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Inspection Summary


Overall summary & rating

Good

Updated 11 February 2020

We carried out an announced comprehensive inspection at Chessel Branch surgery on 28 November 2019 as part of our inspection programme. Due to the way in which the service operated, we were unable to rate the key questions of caring and responsive.

This service is registered with Care Quality Commission (CQC) under the Health and Social Care Act 2008 in respect of some, but not all, of the services it provides. There are some general exemptions from regulation by CQC which relate to particular types of service and these are set out in The Health and Social Care Act 2008 (Regulated Activities) Regulations 2014.

The chief executive officer is the registered manager. A registered manager is a person who is registered with the Care Quality Commission to manage the service. Like registered providers, they are ‘registered persons’. Registered persons have legal responsibility for meeting the requirements in the Health and Social Care Act 2008 and associated Regulations about how the service is run.

Our key findings were:

  • Staff had the information they needed to deliver safe, effective and holistic support to patients.
  • The provider organised and delivered services to meet patients’ needs.
  • There were clear responsibilities, roles and systems of accountability to support good governance and management.
  • Staff felt supported to engage in further training as required in order to successfully undertake their role.
  • There were clear systems and processes in place to keep people safe and safeguarded from abuse.
  • Staff had the information they required in order to deliver safe holistic care to patients even when the clinician had not seen the patient previously.
  • There were clear documented processes in place to record significant events and share learning from these.
  • The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care.

The areas where the provider should make improvements were:

  • Consider including all staff in quality improvement activities.

Dr Rosie Benneyworth BM BS BMedSci MRCGP


Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 11 February 2020

People were protected from avoidable harm and abuse. This included having clearly defined and embedded systems and processes to keep staff and patients safe.

Effective

Good

Updated 11 February 2020

People had good outcomes because they received effective care and treatment that met their needs.

On the day of our inspection, only the physiotherapy service was operating from this hub site and is currently out of scope from registration. There were therefore no regulated activities being undertaken on the day we inspected. However, we were informed that regulated activities were undertaken from this location by SPCL on other days as part of their operational model of service delivery. Chessel branch site as a hub location was only open during core GP hours. The operational model of SPCL as a provider means we were able to utilise information held and evidence collected from the other registered location inspections to ascertain how care and treatment was delivered for patients. Staff working for SPCL worked across the hub locations and therefore had a standardised set of governance policies and procedures as well as processes for monitoring effectiveness.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence based practice. Through discussions with clinicians working at the other hub locations we saw evidence that clinicians assessed and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service)

  • The provider assessed needs and delivered care in line with relevant and current evidence based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.
  • Clinicians had enough information to make or confirm a diagnosis
  • We saw no evidence of discrimination when making care and treatment decisions.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements. The service made improvements through the use of completed audits. Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality. Audits were typically undertaken at head office location and spanned all hub sites. Staff working at the hubs told us they had opportunities to engage in activities to improve quality and patient outcomes.

  • All clinicians working for the provider Southampton Primary Care Limited had a clinical notes review meeting every six months whereby five of their clinical notes were reviewed as an audit to ensure these were in line with best practice and for ongoing learning and development. There was a standardised records review template in place. Any identified learning from these was discussed with the individual clinicians as part of ongoing supervision. There was mixed feedback about the audit programme. As part of our discussions with GPs working across several hub locations, told us that they did not engage in any other clinical audits and that there was no clinical review of their work beyond the clinical notes review.
  • Other staff told us that staff members were allocated certain lead responsibilities and would undertake reviews of quality with regards to these across all services. For example, the Health Care Assistant we spoke to told us that they were responsible for oversight of stock control and ordering processes across the whole of the organisation.

Effective staffing

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

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC) or the Nursing and Midwifery Council and were up to date with revalidation.
  • 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. Staff were encouraged and given opportunities to develop. Staff told us they had access to a staff dashboard which showed them when their training needs were due for renewal. Staff had opportunities to engage in online training or face to face. We spoke with both clinical and non-clinical staff who worked across the hub sites. They told us that they had access to extensive training and felt their needs were met. One staff member told us that in comparison to other roles they had held in other organisations, they had received better training and support from this provider. We heard examples of support to staff who were new into primary care (such as the move from secondary to primary care) and for those on their induction training. We were told by staff and witnessed examples of when the executive leadership team had moved reception staff around the hub sites to ensure sufficient skills mix was met. For example, moving shifts around to ensure a junior member of staff was placed with a more experienced member in order to support learning and development as well as patient experience.
  • Staff whose role included immunisation and reviews of patients with long term conditions had received specific training and could demonstrate how they stayed up to date.

Coordinating patient care and information sharing

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

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. All clinicians had access to a variety of operational systems used by organisations across the city, such as elements of hospital data and the two different GP clinical notes systems. This meant that clinicians when working at this site, would have access to a full patient history in order to provide joined up care with all services involved in that patient’s care. Clinicians working across the all of the provider’s sites sent discharge summary documents directly to the patient’s registered GP. SPCL staff had strong working relationships with all local organisations including care homes and secondary care services.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. We saw examples of patients being signposted to more suitable sources of treatment where this information was not available to ensure safe care and treatment. Both nursing staff and reception staff told us examples of when patients may need re-booking to another hub site if the care or treatment required was not possible at this hub site. For example, administration staff, who booked appointments used the details they had been given to determine the most appropriate clinician. For example, we were told on the rare occasion, the presenting problem may be more complex than initially described and a patient might require a GP not a nurse. In this instance, the patient would be re-booked for an appointment with a GP on the same day at a different hub location.
  • The provider had risk assessed the treatments they offered. They had identified medicines that were not suitable for prescribing if the patient did not give their consent to share information with their GP, or they were not registered with a GP. For example, medicines liable to abuse or misuse, and those for the treatment of long term conditions such as asthma. Where patients agreed to share their information, we saw evidence of letters sent to their registered GP in line with GMC guidance.
  • Care and treatment for patients in vulnerable circumstances was coordinated with other services.
  • Patient information was shared appropriately (this included when patients moved to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. There were clear and effective arrangements for following up on people who had been referred to other services

Supporting patients to live healthier lives

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

  • Where appropriate, staff gave people advice so they could self-care.
  • Risk factors were identified, highlighted to patients and where appropriate highlighted to their normal care provider for additional support. For example, if clinicians working at the hubs had the initial patient contact and a follow up was required, patients were referred back to their regular GP to undertake the rest of the care and treatment.

  • Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs.

Consent to care and treatment

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

.

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

Caring

Insufficient evidence to rate

Updated 11 February 2020

We were unable to rate caring as part of this inspection at the time of our inspection there were no regulated activities being undertaken by the provider at this registered location. Only the physiotherapy services were being provided from this location on the day we inspected which is currently not within scope for CQC registration. Regulated activities were being delivered from this location on other days during the month of November. As part of the inspection comment cards were available for patients to provide feedback on services delivered at this location but we did not receive any responses, nor was there any patient feedback on NHS choices or other external sources. We therefore did not have sufficient evidence about delivering caring services, from this registered location, to rate this key question.

Responsive

Insufficient evidence to rate

Updated 11 February 2020

We were unable to rate responsive as part of this inspection as at the time of our inspection there were no regulated activities being undertaken by the provider at this registered location. Only the physiotherapy services were being provided from this location on the day we inspected which is currently not within scope for CQC registration. Regulated activities were being delivered from this location on other days during the month of November. As part of the inspection comment cards were available for patients to provide feedback on services delivered at this location but we did not receive any responses, nor was there any patient feedback on NHS choices or other external sources. We therefore did not have sufficient evidence about delivering responsive services, from this registered location, to rate this key question.

Responding to and meeting people’s needs

The service organised/ did not organise and delivered/deliver services to meet patients’ needs.

It took account of patient needs and preferences.

  • The provider understood the needs of their patients and improved services in response to those needs.
  • The facilities and premises were not always appropriate for the services delivered. The building was an old building and required some refurbishment. Refurbishment work was the responsibility of the host site of which Chessel Branch hub site operated out of. SPCL as a provider were working with the host site and the Clinical Commissioning Group to identify what refurbishment was required and put an action plan in place to address these issues.
  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others.

Timely access to the service

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

  • 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.
  • We received no comments from patients regarding access to service specific to this hub location. However, feedback from patients about the service as a whole (extended access across hub sites) was positive about ease of obtaining an appointment. Patients could not book directly into appointments at this hub location but were able to do so by contacting their registered practice and requesting an extended access/hub appointment which would be booked on their behalf.
  • Referrals and transfers to other services were undertaken in a timely way.

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 service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.
  • The service had complaint policy and procedures in place. The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care.

We were unable to obtain patient feedback specific to this hub site as part of this inspection as no comment cards had been completed an no feedback provided through external sources such as NHS choices website. However, on our inspection of the head office location we were able to review the complaints process end to end which was reviewed and addressed by the organisation centrally. We saw examples of completed complaints processes and the service had acted appropriately.

Well-led

Good

Updated 11 February 2020

The leadership, governance and culture were effective and supported the delivery of high quality person-centred care.

The provider Southampton Primary Care Limited (SPCL) has eight registered locations. This inspection was for one of the hub sites which delivered extended access services: Chessel Branch Surgery. The organisational structure of SPCL was that there was a single overarching governance and leadership structure spanning across the organisation. This covered policies and procedures, recruitment, training and development and infection control amongst others. On the day of our inspection only physiotherapy services were operational by SPCL at this hub location. Physiotherapy services are not regulated by CQC. On other days in November regulated activities were being undertaken from this premises. Any staff feedback obtained supporting this section refers to interviews of staff undertaken at other SPCL registered location inspections. Staff worked across the organisation and therefore work across the hub locations.

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. The leadership team at board level had a strong understanding of local challenges faced by practices and the differences in geographical area across the city. The directors created a newsletter as a way of communicating information easily to member practices.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership. As the location was not staffed by SPCL staff during our inspection day we were unable to establish staff views around leadership. However, we had assurances around visibility of the leadership team from interviews with staff at other SPCL registered location inspections and all staff worked across all locations. Staff spoken to on those inspections were positive about the visibility of the leadership team.
  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service.

Vision and strategy

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

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.
  • The aims of the provider, SPCL, included to strengthen the capacity of practices, tender for new services and to strengthen clinical governance across member practices in order to enhance quality improvements. The vision was to offer centralised training and development to all member practices in order to share the vision and deliver high quality care across the city to benefit the 283,000 patient population of residents in Southampton.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them. Staff had an understanding of the overarching vision, values and strategy delivered by SPCL as an organisation. They had an understanding of their role in achieving the vision and were able to describe the journey that the organisation had gone on from inception to present day. Staff spoken to were able to briefly summarise what the organisation’s overarching objectives and vision was such as providing patient access if needed and ensuring patients have a smooth experience.
  • The service monitored progress against delivery of the strategy.

Culture

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

  • The executive leadership team at SPCL had undertaken a staff survey in February 2019 of all staff working across the organisation and included staff who would work at Chessel Branch Surgery hub site. Results (completed by 33 out of 42 employees, therefore a response rate of 79%) showed that 85% of staff felt they received the respect they deserved from colleagues at work. The results also highlighted, 88% were satisfied with the quality of care they gave to patients with the remainder answering ‘not applicable’ to this question.
  • The service focused on the needs of patients.
  • Leaders and managers 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 told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed. Staff told us that they felt they were taken seriously when raising a concern and they also received feedback. Data collected from the SPCL 2019 staff survey indicated that 94% of respondents agreed they were encouraged to report errors, near misses and incidents. In addition, 70% of staff felt that SPCL took action to ensure that incidents were not repeated and 85% reported feeling secure in reporting concerns about unsafe clinical practice.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary. Clinical staff, including nurses, were considered valued members of the team. They were given protected time for professional time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff. Chessel Branch Surgery as a hub location was only open during core GP hours. As such the clinicians working for the hub would be working alongside the staff who work at Chessel Branch Surgery delivering registered activities during core GP services. Staff spoken to during other inspection told us of the strong working relationships built with the staff working at the locations that were hosting the hub services. There were governance systems in place to ensure staff had the support they required during their shift which included an instant messaging system active for all staff working at any time period and contact numbers of the leadership team and on-call members of staff.
  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. 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 interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.
  • There was a dedicated infection control lead in place to oversee the systems and processes across all the hub sites. Documentation was stored centrally at this location and also available to staff via the intranet. During this inspection we saw the computerised system for checking stock on the hub trolley at the start and end of each shift. This was submitted electronically to head office for real time monitoring.
  • There were service level agreements in place between SPCL and this service.

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 service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. 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 services to improve quality.
  • The provider had plans in place and had trained staff for major incidents. The IT system designed for the provider allowed staff to move from premises to premises and remote working in the event of adverse incidents. Operational monitoring of systems and processes were undertaken from the head office location which forms this inspection report.
  • The provider had a provider level business continuity plan and service level agreements with each hub site which covered potential risks.
  • There was an embedded IT system in place which was under constant development. The system was multi-faceted with access levels depending upon managerial or staffing role. All staff could access performance data required for their role including access to training records.

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 submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

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

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. For example, the leadership team created an action plan following the staff survey results to address feedback raised by staff. This included establishing more routine meetings and regular 1:1s for administrative staff. Staff spoken as part of other provider registered location inspections told us there were regular meetings.
  • Staff could describe to us the systems in place to give feedback. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings. Internal staff survey results from February 2019, showed that 48% agreed that communication with senior management and staff was effective and that feedback was acted on by managers. This is contrary to the feedback received from staff spoken to at this service which were all positive about having input.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

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

  • There was a focus on continuous learning and improvement both for clinical and non-clinical matters. Staff spoke about the staff dashboard and how they had oversight of their own training and development needs and the staff intranet. Staff spoken to as part of other provider registered location inspection spoke positively about the instant messaging system in place for staff to use in order to link with staff working at other hub sites and how valuable this was when working an evening shift at one of the hub locations.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared from head office across all hub sites and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • There were systems to support improvement and innovation work.
  • The provider was a registered training organisation and as such had students undertaking clinical placements; these included Physicians associates and student nurses.