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GP+ Nottingham City (NHS Upper Parliament Street)

Inspection Summary


Overall summary & rating

Updated 25 April 2019

We carried out an announced comprehensive inspection at NHS Upper Parliament Street on 14 February 2019 as part of our inspection programme. This was the first inspection of the service since its registration with the Care Quality Commission (CQC) as the provider of the service in January 2018.

While the service had been registered just over a year ago, systems and processes were very well-embedded. Patient and stakeholder feedback was extremely positive regarding the quality and accessibility of services. The provider had a clear vision and strategy and all staff were energetic and committed to providing high quality and sustainable care.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as good overall.

We rated the practice as outstanding for providing responsive services because:

  • Services were tailored to meet the needs of individual patients. The service had identified areas where there were gaps in provision locally and had taken steps to address them.

We also rated the practice as good for providing safe, effective, caring and well-led services because:

  • The practice provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Patients were treated with respect and commented that staff were kind and caring and involved them in decisions about their care.
  • The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care.

We saw an area of outstanding practice:

  • The service had provided a smoking cessation service for the whole of Nottingham City which had led to a significant quit rate amongst the patients using the service. This service had now been commissioned to expand further.

The areas where the provider should make improvements are:

  • Continue to develop a record of staff immunisation status for all diseases recommended by Public Health England.
  • Review the arrangements for ensuring the security of prescription printer paper.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 25 April 2019

We rated the service as good for providing safe services.

Safety systems and processes

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

  • The service had appropriate systems to safeguard children and vulnerable adults from abuse. Policies and procedures were in place covering child and adult safeguarding. The Clinical Lead GP was the lead member of staff for safeguarding. 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 would be discussed at relevant meetings.
  • Notices were displayed to advise patients that a chaperone service was available if required. 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 service carried out appropriate staff checks at the time of recruitment and on an ongoing basis. The service checked to ensure that clinical staff were registered and had up to date medical indemnity insurance in place. The service kept a record of staff immunisation status in relation to hepatitis B but did not record immunisation status for all diseases recommended by Public Health England. The provider agreed to review this immediately following our visit.
  • The service had systems to ensure that facilities and equipment were safe and in good working order. This included appropriate arrangements with the GP practice that shared the premises, the owner of the premises and its property management agency. Equipment and safety systems were regularly checked by external contractors to ensure they were adequately maintained and were safe to use. Appropriate fire systems were in place and fire marshals had undertaken relevant training.
  • There was an effective system to manage infection prevention and control. We observed the premises to be clean and staff followed infection control guidance and attended relevant training. Staff knew what to do if they sustained a needlestick injury. We saw evidence of cleaning specifications and records were in place to demonstrate that cleaning took place. The service undertook regular infection prevention and control audits and acted on the findings. The provider had appropriate arrangements in place with the owner of the premises and the property management agency to ensure that the premises was kept hygienic and infection control risks were minimised.
  • 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. Changes in the skill mix of staff had taken place since registration in order to better meet patient needs.
  • There was an effective induction system for temporary staff tailored to their role. A checklist for locum staff was in place. Each clinical room had a ‘clinicians box’. This was a box of useful information placed in the clinical room at the start of each session of appointments so that all clinical staff had quick access to the information they needed.
  • The service 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. Staff had received recent sepsis or sepsis awareness training.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • The service had a comprehensive business continuity plan in place for major incidents such as power failure or building damage. The plan included emergency contact numbers for staff. The service had effectively managed two separate significant incidents affecting the premises minimising the impact on the service provided to patients.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Patients gave consent to the service accessing their full medical records as a part of the appointment booking process. The care records we saw showed that information needed to deliver safe care and treatment was available to staff. Staff only had access to the patient’s full medical records for the day of the appointment at the service. Their access was removed at the end of the day to ensure the confidentiality and security of records.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. Systems were in place to ensure staff could document each consultation into the patient’s full medical records. Clear processes were in place for staff to use when they were unable to access vital clinical information about the patient. This process was required when patient consent for access to records was not obtained at the time of booking an appointment.
  • Staff could not refer directly or via Choose and Book. However, if they felt a referral was necessary they would document this is in the records and staff would contact the patient’s practice to ensure that the referral had been made by staff at the patient’s practice in line with their recommendations. If it was a two week wait referral for a suspected diagnosis of cancer, staff would contact the patient’s practice the following day.
  • Test results went back to the patient’s practice. NHS Upper Parliament Street staff contacted the practice to ensure that these test results had been seen and actioned.

Appropriate and safe use of medicines

The service had systems for the appropriate and safe use of medicines, including medicines optimisation.

  • The systems for managing and storing medicines, including medical gases, emergency medicines and equipment, minimised risks. However, arrangements for ensuring the security of prescription printer paper required review. The provider agreed to review this during our visit.
  • Staff prescribed medicines to patients and gave advice on medicines in line with current national guidance.

Track record on safety and lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed safety using information from a range of sources.
  • Staff understood their duty to raise concerns and report incidents and near misses. They told us that leaders and managers supported them when they did so. The significant event reporting policy emphasised that the reporting process was not to apportion blame and should also be used to share learning from positive events.
  • There were robust systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and acted to improve safety in the service. The service had changed standard operating procedures and employed a security guard as a result of lessons learned from events.
  • The service acted on and learned from external safety events as well as patient and medicine safety alerts. The GP Clinical Lead had clinical oversight of the alerts and records were kept of all the medicines and safety alerts and actions undertaken for relevant alerts. Medicines and safety alerts were discussed in relevant staff meetings to ensure learning.

Effective

Good

Updated 25 April 2019

We rated the service as good for providing effective services.

Effective needs assessment, care and treatment

Patient needs were assessed and care and treatment was delivered in line with current legislation, standards and evidence-based guidance supported by clear pathways and tools.

  • The service had systems and processes to keep clinicians up to date with current evidence-based practice. Clinicians had access to up-to-date guidance which was also discussed at team meetings. The clinical lead audited 10% of consultations which also ensured clinicians followed current evidence-based practice.
  • 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 clinicians made care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.
  • Reception staff knew to contact clinical staff for any patients presenting with high risk symptoms such as chest pain or difficulty in breathing.

Monitoring care and treatment

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

  • There was evidence of quality improvement and the service routinely reviewed the effectiveness and appropriateness of the care provided. The clinical lead was employed to spend 50% of their time on quality improvement activity and audited 10% of all consultations provided by the service. Any issues identified were discussed with clinicians and monitored to ensure improvement.
  • The service had undertaken an audit of its prescribing of co-codamol of a specific dosage strength which is not recommended practice. The audit identified 15 prescriptions issued in the two months leading up to the audit. The clinical lead emailed all clinicians regarding this area, placed an alert on IT systems to remind clinicians and then carried out a second audit which identified no prescriptions in the two months following their email.

Effective staffing

The service could demonstrate that staff had the skills, knowledge and experience to carry out their roles.

  • Staff had the skills, knowledge and experience to deliver effective care.

  • The service understood the learning needs of staff and provided training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The service provided staff with ongoing support. There was an induction programme for new staff. This included informal one to one meetings, appraisals, clinical supervision and revalidation. All staff had an appraisal within the last 12 months.
  • The service could demonstrate how they ensured role-specific training and updating for relevant staff.
  • 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.

  • The service shared clear and accurate information with relevant professionals.
  • Patients received coordinated and person-centred care.

Helping patients to live healthier lives

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

  • As an extended hours hub, the service was not able to provide continuity of care to support patients to live healthier lives in the way that a GP practice would. However, we saw the service demonstrate their commitment to patient education and promotion of health and well-being advice.
  • Staff we spoke to demonstrated a good knowledge of local and wider health needs of patient groups who might attend the service. GPs and nurses told us they offered patients general health advice within the consultation and if required they referred patients to their own GP for further information.
  • The service provided the smoking cessation service for Nottingham City (see responsive section of this report).
  • The provider offered signposting training and information to all practices in Nottingham City. Its vision was, ‘helping patients to get the best help, the first time.’ NHS Upper Parliament Street staff had received signposting training and were able to direct patients to appropriate support services.

Consent to care and treatment

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

.

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

Caring

Good

Updated 25 April 2019

We rated the service as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion. Feedback from patients was extremely positive about the way staff treat people.

  • Staff understood patients’ personal, cultural, social and religious needs.
  • The service gave patients timely support and information to cope emotionally with their care, treatment or condition.
  • 96 of the 98 patient Care Quality Commission comment cards we received were very positive about the service experienced. This is in line with feedback received by the service. Patients reported that all staff were friendly, kind and helpful.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available. 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 helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • Interpretation services were available for patients who did not have English as a first language.
  • Patient information leaflets and notices were available in the patient waiting area which told patients how to access support groups and organisations.
  • Information about support groups were available on the service’s website.
  • Patient comment cards were positive in this area. Patients reported that they had time to talk, ask questions and were listened to. They commented that they were supported to make decisions and given clear advice.

Privacy and dignity

The service respected patients’ privacy and dignity.

  • Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations, investigations and treatments.
  • Consultation and treatment room doors were closed during consultations.
  • 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.
  • There were arrangements to ensure confidentiality at the reception desk.
  • Patient comment cards were positive in this area. Patients commented that all staff treated them with respect and protected their privacy and dignity.

Responsive

Outstanding

Updated 25 April 2019

We rated the service as outstanding for providing responsive services.

This was because:

  • Services were tailored to meet the needs of individual patients. The service had identified areas where there were gaps in provision locally and had taken steps to address them.

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

  • The facilities and premises were appropriate for the services delivered. The premises were located in the centre of Nottingham close to tram and bus services. While car parking was not available on-site, car parking was available nearby. The premises had been identified by the provider as the best location with sufficient space to provide an accessible service for all Nottingham City practices.
  • The service understood the needs of its population and tailored services in response to those needs. Nottingham City has high levels of people smoking. The local authority funded smoking cessation service stopped on 1 April 2018 with no plans to replace the service. All the clinical pharmacists, practice nurses and healthcare assistants at NHS Upper Parliament Street undertook the required training to provide a smoking cessation service. The ‘Stub It!’ smoking cessation service consisted of three appointments with trained stop smoking clinicians over a 12-week period. Since its launch, over 300 patients had started the 12-week programme. To date, 54% of those had successfully quit their smoking habit as a result of the programme. The service had received funding to commission three weekly daytime smoking cessation clinics to increase the capacity of the service. This would provide 12 weeks of support for 600 patients. The service was also about to start working in partnership with maternity services across the city, targeting pregnant women and their partners.
  • All appointments were 15 minutes in length to allow for more detailed consultations with patients that met their needs. Clinicians available at the service were GPs, nurses, healthcare assistants, physiotherapists and clinical pharmacists. All clinicians working at the service were surveyed in January 2019. Clinicians were all positive regarding their experience of working at the service and particularly noted the 15-minute appointment lengths.
  • While all patient appointments were pre-booked, the service gave a number of examples where they had seen patients who were in need and had not pre-booked. The service was located on the site of a previous walk-in centre which meant that some people still walked in and asked to see a clinician.
  • The service had run an extensive advertising campaign prior to its opening to raise public awareness. This included advertising across Nottingham, on tram stops, in pharmacies and hospitals and social media and coverage in local newspapers, radio and television.
  • The service had an ongoing advertising campaign which includes pop-up banners advertising the service which GP practices can display so that patients were made aware of the service.
  • The provider had developed videos and print guidance on how to book patients into the service to help staff in GP practices across Nottingham City. Practice staff were also provided with an appointments guide which helped them to book patients with the correct clinician for their patient. The service held training events for Nottingham City GP practice staff twice a year to keep them updated, including information on any changes or developments. This allowed practice staff to access the right care at the right time for their patients.
  • The service obtained regular feedback from patients through a patient survey which was given to patients at each consultation. From April until December 2018, 3769 surveys were completed and 95% of patients said that they would recommend the GP+ Service to their friends & family. This included from October to December 2018 when 927 surveys were completed and 97% of patients said they would be ‘extremely likely’ or ‘likely’ to recommend the service to others (82% said that they would be extremely likely). The practice had considered the small amount of comments from patients who would not be likely to recommend and set out their responses in their quarterly report to Nottingham City practices.
  • The service had surveyed all Nottingham GP practices regarding their experience of NHS Upper Parliament Street. 95% of practices felt the arrival of the service had impacted positively on their own practice.
  • 96 of the 98 patient Care Quality Commission comment cards we received were very positive about the service experienced. Patients commented that the service fully met their needs. A number of patients particularly noted the stop smoking service and the impact it had had on their lives.

Timely access to care and treatment

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

  • Patients had timely access to initial assessment, diagnosis and treatment.
  • The service was open between 4pm to 8pm Monday to Friday and between 9am to 1pm on Saturdays. The service was available to patients from all 52 practices in the Nottingham City CCG area.
  • NHS Upper Parliament Street had provided extra appointments to accommodate for winter pressures during the December and January months. An extra session of appointments was held from 10am to 2pm Monday to Friday from 17th December 2018 to 13th January 2019. The service surveyed patients attending these extra appointments. 60% of patients said that if the appointments had not been available they would have used other NHS services (A&E, Urgent Care Centre, Pharmacy and 111 service).
  • Patients were referred by their own practice to ensure that patients were seen appropriately by the service and so that patients consented to the service having access to their full medical records.
  • Stakeholders were extremely positive regarding the quality of the service and the range of services provided.
  • Patient comment cards were very positive in this area. Patients commented that appointments were easily available and at convenient times.

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The service learned lessons from individual concerns and complaints and from analysis of trends. It acted as a result to improve the quality of care. We saw an example of where the service had used the information posted by a patient on social media to analyse and improve processes.

Well-led

Good

Updated 25 April 2019

We rated the service as good for well-led.

Leadership capacity and capability

There was compassionate, inclusive and effective leadership at all levels.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges, administrative, premises and clinical, 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. All staff were positive about the management of the service and felt very well supported. Staff commented positively about their immediate management but also about members of the provider’s board who they saw regularly at the service. Service managers also spoke highly of their interactions with members of the provider’s board and said that they were easily accessible and extremely supportive.
  • The service had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

The service had a clear vision and credible strategy to provide high quality sustainable care.

  • There was a clear vision and set of values. The vision was, ‘Providing effective, safe, caring, convenient healthcare to our patients in the heart of the city’. The service 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. Staff were observed to act in line with values during our inspection.
  • The strategy and supporting objectives were stretching, challenging and innovative, while remaining achievable. The strategy was in line with health and social care priorities across the region and the service had planned its services to meet the needs of the service population.
  • The service monitored progress against delivery of the strategy.

Culture

The service had a culture which drove high-quality sustainable care.

  • Staff stated they felt respected, supported and valued. They were extremely proud to work in the service.
  • The service was fully focused on the needs of patients.
  • 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 could raise concerns and they were actively encouraged to do so. They had full confidence that these would be addressed. Policies supported this. Records showed high levels of event reporting with appropriate responses. Monthly team meetings shared learning with all staff.
  • 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.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

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

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care. Governance and performance management arrangements were proactively reviewed and reflected best practice.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Service leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. This included appropriate governance arrangements with third parties.
  • The local management team included a service manager and a clinical lead who were overseen by a senior management team which consisted of a chief operating officer and members of the provider’s board.
  • The service held regular governance meetings which considered audit findings, significant events, safety alerts and complaints. This included a bi-weekly meeting between the clinical lead and the service lead and a two-monthly meeting of a quality and safety committee which reported directly to the provider’s board.

Managing risks, issues and performance

The service had 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 service had processes to manage current and future performance. Service leaders had oversight of safety alerts, incidents, and complaints.
  • Audits 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 service had plans in place and had trained staff to deal with major incidents. Two significant premises-related incidents had been effectively responded to by staff minimising the effect on the service.
  • The service considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The service 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 service used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The service used information technology systems to monitor and improve the quality of care.
  • The service submitted data and notifications to external organisations.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

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

  • 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. The service obtained feedback from patients from a range of sources including local Healthwatch, social media, complaints, comments and suggestions, direct feedback during clinical encounters and patient surveys.
  • The staff we spoke to informed that they were always consulted before making any changes that may affect their work.
  • The service was transparent, collaborative and open with stakeholders about performance. The service reported to all the Nottingham City GP practices on a quarterly basis on their performance.
  • Staff had attended a local community event where people were offered health checks and were informed about the service.
  • The service used a business social media platform to communicate with staff which could be accessed in a computer or through a mobile application. The staff could access local policies, protocols and updates through this platform and used it to share knowledge and experience.

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 service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • Staff continually reviewed processes to ensure they remained relevant and effective. Staff were encouraged to offer suggestions for improvement and were listened to.