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Archived: Special Allocation Scheme (Camden, Islington and Haringey) Good

Inspection Summary


Overall summary & rating

Good

Updated 16 January 2019

This service is rated as Good overall. We carried out an announced comprehensive inspection on 20 November 2018. It was the first scheduled comprehensive inspection of the service, which was registered by the Care Quality Commission on 29 November 2017.

The service provides a small number of patients in Camden, Islington and Haringey, who are otherwise excluded from general practice registration, with access to a GP. The service is not provided to patients under 18-years of age. It was established as a pilot scheme, intended to operate for 12 months from 1 December 2017. However, it has now been extended until 31 March 2019.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

At the inspection we found:

  • The provider 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 provider routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 16 January 2019

We rated the service as good for providing safe care.

Safety systems and processes

The provider had systems to keep people safe.

  • The provider had appropriate systems to safeguard vulnerable adults from abuse. For example, it had up to date policies and staff had received up-to-date safeguarding and safety training appropriate to their role. Reports and learning from safeguarding incidents at all the services operated by the provider were available to staff. We saw minutes confirming safeguarding issues were discussed at clinical governance meetings.
  • There was a standard operating procedure in place in relation to patients who failed to attend appointments, involving an assessment of risk and safeguarding considerations.
  • The provider had a policy on chaperoning, which had been reviewed and updated in October 2018. Posters at the location informed patients of the availability of chaperones. Staff who acted as chaperones were trained for their role and had received a 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, harassment, 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 were effective systems in place to manage infection prevention and control (IPC). There were named leads and deputies responsible for IPC issues. All staff had received appropriate IPC training. There were arrangements for managing waste and clinical specimens to keep people safe.
  • There were effective arrangements to keep facilities and equipment safe and in good working order.

Risks to patients

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

  • The landlord had carried out a full health and safety risk assessment in April 2018. The provider’s staff understood their responsibilities to manage emergencies within the service. Equipment to deal with medical emergencies, including a defibrillator and a portable oxygen supply were available on site. These were monitored and logged. The provider had carried out a risk assessment relating to appropriate emergency medicines, which it continued to monitor and review according to clinical need and individual risk assessment of people using the service. The provider had a written protocol relating to emergency medical responses and staff had up to date training in basic life support.
  • Clinicians knew how to identify and manage patients with severe infections including sepsis. We saw guidance issued by the National Institute for Health and Care Excellence (NICE) relating to sepsis was posted in the consultation rooms used for the service.
  • There were appropriate arrangements to cover staff absences, set out in a standard operating procedure and the provider had in place an up-to-date Business Continuity Plan, which included making provision for telephone consultations with patients or home visits, should the premises be unavailable for use on a short-term basis. Service commissioners would make alternative arrangements in the event of longer periods.

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 information needed to deliver safe care and treatment was available to staff.
  • The provider 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.
  • There were up to date standard operating procedures relating to patients’ two-week referrals and the management of pathology results.

Appropriate and safe use of medicines

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

  • The systems for managing and storing emergency medicines and equipment, minimised risks.
  • The provider had an up to date prescribing policy, last reviewed in November 2018. Staff prescribed medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing to support good antimicrobial stewardship in line with local and national guidance.
  • 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.
  • There were appropriate arrangements relating to prescription security with a written protocol in place.

Track record on safety

The provider had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The provider monitored and reviewed safety using information from a range of sources.
  • The provider had an effective system to receive, review and action safety alerts appropriately.

Lessons learned and improvements made

The provider learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses and they were supported to do so.
  • There were effective systems for reviewing and investigating when things went wrong. The provider learned and shared lessons, identified themes and took action to improve safety. We saw a log of 4 significant events, which had been appropriately recorded, investigated and from which learning points were shared.
  • The provider acted on and learned from safety events at its other locations and externally, as well as patient and medicine safety alerts.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 16 January 2019

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

Effective needs assessment, care and treatment

The provider 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 advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.
  • The provider worked closed with local community services and other health and social care organisations to co-ordinate patient care.
  • The provider currently had only two patients aged over 60 registered.

People with long-term conditions:

  • Double appointment slots were provided to patients with medical or mental health complexities.
  • 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.

Families, children and young people:

  • The service was not commissioned to see children under 18-years of age.
  • Younger adult patients were offered appointments and active signposting for travel vaccination, Sexually Transmitted Disease testing and substance-misuse management at specialist clinics.

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

  • 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:

  • Appointments were offered to homeless people.
  • There was continuity of care, with appointments being provided with the same clinician.
  • Where needed, double appointments with an interpreter were offered to refugees and asylum seekers.
  • Patients with multiple medical and psychological concerns were directed to support organisations.
  • There was a named lead for safeguarding and all staff were trained to appropriate levels. The provider worked closely with the district nursing team, health visitors and the social services safeguarding team.
  • The provider currently had only one patient on the vulnerable adult register.

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

  • The provider assessed, reviewed and monitored the physical health of people with depression and other mental health issues including personality disorders.

  • 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 service had arrangements in place to help them to remain safe.

Monitoring care and treatment

The provider had a programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided.

Being a very specialised service, it did not participate in the Quality Outcome Framework (QOF), which operates for mainstream general practices. However, there were processes in place for monitoring care and treatment to bring about improvement. These included a protocol in respect of implementing National and local guidelines, such as those issued by the National Institute for Health and Care Excellence (NICE). These included Clinical Guidelines, Technology Appraisals, Public Health Guidance and Interventional Procedures.

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

Effective staffing

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

  • The provider 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. All staff were up-to-date with mandatory training. Staff were encouraged and given opportunities to develop.
  • Staff had appropriate knowledge for their role.
  • The provider gave staff 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 which showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The provider shared clear and accurate information with relevant professionals when discussing and co-ordinating patients’ healthcare.
  • There was a standard operating procedure for managing medical records when patients moved between services.
  • Patients received co-ordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital.
  • Patients were reviewed on a three-monthly basis to assess whether they might return to regular general practice.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The provider identified patients who might be in need of extra support and directed them to relevant services.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health.
  • Staff discussed changes to care or treatment with patients as necessary.
  • The provider supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns and tackling obesity.

Consent to care and treatment

The provider obtained consent to care and treatment in line with legislation and guidance. It had an up to date protocol, last reviewed and updated in February 2018, to combine its Consent and Mental Capacity policies.

  • 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 regarding their care.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.

Caring

Good

Updated 16 January 2019

We rated the service as

good

for caring.

The service did not participate in the national GP patient survey. However, we saw from other feedback, such as the provider’s own patient survey results and the CQC comments cards which patients completed, that patients rated the service highly.

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 provider gave patients timely support and information.
  • Feedback from patients who had completed our comments cards and from the provider’s own patient survey data was very positive regarding this aspect of the service.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. The provider was aware of the Accessible Information Standard, a requirement to make sure that patients and their carers can access and understand the information they are given.

  • Staff communicated with people in a way they could understand.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.

Privacy and dignity

The provider respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.

Please refer to the evidence tables for further information.

Responsive

Good

Updated 16 January 2019

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

Responding to and meeting people’s needs

The provider organised and delivered services in accordance with its contract with service commissioners. Where possible, it took account of patients’ needs and preferences.

  • The provider understood the needs of the patient groups and where possible under the terms of its service contract made reasonable adjustments to meet those needs.
  • All patients using the service were referred by the service commissioners.
  • Telephone consultations were available, which supported patients who were unable to attend the service during its working hours.
  • Home visits were available, subject to appropriate individual risk assessments being carried out.
  • The facilities and premises were appropriate for the services delivered.
  • Patients with complex needs were appropriately supported to access other services available to them.

Older people:

  • Home visits were available, subject to any necessary risk assessment and telephone consultations were provided.

People with long-term conditions:

  • The provider had a standard operating procedure relating to the management of 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 a single appointment.
  • The provider held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.
  • The service did not include providing palliative care.

Families, children and young people:

  • The service readily accommodated young people who found it difficult to meet appointment times, working with them to improve their attendance and compliance to care.
  • Patients registered with the service were individuals. Under the terms of the service contract, no appointments were provided to their family members.

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

  • The commissioned service had restricted opening times and limitations to what could be offered to patients with specific access needs. However, where possible appointments were offered to working age patients to suit them.
  • The service did not currently provide cervical cancer screening. Eligible patients had their screening carried out at the local extended hours hubs, subject to suitable risk assessment.

People whose circumstances make them vulnerable:

  • Carers were offered information about local organisations that could help in various situations.
  • Facilities were provided to patients with communication difficulties and language barriers, including interpreter services via telephone.
  • Sign language practitioners were available by appointment.

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

  • Longer appointments were available to those patients with mental health problems and to those with communication difficulties.
  • Staff we spoke with had a good understanding of how to support patients with mental health needs.

Timely access to care and treatment

Patients could access care and treatment from the practice within an acceptable timescale for their needs, in accordance with the service contract.

  • 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 the appointment system was easy to use.

Listening and learning from concerns and complaints

The provider 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 complaints policy, which was last reviewed in January 2018, and procedures were in line with recognised guidance. The provider learned lessons from individual concerns and complaints and also by analysing trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 16 January 2019

We rated the service as good for providing well-led care.

Leadership capacity and capability

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

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The provider had effective processes to develop leadership capacity and skills.

Vision and strategy

The provider had a clear vision and credible strategy to deliver high quality, sustainable care.

  • There was a clear vision and set of values. The provider had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The provider planned its services to meet the needs of service users.
  • The provider monitored progress against delivery of the strategy.

Culture

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

  • Staff stated they felt respected, supported and valued. They were proud to work in the service.
  • The provider focused on the needs of patients.
  • Leaders acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence these would be addressed.
  • There were processes for providing staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • The provider actively promoted equality and diversity.
  • There were positive relationships between staff members.

Governance arrangements

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

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • The provider had a range of policies and procedures which were regularly reviewed. Staff were notified of changes and were required to read the policies and sign them.

Managing performance and risks

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 provider had processes to manage current and future performance. 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 provider had plans in place and had trained staff for major incidents.
  • The provider considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The provider acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The provider used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The provider used information technology systems to monitor and improve the quality of care.
  • The provider submitted data or notifications to external organisations, such as service commissioners 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 provider involved patients, staff and external partners to support high-quality sustainable services.

  • Feedback was encouraged from patients, staff and external partners and concerns were acted on to shape services and culture. There was a standard operating procedure in place in relation to seeking and acting upon patient feedback.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The provider made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good