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Inspection Summary


Overall summary & rating

Good

Updated 6 August 2018

This practice is rated as Good overall.

The key questions at this inspection 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 New Bank Health Centre on 19 June 2018. The GP provider, The Robert Darbishire Practice Limited took over this practice in October 2017 and the registration of the service with the CQC was completed in December 2017.

This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

  • The provider upon taking over the practice in October 2017 identified several areas requiring immediate improvement. This included systems to ensure patients received safe, appropriate care quickly and improvements in the health and safety of the premises and equipment. The provider implemented a comprehensive plan to improve and develop the practice and service delivery.
  • This inspection identified many areas where changes had been implemented and the plan was ongoing to ensure the implementation of improvements.
  • The practice now had clear systems to manage patients’ care, and systems of call and recall were established and fail-safe monitoring implemented to ensure patients received the right care quickly.
  • The practice had clearly defined and embedded systems to minimise risks to patient safety. A ‘Red Flag’ policy was accessible to all staff from their desktop computer whereby specific health care symptoms were triggers for staff to take immediate action.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was an history of negative feedback from patients. The practice was trying to address this by providing a stable well trained staff team and plans were in place to change the telephone system to improve access.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Implement the planned upgrade to the telephone system to improve patient telephone access.
  • Continue to identify and support patients who are also carers.
  • Establish methods of formal patient feedback including developing a patient participation group.
  • Continue to implement the strategy to improve achievement in cervical cytology.

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 6 August 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. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Learning from safeguarding incidents was available to staff. Staff who acted as chaperones were trained for their role and had received an enhanced 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 Robert Darbishire Practice Limited became the provider for the GP service in October 2017. Up to date validated data to compare performance in medicines management at the practice was not available. However, the practice provided some data supplied by the clinical commissioning group (CCG) medicine optimisation team which demonstrated the practice bench marked their performance within the CCG.
  • 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 undertaken an audit of patient medicine reviews and the actions implemented in response to this resulted in improvements. For example, the checks undertaken on prescribed items improved from 46% to 72% and the provision of health care checks increased from 40% to 98%.
  • 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 adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and acted to improve safety in the practice.
  • 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

Good

Updated 6 August 2018

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

Effective needs assessment, care and treatment

The practice had systems in place 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.

  • The practice instigated a thorough and ongoing assessment of patients' needs upon taking over at the surgery. This assessment and audit process identified several areas requiring improvement and an action plan was implemented to address these areas. The areas of improvement included introducing systems of record management, building patients registers, identifying patients with a long-term condition and providing the right health care checks in a timely manner, introducing a patient recall system and systems of medication review.
  • 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. For example, the practice used the resources of charities such as Jo’s Cervical Cancer Trust to help support patients with different cultural understanding to access screening.
  • 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 vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

  • The practice had implemented immediate action upon taking over the service at New Bank Health Centre in October 2017. The initial assessments identified gaps in patients records in relation to care and treatment of their long-term condition. The practice initiated a comprehensive action plan to improve this.
  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. Systems of call and recalling patients for appointments were now established. 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.
  • 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 published data available regarding the practice’s performance on quality indicators for long term conditions reflected the performance of the previous provider. This data was generally in line with local and national averages. The new GP provider anticipated future performance to improve.

Families, children and young people:

  • Childhood immunisation uptake rates were below the target percentage of 90%. The practice was aware of this and were implementing an action plan to improve this. The practice liaised with the childhood health surveillance team to provide a catch-up immunisation programme.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.

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

  • The published data available regarding the practice’s performance for cervical screening was 55.6%, which was below the 80% coverage target for the national screening programme. However, this data reflected the performance of the previous provider of the GP service. The new GP provider had acted to improve this screening and had worked with Jo’s Cervical Cancer Trust to target hard to reach patients including those with different cultural understanding of this screening and those whose first language was not English.
  • The practice had recognised uptake for other screening programmes including breast and bowel cancer screening were below the national average and was implementing a plan to improve this.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • The practice had just received funding from the clinical commissioning group (CCG) to offer patients access to health assessments and checks including NHS checks for patients aged 40-74. The practice had systems established to 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 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.
  • The published data available regarding the practice’s performance on quality indicators for patients experiencing poor mental health including dementia reflected the performance of the previous provider. This data was in line with local and national averages. The new GP provider anticipated future performance to improve.

Monitoring care and treatment

The practice was part of a larger organisation which had comprehensive systems established to monitor care and treatment. A programme of continuous quality improvement activity was implemented to ensure a safe effective service was provided to patients. Examples of quality improvement included the establishment of clinical lead areas and a programme of clinical audit. In addition:

  • The practice used the Quality Outcomes Framework (QOF) to monitor performance and effectiveness. (QOF is a system intended to improve the quality of general practice and reward good practice.) The practice provided unverified data to indicate they had achieved 100% of the available points for the year 2017/18.
  • The practice was aware of the challenges of the local population demographics and worked hard to provide care and treatment to patients.
  • The practice used information about care and treatment to make improvements. For example, weekly practice development meetings were held where regular planned topics included staff training and educational updates.

Effective staffing

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

  • The service delivery and management of New Bank Health centre changed in October 2017 to the registered organisation The Robert Darbishire Practice Limited. At the time of transition, the staff employed by the previous GP provider left the practice leaving a staffing deficit. The new GP provider organisation initially used their existing resources from their other GP locations to staff the practice. They initiated a structured programme of recruitment that included opportunities for staff employed by the organisation to progress. At the time of our visit a stable clinical and administrative team was established with clinical and managerial support provided by the parent organisation.
  • The organisation had a structured training programme for all staff which included core subjects such as health and safety, safeguarding, equality and diversity and corporate policy and procedures
  • Staff from New Bank Health Centre attended the weekly practice development meeting and there was a standing agenda set for each week. The practice development meetings were used to review quality improvement and provide training. For example, a fire lecture and chaperoning training was scheduled for July 2018 and an Ear Nose and Throat (ENT) consultant was scheduled to deliver updates to the clinical team on paediatric ENT, Red Flags and rhinitis.
  • The GP clinical lead at the practice was a GP trainer and the practice planned on teaching undergraduate medical students.
  • Staff were trained and knowledgeable about their role and responsibilities to carry out appropriate activities such as reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, 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 6 August 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 practices GP patient survey results were below local and national averages for questions relating to kindness, respect and compassion. However, this data was collected between January and March 2017 when the former GP provider delivered services.
  • The new GP provider had reviewed the GP patient survey to identify themes and implement action to improve the quality of service. The practice had implemented a range of actions to improve the patient experience and this included improvements in the recruitment and retention of permanent staff both clinical and administrative, improvements to the patients records and monitoring systems and improvements to the practice environment.

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 we spoke with had a good understanding and awareness of working with patients to deliver a patient focused service.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available as required.
  • Staff working at the practice could speak a range of languages which promoted improved communication with some patients who did not have English has their first language.
  • 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 recognised they had further work to do to improve their records of those patients who were carers.
  • The GP patient survey results were below local and national averages for questions relating to involvement in decisions about care and treatment. The practice was aware of this and had analysed the results to identify themes and was implementing action to improve service delivery.

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 6 August 2018

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. A programme of improvement was being implemented and the provider of the GP practice implemented a system of quality monitoring to provide a safe, responsive service to the local patient population.
  • Telephone 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 had 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.
  • The practice promoted continuity of care by trying to ensure patient appointments were with the same clinician.

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 and urgent appointments for those with enhanced needs.

People with long-term conditions:

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

Families, children and young people:

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

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

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, pre-bookable Saturday morning appointments were available.

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 could access care and treatment from the practice within an acceptable timescale for their needs.

  • The GP provider had implemented fail safe systems of call and recall with regular monthly checks to ensure patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that telephone access was poor, but could usually get an appointment once they got through on the telephone. The GP provider had acted in trying to improve telephone access at the practice and anticipated that a contract with a supplier to provide improved telephony services would be agreed soon.
  • GP patient survey data available for the practice referred to data collected when the practice was registered under a different provider. However, the new GP provider had reviewed the data to identify themes and implement action to improve the quality of service. Actions implemented including sourcing a new telephony system to increase patient telephone access, employing a stable staff team and delivering a comprehensive training and development programme, that included elements of customer service training

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 organisation 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.

Checks on specific services

People with long term conditions

Good

Families, children and young 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