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Lancaster Medical Practice Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 14 September 2018

This practice is rated as outstanding overall. (Whilst under their former providers, each of the four practices which now make up Lancaster Medical Practice were previously rated good overall with one domain or population group rated outstanding. Inspections of these practices took place between October 2014 and December 2015)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Outstanding

Are services caring? – Good

Are services responsive? – Outstanding

Are services well-led? - Outstanding

We carried out an announced comprehensive inspection at Lancaster Medical Practice on 2 and 3 August 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • 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.
  • All of the 167 staff at the practice had completed mandatory training and had received an appraisal in the past 12 months.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • The involvement of other organisations and the local community was integral to how services were planned and ensured services met people’s needs. The practice had lead roles in the integrated care community and worked closely with the university.
  • Leaders had the capacity and skills to deliver high-quality, sustainable care. They had an inspiring shared purpose, strived to deliver and motivated staff to succeed.
  • Staff told us they felt supported and engaged during and since the merger.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We also saw several areas of outstanding practice:

  • The practice used a cultural values assessment tool to understand the culture and values of staff at each of the four legacy practices and to determine the desired cultural values for the merged practice. Staff were given “cultural training” to try and further embed these shared values and encourage staff to think as one practice, rather than as four separate entities. Staff we spoke to told us that this exercise had been an important factor in ensuring the success of the merger.
  • As well as public consultations at each of the sites, the practice set up a dedicated email address for patients to communicate with the practice about the merger. They released a range of informative material to keep people up-to-date, such as lists of frequently asked questions. They kept in touch with patients via letter, email and social media. The practice devised a methodology and key messages for engaging with patients, staff and external partners to ensure that the information they were giving was consistent and clear.
  • The practice had developed a new role following the merger: Patient Care Administrators (PCAs). They performed an administrative and coordination role for the clinical teams. This reduced the workload of clinicians and gave them more time for appointments. As PCAs were assigned to particular teams they developed close links with both the patients and the clinicians.
  • Group consultations had been trialled at the practice to assist patients following treatment for cancer. The nurse leading the consultations used the Macmillan concerns checklist to gauge patients’ wellbeing and found that each of the patients reported a more positive outlook following the intervention. The project won the Most Innovative Group Consultation award from Health Education England (HHE) in November 2017. The practice planned to use the same method to help patients with other long-term conditions, such as diabetes.
  • A nurse at the practice was awarded a grant to establish a mental health support group for new students at the university. This was set up in response to a review that found 9% of the practice’s 11,000 student population had attended the practice within the past 12 months with concerns about their mental health. Feedback collected by the practice showed students found the programme beneficial.

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

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

Inspection areas

Safe

Good

Updated 14 September 2018

We rated the practice as good for providing safe services.

Safety systems and processes

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

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. The practice held monthly safeguarding meetings with health professionals including midwives and health visitors. There were separate safeguarding leads for adults and children, as well as a nursing lead for safeguarding. All staff knew how to identify and report concerns and learning from safeguarding incidents were available to staff. Staff received up-to-date safeguarding and safety training appropriate to their role.
  • Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (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, 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.
  • There was an effective system to manage infection prevention and control.
  • 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

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

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, 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.
  • 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.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

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

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed and 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. Antibiotic prescribing was comparable to CCG and England averages.
  • 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.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed safety using information from a range of sources.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were 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 Quality and Performance committee had oversight of all significant events in the practice. They met on a monthly basis to review trends.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the evidence tables for further information.

Effective

Outstanding

Updated 14 September 2018

We rated the practice and two of the population groups as outstanding for providing effective services overall

.

The remaining four population groups were rated as good for this domain.

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

Effective needs assessment, care and treatment

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 were frail or may have been 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.
  • Patients aged over 75 were invited for a health check. If necessary they were referred to other services such as voluntary services and supported by an appropriate care plan.
  • The practice followed up on older patients discharged from hospital and 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.

People with long-term conditions. This population group was rated outstanding:

  • 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 high‑intensity 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 established an in-house respiratory team to offer clinics to patients who suffered long-term respiratory conditions in order to manage these in the community and avoid referrals to secondary care. This was established as a result of an audit in to the care of patients with COPD. The team included GPs, nurses and a pharmacist from within the practice with support from a respiratory consultant from the local acute hospital. Clinics were offered at two different sites across the city to give patients a choice of where they attended. Of the 99 patients referred to the team since it began in January 2018, 95 had been managed without the need for onward referral to secondary care.

Families, children and young people. This population group was rated outstanding:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates were well above the World Health Organisation target percentage of 90% for immunisations. There was an immunisations lead at the practice who produced a newsletter for staff to help them stay up to date with the immunisation programme and to promote this to patients.

  • 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 in secondary care or for immunisation.
  • The practice collaborated with a programme in the local area which aimed to support families whose children showed a high number of hospital admissions or A&E and GP attendances. This had led to an 88% reduction in all attendances or admissions for children who were part of this scheme.

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

  • The practice’s uptake for cervical screening was in line with local and national averages, but below the 80% target coverage rate. The practice were taking steps to try and increase uptake.
  • The practice’s uptake for breast and 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 have made 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.
  • The practice collaborated with a programme in the local area which aimed to help patients who suffered drug and alcohol addiction by referring them to a support service. There was a 37% reduction in GP attendances among the patients referred to the service within 18 weeks of the intervention.

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.
  • The number of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the previous 12 months was comparable to the national average.
  • The number of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive, agreed care plan documented in the previous 12 months was in line with the national average.
  • The practice specifically considered the physical health needs of patients with poor mental health and those living with dementia.
  • 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.

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. Where appropriate, clinicians took part in local and national improvement initiatives, such as the clinical commissioning group’s (CCG) Quality Improvement Scheme.

  • The practice had achieved 551 of the total number of 559 QOF points available in 2016/17, compared to the CCG average of 549 and the national average of 539. Overall the practice exception reporting rate was slightly higher than local and national averages at 6.3% (CCG average 5.1%, national average 5.7%).
  • Unverified data from 2017/18 showed QOF performance had dropped only slightly and came out better than forecast. The practice achieved 537 of the total number of 559 QOF points available, compared to the forecast of 531. However, exception reporting had increased to 10%. The practice were taking steps to reduce their exception reporting. As these figures are unverified they cannot be compared to local and national averages.
  • The practice used information about care and treatment to make improvements. There was an established programme of audit which was discussed at clinical meetings. We saw several examples of two-cycle audits where improvements had been identified and 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. All of the 167 members of staff were up-to-date with mandatory training at the time of inspection. New staff had access to online training prior to their start date so they could complete relevant training before taking up their posts. Clinical staff at the practice were granted one week of study leave per year.
  • The practice provided staff with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation. Every member of staff had received an appraisal in the past 12 months. There was a corporate induction programme for all new staff to introduce them to the culture of the practice and allow them to get to know staff at all levels of the organisation. There was a separate role-based induction to support staff as they started their posts.
  • 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. In 2017, 71% of palliative patients died in their preferred place of death.

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 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 and tackling obesity campaigns.
  • The practice worked closely with other organisations and the local integrated care community to support patients to live healthier lives. For example, they referred patients to a programme of exercise in which 68% of patients who completed the programme lost weight and 74% reduced their cholesterol.

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 September 2018

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 National GP Patient Survey results in July 2017 were above local and national averages for questions relating to kindness, respect and compassion. These results were obtained during the period when the practice was undergoing its merger. The recently-published results from August 2018 show that patient feedback in this area continues to be above average.

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 identified carers and supported them. They had identified 1% of their patient list as being a carer.
  • The practice’s National GP Patient Survey results in July 2017 were above local and national averages for questions relating to involvement in decisions about care and treatment. These results were obtained during the period when the practice was undergoing its merger. The recently-published results from August 2018 show that patient feedback in this area continues to be above average.

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

Outstanding

Updated 14 September 2018

We rated the practice, and four of the population groups, as outstanding for providing responsive services

.

The remaining two population groups were rated as good for this domain.

Responding to and meeting people’s needs

People’s individual needs and preferences were central to the planning and delivery of tailored services. The services were flexible, provided choice, and ensured continuity of care.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • The involvement of other organisations and the local community was integral to how services were planned and ensured services met people’s needs. There were multiple examples of interventions which the practice had supported or collaborated on with other agencies which had had a positive impact on patients.
  • There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that meets these needs and promotes equality. This included people who were in vulnerable circumstances or who had complex 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 Lancaster University Medical Centre site had been awarded a “Gold Star” award in 2017 by a national disability advocacy group for its accessibility.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who were more vulnerable or who had complex needs. They supported them to access services both within and outside the practice. The practice employed their own clinical care co-ordinators who carried out holistic assessments of frail patients in their own homes to ensure they had the care and support they required. The practice had given presentations to other practices in the area to promote this role for wider use.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.
  • Self-help and self-referral forms were available on the practice website.
  • The practice employed a team of pharmacists who were able to offer patients advice and medication reviews. The pharmacists were aligned with the clinical teams for increased continuity of care.
  • There were in-house physiotherapy clinics and a musculoskeletal service to save patients having to wait to access these services in secondary care.

Older people:

  • All patients over 75 had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
  • Nurses at the practice provided a wound dressing service. This was available at each of the seven sites. The service was put in place in response to patient feedback gathered during the merger.

People with long-term conditions. This population group was rated outstanding:

  • 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 multidisciplinary team to discuss and manage the needs of patients with complex medical issues.
  • Group consultations had been trialed at the practice to assist patients following treatment for cancer. The practice identified a need for increased care of these patients’ wellbeing once treatment had ended and contact with health professionals had reduced. The nurse leading the consultations used the Macmillan concerns checklist to identify what concerns each of the patients had and the extent to which they felt worried by these. They repeated the checklist following the consultations and found that each of the patients reported fewer concerns and that they felt less troubled about any concerns they still had. The project won the Most Innovative Group Consultation award from Health Education England (HHE) in November 2017. The practice planned to use the same method to help patients with other long-term conditions, such as diabetes.
  • The practice established an in-house respiratory team to offer patients with long-term respiratory conditions the chance to manage their care in the community and avoid referrals to secondary care. This was established in response an audit in to the care of patients with chronic obstructive pulmonary disease (COPD) and was part of a wider scheme in the local area to join up primary and secondary care. The introduction of the team had led to a reduction in referrals to secondary care, allowing patients to stay in their own homes.
  • The practice worked closely with other organisations and the local integrated care community to support patients with long-term conditions. They referred to an exercise programme which helped patients with long-term conditions such as diabetes or COPD to improve their health and wellbeing.
  • The practice nurses operated a chronic disease home visiting service. This allowed them to review the care and management of patients with long-term conditions who were housebound and unable to attend clinics at the practice sites. The GPs saw any patients who were acutely unwell, and the home visits were simply to support patients with the management of their condition. Each practice nurse had one session blocked out a month for home visits.

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.
  • Urgent appointments were embargoed for any unwell children or pregnant women who needed to be seen on the day they called.
  • All of the practice’s premises were suitable for children and babies.
  • The practice hosted weekly midwife and health visitor clinics.
  • The practice collaborated with a programme in the local area which aimed to support families whose children showed a high number of hospital admissions or A&E and GP attendances. This had increased the number of available GP appointments by reducing attendances among this group.

Working age people (including those recently retired and students). This population group was rated outstanding:

  • 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. Extended opening hours appointments and repeat prescriptions were available to order online.
  • Evening and weekend appointments were available. The practice worked with the local GP Out of Hours provider to provide the “extended access” service to patients in Lancaster. At the time of inspection, we were told by the Out of Hours provider that Lancaster Medical Practice was the only surgery in the area providing extended access appointments.
  • The practice used a text messaging service for appointment reminders, information on the service such as the practice newsletter, and to enable patients to give direct feedback.
  • The practice produced a guide to health services for international students to help them understand what each of the services did and how to access them. They also gave a presentation to new students and their families during Fresher’s Week to explain the services on offer at the practice.
  • Each year the practice invited an international student from the university to give a talk to staff about cultural differences in order to make staff more aware of these and help them to respond better to the needs of students coming from overseas.
  • The practice worked closely with the university’s counselling and wellbeing services to ensure patients received the support they required.
  • The practice offer a full range of sexual health services, including contraception advice and STI screening. This service could be accessed at two sites and was open to people who were not registered as patients at the practice.

People whose circumstances make them vulnerable. This population group was rated outstanding:

  • 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.
  • The practice had worked with the police to provide services to patients who were on the witness protection scheme.
  • Patients with a learning disability were given a “hospital passport”. This contained important information which would be helpful to clinicians in the event of the patient being admitted to hospital and being unable to communicate their needs or concerns.
  • All staff had undergone training in counter-terrorism to spot and report signs of radicalisation. The practice worked closely with the university and local agencies on their counter-terrorism programmes. They were due to take part in an anti-terrorism exercise at the university campus in September where staff would be trained how to assist patients and members of the public in the event of a terrorist attack.
  • The practice saw from an audit of appointments that the uptake of learning disability reviews had reduced following the merger. They therefore introduced pictorial letters to invite patients to review. These letters included pictures which helped to explain what the review was for and what would happen at the appointment. In the four months since their introduction 31 patients had attended for review, compared to a total of 69 patients in the preceding 12 months.
  • The practice offered support to Syrian refugees and asylum seekers. They were working closely with the local clinical commissioning group to access these patients’ medical records. While the patients could see any GP, the practice employed a Syrian GP who often saw this patient group.
  • The practice took part in programmes with partners in the local area to support patients who suffered drug and alcohol addiction. These had reduced the need for these patients to attend the surgery, thereby freeing up GP appointments. The practice had focussed on this area after identifying that 4% of the patient list had sought advice on alcohol intake in the past 12 months.

People experiencing poor mental health (including people with dementia). This population group was rated outstanding:

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia. The practice had actively focussed on providing support for people experiencing poor mental health after a review of consultations found 5% of all appointments at the practice in the past 12 months had been for mental health concerns.
  • A nurse at the practice was awarded a grant to establish a mental health support group for new students at the university. This was set up in response to a review of student appointments which found that from the 11,000 students registered with the practice, 9% had attended the practice within the past 12 months with concerns about their mental health and 5% had been referred to secondary mental health services. The group became a 10-week programme for up to 10 students which aimed to focus on different aspects of mental health. Feedback collected by the practice from those who attended showed students found the programme beneficial.
  • The practice held regular meetings with the university to identify any students who may need additional support due to their mental health. They were made aware of students returning from periods of study leave which had been granted due to poor mental health so they could ensure these students were registered with a practice.
  • The practice helped to establish and promote a support group for patients with social anxiety. The group was now patient-led. Clinicians at the practice could refer patients to the group.
  • A “Listening Service” was established by the practice. This was a free, confidential service facilitated by volunteer listeners. Appointments were available for patients or practice staff who felt they would benefit from an opportunity to discuss their concerns related to matters such as illness, the prospect of surgery, a difficult diagnosis or bereavement. Appointments could be made by a GP, nurse or team member, or by self-referral. Patients and staff members we spoke to on the day of inspection spoke highly of the service. 139 people had used the service since it was started in September 2016.
  • Patients with dementia were invited to attend for an annual review in their birthday month, to help ensure their needs were being met appropriately.
  • Clinical staff actively carried out opportunistic dementia screening, to help ensure patients were receiving the care and support they needed to stay healthy and safe.
  • Alerts had been placed on the clinical system to ‘flag’ patients with dementia, so clinicians could take this into account during a consultation.
  • Dementia patient-support packs had been developed, to help provide patients and their carers with a range of helpful information.
  • Carers of patients with dementia were invited to attend a health check.

Timely access to care and treatment

Patients were able to access care and treatment from the practice within an acceptable timescale for their needs and in a way that suited them.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately. Feedback we received on patient comment cards was mostly positive about access to appointments.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • The practice’s GP Patient Survey results were above local and national averages for questions relating to access to care and treatment.
  • The practice offered 15-minute appointments as standard. Longer appointments were available for those who needed them.

A number of processes and job roles were redesigned following the merger to ensure that patients continued to be able to access appointments in a way and at a time that suits them, and which ensured continuity of care. These included:

  • Clinicians were divided into four teams, split by geographical area. These teams included GPs, nurse practitioners, practice nurses and pharmacists. Where possible, patients remained under the care of the GP they had pre-merger. If patients were unable see their usual GP, they would be given an appointment with another clinician in the same team to ensure it was likely to be someone they had seen before. Patients could still choose to see any doctor at any of the seven practice sites if they wished. The caseloads of the clinicians were weighted rather than simply split by number to ensure the workload was distributed equally and all patients would have equal access to their GP. Staff were positive about the way this system worked because it enabled continuity of care for patients through seeing their regular GP as needed or through a buddy system within the team.
  • The practice created the role of Patient Care Administrator (PCA) to support the clinical teams. The PCAs were aligned to a clinical team and were able to book appointments, review and action any normal test results, review and action letters/correspondence that doctors did not need to see and perform general administrative duties for clinicians. This reduced the administrative workload of clinicians and gave them more time for appointments. As PCAs were assigned to particular teams they developed close links with both the patients and the clinicians. Feedback from patients was positive about this service and patients came in asking to see their PCA by name as needed.
  • Following a review of the appointment system during the merger, the Clinical Assessment Team (CAT) was established to deal with urgent appointments. A colour-coded triage system was developed by clinicians, and receptionists had training in how to use it. This allowed receptionists and PCAs to book patients who needed an urgent appointment with the relevant clinician.
  • The appointment system was constantly reviewed to ensure it was working as well as it could be. Since the merger, the size and number of clinical teams had been changed, as had the scope of the CAT in an attempt to improve access to appointments and continuity of care.
  • Appointments were available with nurse practitioners and pharmacists as well as GPs. The practice had worked hard to promote these roles to their patients in order to encourage uptake of appointments with them.
  • We checked the appointment system in real time on the day of inspection. At 3pm there were still same day appointments available at 4.15pm onwards and routine pre-bookable appointments within the following two weeks.

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. There was an active review of complaints and how they were managed and responded to, and the improvements made as a result. People who use services were involved in the review.

  • Information about how to make a complaint or raise concerns was available in the reception area which patients could access without asking a member of staff. 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. The practice Quality and Performance committee had oversight of all complaints in the practice and met on a monthly basis to review trends.

Please refer to the evidence tables for further information.

Well-led

Outstanding

Updated 14 September 2018

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

Leadership capacity and capability

The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. Leaders had the capacity and skills to deliver high-quality, sustainable care. They had an inspiring shared purpose, strived to deliver and motivated staff to succeed.

  • The partners and the management team had overseen the merger of four practices into one of the largest practices in the area, with 55,000 patients across seven sites. By putting innovative new systems and ways of working in place, and by promoting a culture of embracing change among staff and patients, they had managed to achieve this with minimal impact on clinical outcomes and without having any serious untoward events. Patient feedback remained better than other practices locally and nationally, and a number of new initiatives, such as group consultations for cancer patients, had been established in the first 12 months of the merger with a demonstrable positive impact on patient care.
  • A project team was established to oversee the merger, allowing partners time to continue to see patients. This team developed to become the practice management team once the merger had taken place. The management structure of the practice was changed to ensure that new systems would be in place following the merger to allow the practice to continue to operate safely. This structure was under constant review to ensure it was working.
  • 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.
  • Clinicians at the practice had lead roles in the local integrated care community and GP federation. They had been involved in developing and leading programmes and interventions together with other local services which had led to improved outcomes for patients.
  • The practice had been proactive in facing one of their biggest challenges, which was recruitment of clinical staff. There was a Workforce Planning Committee which was solely responsible for recruitment and retention of staff. They monitored increased demand for appointments as well as known upcoming changes to the workforce, such as retirements, and used that information to plan recruitment. Rather than replacing staff “like-for-like” they looked for the best ways to recruit, for example, by replacing one outgoing GP partner with a salaried GP and a nurse practitioner. The practice had also produced a brochure which it used at recruitment conferences to attract staff to the practice. GPs in the area wanted to work for the practice and saw its way of working as innovative but also supportive to good patient care and staff well-being.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care. The strategy and supporting objectives were stretching, challenging and innovative while remaining achievable.

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were involved in developing the vision, values and strategy. They were therefore aware of them 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 regularly monitored progress against delivery of the strategy.

Culture

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

  • During the merger, leaders at the practice used Barrett’s Cultural Values Assessment tool to gauge an understanding of the culture and values of staff at each of the four legacy practices and to determine the desired cultural for the merged practice. This allowed the practice to understand the aspects of their culture and values that they already shared and wanted to keep as they merged. Staff we spoke to told us that by undertaking this exercise and by learning that the four practices had more in common than they had differences, it embedded a shared sense of a common purpose among staff. Staff were given “cultural training” to try and further embed these shared values and encourage staff to think as one practice, rather than as four separate entities working together. Staff we spoke to told us that this exercise had been an important factor in ensuring the success of the merger.
  • Staff stated they felt respected, supported and valued. There were high levels of staff satisfaction and staff were proud of the organisation as a place to work. They spoke highly of the culture.
  • There were consistently high levels of constructive staff engagement. Staff we spoke to told us they felt well-supported both during and since the merger and they gave us multiple examples of when this had happened.
  • The practice focused on the needs of patients.
  • Leaders and managers acted on any behaviour and performance which was 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. Staff were supported to meet the requirements of professional revalidation where necessary. The practice put a strong emphasis on staff development. Clinical staff were given one week of study leave per year. The practice’s processes had allowed them to ensure that, despite the extra workload of the merger and the increased workforce, 100% of the 167 members of staff had completed their mandatory training and had received an appraisal in the past 12 months.
  • There was a corporate induction programme for all new staff to introduce them to the culture of the practice and for them to get to know staff at all levels of the organisation. This was separate from the role-specific induction. One of the nursing team had developed an induction programme for all new nursing staff at the practice which included clinical skills training and a competency framework to ensure all nurses were working at a high standard when they started their role.
  • There was a strong emphasis on the safety and well-being of all staff. We were given multiple examples by staff members of times when they had been supported to improve their physical and mental wellbeing. Staff at the practice could access the practice’s Listening Service for support.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally. Furthermore, an international student from the university gave a talk to staff at the practice each year about cultural differences so staff could take these into account when supporting patients from other countries.
  • 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. Governance and performance management arrangements were proactively reviewed and reflected best practice.

  • 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 practice had developed a number of roles to support the delivery of high-quality care. These included the Patient Care Administrators, who performed an administrative and coordination role for the clinical teams, freeing up clinician time to treat patients. They had also employed Clinical Care Coordinators and a team of pharmacists who were able to support patients. The practice was able to show that since the merger and the introduction of these roles their patients had had fewer elective and non-elective admissions to secondary care, suggesting the practice was better equipped to treat their patients within the community and reducing the burden on secondary care.
  • Due to the size of the practice, management and governance was split into three main areas, each with their own “Head of” and levels of management below. These areas were Patient Services, Corporate Services and Quality and Performance.
  • There were a number of “working groups” established within the practice to oversee certain areas. These included a Quality and Improvement group and a Workforce Planning group.
  • Governance and performance management arrangements were proactively reviewed and reflected best practice. For example, the original formation of nine clinical teams was changed to four teams aligned by geographical area following a review. The practice had also moved to weighted caseloads following a review of clinician workload. Patients were given a weighting based on their health needs and level of clinical input. Weightings were then distributed equally among clinicians, rather than splitting the list by number.
  • 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. These policies and procedures were included in a daily email to staff – the Daily Bulletin – to ensure they remained at the forefront of people’s minds.
  • Managers and partners had access to a WhatsApp group to facilitate secure communication across a large team based over seven sites.

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 were collaborating with researchers at Lancaster University on new methods of validating data to ensure their methods of data collection and interpretation were as effective as possible and gave the best possible indication of performance.
  • The practice had plans in place and had trained staff for major incidents. This included working with the university and other agencies to prepare for major incident that would affect the whole university campus, not only the surgery.
  • The practice considered and understood the impact on the quality of care of service changes or developments.
  • The practice had undertaken the “Quickstart” programme which aimed to standardise rooms and job roles across the practice. This had been completed so that staff working in any of the seven sites had access to the same equipment and resources, and these were stored in the same place and maintained in the same way.

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. Meetings were repeated during the week so that staff had some flexibility to attend. This process was put in place as a response to the increased workforce at the practice following the merger to ensure that as many people as possible were able to attend meetings.
  • The practice used performance information which was reported and monitored. The practice participated in local quality improvement schemes and monitored their performance through this.
  • 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. Rigorous and constructive challenge was welcomed and seen as a vital way of holding services to account.

  • The practice engaged with patients, staff and external partners before, during and after the merger. As well as public consultations at each of the sites, the practice set up a dedicated email address for patients to communicate with the practice about the merger. They released a range of informative material to keep people up-to-date, such as lists of frequently asked questions. They kept in touch with patients via letter, email and social media. The practice devised a methodology and key messages for engaging with patients, staff and external partners to ensure that the information they were giving was consistent and clear.
  • The practice collected feedback before the merger from patients at each of the practice. This showed patients were split equally between feeling positive and negative about the merger. The practice gathered patient concerns and put in place measures to address these, such as the wound dressing service and the clinical teams to ensure continuity of care. Feedback collected by the practice and by our inspection team during the inspection showed that 16 months after the date of the merger the majority of patients were now positive about the outcome. Comment cards we received said that while they had been initially sceptical they now saw the merger as a positive.
  • 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 practice held regular meetings with external partners, such as the university.
  • The service was transparent, collaborative and open with stakeholders about performance.
  • There was a newsletter for staff and patients which kept them up-to-date about changes at the practice.
  • Communication with staff was seen as a priority given the increased workforce across seven sites. As well as a range of flexible meetings for staff to attend, the practice sent a “daily bulletin” by email to all staff. This contained important information for that day, such as who was working and where, who was on call, as well as links to important documents and contact details.
  • Leads used newsletters as a way to communicate with staff. For example, the immunisation lead produced a “Jab Jotter” which was a newsletter which kept staff up-to-date about immunisations.
  • Positive messages were passed on to staff every Thursday in an email called “Thursday Thank Yous”. Staff could recommend things to include in the email. Staff we spoke to appreciated the email and felt it was good for staff morale as well as keeping them informed.
  • We saw that the practice took the time to respond to all feedback left on NHS Choices. We also saw that where negative feedback had been left by patients, on several occasions those same patients had left a follow-up review after their matter had been dealt with by the practice to say they were happy with how their concerns had been handled.

Continuous improvement and innovation

The leadership drove continuous improvement and staff were accountable for delivering change. Safe innovation was celebrated. There was a clear approach to seeking out and embedding new ways of providing care and treatment.

  • We saw multiple examples of improvements suggested by staff which had been supported and promoted by management. These included group consultations for cancer patients, the mental health programme for students and the introduction of pictorial letters for learning disability patients. All of these had led to demonstrated improvements for patients.
  • Managers at the practice were always looking for innovative ways of working, such as introducing the clinical teams and the Patient Care Administrators. There was a Quality and Improvement Team who looked for areas where further improvements could be made. The team included a Quality Ambassador whose role was to engage with patients and staff to look for improvements to care.
  • 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.
  • Leaders at the practice had engaged with local external partners to help develop a Quality Improvement Scheme for the Morecambe Bay area which was aimed at reducing inequalities in care.
  • The practice was due to continue growing over the next 12 months with the addition of 11 new GPs and a projected list size of 66,000 patients.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Outstanding

Families, children and young people

Outstanding

Older people

Good

Working age people (including those recently retired and students)

Outstanding

People experiencing poor mental health (including people with dementia)

Outstanding

People whose circumstances may make them vulnerable

Outstanding