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Hetherington Group Practice Good

Inspection Summary


Overall summary & rating

Good

Updated 7 May 2019

This service is rated as Good overall.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Hetherington Group Practice on 12 and 26 March 2019. We carried out this inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the service was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008.

At this inspection we found:

  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

  • The service had implemented systems that had reduced the rate of patients not attending appointments from 12% to 2%. They had shared the learning of how they had achieved this with other Federations and GP practices within the Lambeth CCG area.

The areas where the provider should make improvements are:

  • The service should ensure that it holds copies of risk assessments and checks undertaken by practices (or the owners of the buildings where practices are based) who host the extended access clinics.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 7 May 2019

We rated the service as good for providing safe services.

Safety systems and processes

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

  • The provider conducted safety risk assessments. It had safety policies, which were regularly reviewed and communicated to staff. Staff received safety information from the provider as part of their induction and refresher training. The provider had systems to safeguard children and vulnerable adults from abuse. Policies were regularly reviewed and were accessible to all staff. They outlined clearly who to go to for further guidance.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Safeguarding policies and procedures were clear and the service could co-ordinate with GP services in the area to determine which patients were at risk. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. Disclosure and Barring Service (DBS) checks were undertaken where required. (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).
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. The staff who acted as chaperones were employed by the surgeries who hosted the extended access services. We saw that they were trained for the role and had received a DBS check.
  • The provider had access to all of the infection control policies and procedures undertaken at host sites. The provider was aware of infection control audits but did not hold a copy on site. However, the individual GP practices were members of the federation, and could therefore hold documents on behalf of Lambeth Practices Limited.
  • Equipment was provided, maintained and monitored by the practices who hosted the extended access clinics. The provider did not hold a copy that all of the checks were complete, although we noted that they were. However, the individual GP practices were members of the federation, and could therefore hold documents on behalf of Lambeth Practices Limited. There were systems for safely managing healthcare waste.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • The service had comprehensively risk assessed all aspects of carrying out care at the time that it was conceived. This included the development of an accountability framework and a guide of what presentations could and could not be referred to the extended access hubs.
  • There were arrangements for planning and monitoring the number and mix of staff needed. There was an effective system in place for dealing with surges in demand.
  • There was an effective induction system for temporary staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example sepsis. In line with available guidance, patients were prioritised appropriately for care and treatment, in accordance with their clinical need. Systems were in place to manage people who experienced long waits.
  • Staff told patients when to seek further help. They advised patients what to do if their condition got worse. Where a condition might require management at the patient’s home surgery, for example the ongoing management of a long-term condition, patients were provided with information and the patient’s home practice was made aware that a follow up appointment would be required.
  • When there were changes to services or staff the service 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.

  • Individual care records were written and managed in a way that kept patients safe. The care records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • The service did not routinely make referrals to secondary care, these would be referred back to the patient’s home practice to make, who would also follow up the patient. However, where clinicians did make referrals (such as urgent referrals under the two week wait system), they were appropriate and timely in line with protocols and up to date evidence-based guidance.

Appropriate and safe use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The service utilised the emergency medicines and equipment, and vaccines, kept by the practices hosting the extended access clinics. The provider had systems in place to reimburse the practices for the use of medicines and equipment, and there were systems in place to ensure that medicines were safe to use. Systems and arrangements for managing medicines, including medical gases, emergency medicines and equipment and vaccines, minimised risks. The service utilised prescription stationary from the practices at which they were hosted and kept prescription stationery securely and monitored its use.
  • The service carried out regular medicines audit to ensure prescribing was in line with best practice guidelines for safe prescribing.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with legal requirements and current national guidance. The service had audited antimicrobial prescribing. There was evidence of actions taken to support good antimicrobial stewardship.
  • Processes were in place for checking medicines and staff kept accurate records of medicines.

Track record on safety

The service had a good safety record.

  • The service used comprehensive risk assessments in relation to safety issues that were carried out by the practice at which the services were based. However, they did not hold copies of all of these assessments, as the practices at which the services were based were members of the federation, and as such had oversight.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.
  • There was a system for receiving and acting on safety alerts.
  • Joint reviews of incidents were carried out with partner organisations if required.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events and incidents. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service. Individual feedback was provided to staff on an ad hoc basis, and more general learning points were shared with staff in a regular fortnightly bulletin.
  • The service learned from external safety events and patient safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.

Effective

Good

Updated 7 May 2019

We rated the service as good for providing effective services.

Effective needs assessment, care and treatment

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

  • Clinical staff had access to guidelines from the National Institute for Health and Care Excellence (NICE) and used this information to help ensure that people’s needs were met. The provider monitored that these guidelines were followed.
  • Telephone consultations were in place and there were systems to determine if and when a patients ought to be called in for a face to face consultation.
  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable. The service had mechanisms to ensure those patients that were more vulnerable were seen in their own practice rather than at the extended access hubs.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service had a comprehensive programme of quality improvement activity and routinely received the effectiveness and appropriateness of the care provided.

  • The service had instigated a process of auditing 1% of consultations similar to that undertaken in 111 and out of hours services. We saw that feedback was provided where required, and that performance had improved every quarter in the last year.
  • The service had undertaken an audit of two week waits to ensure that these had been managed safely.
  • The service had undertaken other prescribing and care audits relevant to the service being provided. Details of any learning points were shared in the service’s fortnightly newsletter to all staff.

Effective staffing

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

  • All staff were appropriately qualified. However, we noted that the provider did not hold copies of fire safety and infection control training for all staff, even though this had been completed. Copies were provided following the inspection. The provider had an induction programme for all newly appointed staff.
  • The provider ensured that all staff worked within their scope of practice and had access to clinical support when required.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Staff were encouraged and given opportunities to develop.
  • The provider provided staff with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The provider could demonstrate how it ensured the competence of staff employed in advanced roles by audit of their clinical decision making.
  • There was a clear approach through the service quality audit programme for supporting and managing staff when their performance was poor or variable. Measures included direct staff feedback, mentoring and supervision.

Coordinating care and treatment

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

  • We saw records that showed that all appropriate staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment.
  • Patients received coordinated and person-centred care. This included when they moved between services. One of the aims of the service was to allow practices to focus time on providing care and treatment for patients such as those in vulnerable circumstances and those with multiple long-term conditions. Staff communicated promptly with patient's registered GP’s so that the GP was aware of the need for further action. Staff also referred patients back to their own GP to ensure continuity of care, where necessary.
  • Patient information was shared appropriately, and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way.
  • The service ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

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

  • The service identified patients who may be in need of extra support such as through alerts on the computer system.
  • Where appropriate, staff gave people advice so they could self-care. Systems were available to facilitate this.

Consent to care and treatment

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

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

Caring

Good

Updated 7 May 2019

We rated the service as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.
  • The service gave patients timely support and information.
  • All of the 32 patient Care Quality Commission comment cards we received were positive about the service experienced. Patients noted in particular that all staff were friendly and helpful.

Involvement in decisions about care and treatment

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

  • Interpretation services were available for patients who did not have English as a first language.
  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.
  • Staff communicated with people in a way that they could understand.
  • 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.

Privacy and dignity

The service respected and promoted patients’ privacy and dignity.

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

Responsive

Good

Updated 7 May 2019

We rated the service as good for providing responsive services.

Responding to and meeting people’s needs

The provider organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The provider understood the needs of its population and tailored services in response to those needs. As part of its role the Federation provided analytical information and advice to practices within the Lambeth CCG area about how to improve in areas in which they were not meeting national targets.
  • The service was designed to ensure that practices had sufficient time to monitor those patients with the most complex needs. Lambeth has a higher prevalence of some long-term conditions and of patients requiring care for mental health issues than the national average.
  • The service had implemented systems that had reduced the rate of patients not attending appointments from 12% to 2%. They had achieved this by contacting all non-attendees so that they could undertake a telephone consultation. They had shared the learning of how they had achieved this with other Federations and GP practices within the Lambeth CCG area.
  • The service had a system in place that alerted staff to any specific safety or clinical needs of a person using the service. The service had access to patient records of any Lambeth based patients through the EMIS patient record system.
  • Care pathways were appropriate for patients with specific needs, for example those at the end of their life, babies, children and young people.
  • The facilities and premises were appropriate for the services delivered.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients were able to access care and treatment at a time to suit them. Appointments were available at Streatham High Practice and South Lambeth Road between 12pm and 8pm on weekdays and 8am to 8pm at weekends, and at Hetherington at the Pavillion between 2pm and 6pm on weekdays.
  • The service could be accessed through a patient’s own GP practice or the local 111 service.
  • The reception staff had a list of emergency criteria they used to alert the clinical staff if a patient had an urgent need. The criteria included guidance on sepsis and the symptoms that would prompt an urgent response. services were undertaken in a timely way.
  • Where patient’s needs could not be met by the service, staff redirected them to the appropriate service for their needs.
  • Appointments were available for GPs up to two weeks prior to the appointment for GPs and open ended for nursing appointments. Appointments were available within two days.

Listening and learning from concerns and complaints

The service 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 and it was easy to do. Staff at practices were aware of how to differentiate between complaints about the extended hours service an complaints relevant to their own practice. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. We reviewed three complaints and found that they were satisfactorily handled in a timely way.
  • Issues were investigated across relevant providers, and staff were able to feedback to other parts of the patient pathway where relevant. The service provider worked in partnership with the providers of the GP practices in the local area to share learning.
  • The service learned lessons from individual concerns and complaints and also from analysis of trends.

Well-led

Good

Updated 7 May 2019

We rated the service as good for leadership.

Leadership capacity and capability

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

  • Leaders had the experience, capacity and skills to deliver the service strategy and address risks to it.

  • Managers at the service were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them, and had developed action plans so that these areas might be addressed.

  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

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

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.

  • The service had developed a clear strategy before providing services. This included a comprehensive list of what conditions could and could not be treated at the extended hours hubs and an accountability framework.

  • 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 provider planned the service to meet the needs of the local population.

  • The provider monitored progress against delivery of the strategy.

  • The provider ensured that staff who worked away from the main base felt engaged in the delivery of the provider’s vision and values.

Culture

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

  • Staff felt respected, supported and valued. They were proud to work for the service.

  • The service focused on the needs of patients, and allowed practices to focus their time on those patients with most complex issues.

  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.

  • 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, including nurses, were considered valued members of the team. They were given protected time for professional 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 service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. 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 .

  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance. However, the service did not maintain copies of all off the risk assessments carried out at the sites at which services were provided.

  • There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety.

  • The provider had processes to manage current and future performance of the service. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of MHRA alerts, incidents, and complaints. Leaders also had a good understanding of service performance against targets that had been agreed with Lambeth Clinical Commissioning Group. Performance was regularly discussed at senior management and board level. Performance was shared with staff and the local CCG as part of contract monitoring arrangements.

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

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

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

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance.

  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.

  • The service 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 service used information technology systems to monitor and improve the quality of care.

  • The service submitted data or notifications to external organisations as required.

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

  • Staff were able to describe to us the systems in place to give feedback. The feedback showed that patients were satisfied with the service provided.

  • 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.

  • Staff knew about improvement methods and had the skills to use them.

  • The service 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 provider was involved in developing direct patient services and support services for general practices throughout the borough of Lambeth.