report from the inspection in November 2018 can be found by selecting the ‘all reports’ link for Riverlyn Medical Centre on our website at

This inspection was an announced focused inspection carried out on 6 November 2019 to follow up on breaches of regulations identified at the previous inspection on 13 November 2018. This report covers our findings in relation to actions taken by the practice since our last inspection in respect of the safe domain.

At the last inspection in November 2018 we rated the practice as requires improvement for providing safe services because:

  • Staff immunisation records were not complete to ensure staff were vaccinated appropriately.
  • Patient-specific directions were not appropriately authorised.
  • Safety checks were not fully documented.
  • The infection prevention and control lead did not have sufficient training to support their role.

At this inspection, we found that the provider had satisfactorily addressed these areas. Overall the practice remains rated as ‘good’. The practice is now also rated ‘good’ for providing safe services.

Our key findings were as follows:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Staff immunisation records were kept in line with current Public Health England guidance.
  • Patient-specific directions were authorised by a GP before medicines were given and then scanned into the patient electronic record.
  • Fire risk assessments were carried out every six months by an external provider on behalf of the practice, and actions identified from the assessment were rectified.
  • We saw several training courses on infection prevention and control, including hand hygiene, had been undertaken by the infection control lead. The lead cascaded training to all staff within the practice.
  • Oxygen cylinders and the defibrillator were checked monthly to ensure they were fit for use in an emergency.

Details of our findings and the evidence supporting our rating is set out in the evidence table.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care.

Inspection areas

Safe

Good

Effective

Good

Updated 14 December 2018

At our previous inspection on 7 December 2017, we rated the practice as good for providing effective services. At this inspection we rated the practice as good for providing effective services.

We rated the practice and all the population groups as good for providing effective services overall except for Families, children and young people population group which we rated Requires improvement.

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. Templates on the practice computer system linked with guidance to ensure care was provided in accordance with current evidence-based practice. Any new or revised guidance was discussed at regular clinical meetings. 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.
  • Technology was used to promote patient independence like telehealth and telecare.
  • 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 held quarterly multidisciplinary meetings to discuss vulnerable older patients.
  • 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. Staffing was very stable and staff had a good understanding of individual patients’ needs and circumstances.

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. Patients were also referred to specialist pulmonary nurses where appropriate. A pharmacist carried out regular inhaler assessments for patients to optimise their technique and help support the management of their condition.
  • Adults with newly diagnosed cardiovascular disease were offered 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 could demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension)
  • The practice’s performance on quality indicators for long term conditions was generally in line with local and national averages apart from one diabetes indicator. The practice had identified their performance for this indicator and had worked to improve this area. Diabetes forums had been held to raise patient awareness. A diabetes specialist nurse had a regular clinic in the practice and patients told us they were regularly provided with healthy living guidance. The employment of a full-time practice nurse in January 2019 would allow further resources to be put into this area.

Families, children and young people:

  • Childhood immunisation uptake rates were not in line with the target percentage of 90% or above. The practice provided us with a detailed explanation of why their performance was not in line with targets and actions that they took to encourage childhood immunisation. We noted, however, that clinicians did not book the patient’s next immunisation appointment when a patient attended for immunisation. Clinicians asked parents to book their next appointment at reception. Direct booking of appointments by clinicians during an appointment may encourage attendance for immunisations at the correct time. The employment of a full-time practice nurse in January 2019 would allow further resources to be put into this area.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.
  • The practice adhered to national guidance on determining a younger person’s capacity to consent when consulting with them (for example, contraceptive advice).

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

  • The practice’s uptake for cervical screening was 74.9%, which was below the 80% coverage target for the national screening programme. The practice contacted patients who had not attended for cervical screening at the appropriate time using text, letters and phone. Screening information was also displayed in the practice and patients told us they were offered screening as appropriate.
  • The practice’s uptake for breast cancer screening was slightly above the national average. The practice’s uptake for bowel cancer screening was slightly below the national average. The practice followed up with patients if they did not return their samples for bowel cancer screening.
  • 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 considered the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • 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. 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 in place 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. These checks were carried out at day centres when patients were not able to attend the practice.
  • The practice’s performance on quality indicators for mental health was above local and national averages.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • QOF results for 2017-18 showed an overall achievement of 94.8% compared to the CCG average of 94.5%, and a national average of 96%. The practice’s public health achievement was 100% compared to the CCG average of 97.1%, and a national average of 96.7%.
  • Exception reporting rates for 2017-18 were below local and national averages.
  • 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. For example, we saw some evidence of a regular clinical audit programme. We saw that two cycle audits had been completed which demonstrated improved outcomes for patients.

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 told us they were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included ad hoc one to one meetings, annual appraisals, coaching and mentoring, clinical supervision and revalidation.
  • 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 considered 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 need 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 social prescribing schemes.
  • 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 14 December 2018

At our previous inspection on 7 December 2017, we rated the practice as requires improvement for providing caring services. The practice was below both local and national averages for its satisfaction scores on consultations with GPs and nurses.

We saw evidence where the practice had made improvements when we inspected on 13 November 2018. The practice is now rated as good for providing caring services.

We rated the practice as good 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.
  • The practice’s GP patient survey results were in line with local and national averages for questions relating to kindness, respect and compassion. Patient comment cards completed prior to our inspection were generally very positive regarding the kindness of staff. Many comment cards referred to caring, friendly staff and positive comments were made in relation to all staff including reception staff, nurses and doctors.

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, a hearing loop. The practice was working to improve the range of easy read materials that were available for patients. A number of staff working at the practice were multilingual and could communicate with some patients in their preferred language where their first language was not English. Some staff were also trained in sign language. The practice website is available in various languages.
  • 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 proactively identified carers and supported them.
  • The practice’s GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment.

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

Good

Updated 14 December 2018

At our previous inspection on 7 December 2017, we rated the practice as requires improvement for providing responsive services. The practice was below both local and national averages for its satisfaction scores regarding access to services.

We saw evidence where the practice had made improvements when we inspected on 13 November 2018. The practice is now rated as good for providing responsive services.

We rated the practice, and all 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 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 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, urgent appointments and longer appointments for those with enhanced needs.
  • There was a medicines delivery service for housebound patients.

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.
  • The practice offered home visits to meet the needs of this group when required.

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.
  • A health visitor provided regular weekly clinics on site.
  • The practice carried out eight-week post-natal checks.

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.
  • The practice offered pre-bookable GP appointments in extended hours on Tuesday evenings each week.
  • The practice participated in an extended access scheme which offered access until 8pm Monday to Friday, and for four hours a day on a Saturday and Sunday.
  • The practice offered telephone appointments when appropriate.
  • Online services were available including appointment bookings, repeat prescription requests (including the electronic prescription service, enabling patients to collect their medicines directly from their preferred pharmacy), and patients could request access to coded medical records.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily 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.

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. GPs carried out minor surgical procedures at the practice. This was also available to patients at nearby practices.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • The practice’s GP patient survey results were line with local and national averages for questions relating to access to care and treatment apart from telephone access. The practice was introducing a new telephone system in March 2019 to address concerns about telephone access to the practice. Additional staff were being recruited to cover reception and reduce telephone response issues.

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 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 14 December 2018

At our previous inspection on 7 December 2017, we rated the practice as requires improvement for providing well-led services. Improvements were required to ensure governance systems operated effectively; including ensuring oversight of locum staff and the arrangements to identify,

monitor and mitigate risks.

We saw evidence where the practice had made improvements when we inspected on 13 November 2018. The practice is now rated as good for providing well-led services.

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. Staff told us that GP partners were very supportive and approachable.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.
  • Staff had identified lead areas of responsibility, for example, safeguarding and prescribing.

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.
  • 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 care priorities across the region. The practice planned its services to meet the needs of the practice population. One of the GP partners sat on the local CCG’s Clinical Council.
  • 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. Most staff had worked in the practice for a number of years.
  • 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 needed. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Staff felt supported.
  • 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 co-ordinated person-centred care. The governance arrangements had been improved following the appointment of the practice manager. Governance arrangements were in place regarding the oversight of locum staff.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of 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 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 used information technology systems to monitor and improve the quality of care.
  • 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 which felt listened to by the practice.
  • 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 is involved in research and is identified as a research hub.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Requires improvement

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