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Inspection Summary


Overall summary & rating

Good

Updated 22 October 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 Balaam Street Surgery on 26 September 2018 as part of our inspection programme and following a change to the provider’s registration. The practice was previously registered as a partnership, and this inspection was of the new individual provider who registered with the CQC in March 2018.

At this inspection we found:

  • There were no recent fire drills documented by the practice.
  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. Staff had received up to date safeguarding training appropriate to their role.
  • Staff had the skills, knowledge and experience to carry out their roles.
  • The practice reviewed and monitored the effectiveness and appropriateness of the care it provided. Care and treatment was delivered according to relevant and current evidence based guidance and standards.
  • The practice had an active patient participation group who were involved with the development of the practice.
  • The practice had implemented a new online booking and triage system to improve access to appointments.
  • There was a clear leadership structure, and staff told us that they felt able to raise concerns and were confident that these would be addressed.
  • There was a focus on continuous learning and improvement.

The areas where the provider should make improvements are:

  • Take action to ensure that fire evacuation drills are completed and documented appropriately.
  • Review where documents relating to staff checks and training are saved on the computer system.
  • Develop a system for ensuring that electrical and medical equipment in the doctor’s bag is in good working order.
  • Take action to ensure there is a functioning hearing loop which staff know how to use.

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

Please refer to the detailed report and the evidence t

ables for further information.

Inspection areas

Safe

Good

Updated 22 October 2018

We rated the practice as good for providing safe services.

Safety systems and processes

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

  • The practice had systems to safeguard children and vulnerable adults from abuse and staff knew how to identify and report concerns.
  • We saw evidence of appropriate adult and child safeguarding training for all staff, except there was no evidence that one of the nurses had completed any adult safeguarding training in their staff file. However, following the inspection the practice provided evidence that the nurse had completed adult safeguarding training in July 2017 and said that the certificate had been saved elsewhere on the computer system.
  • 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.) However, one non-clinical staff member was trained to act as a chaperone but they only had a standard rather than an enhanced DBS check and there was no risk assessment in place to support this decision. Following the inspection, the provider sent evidence demonstrating that an enhanced DBS check had been requested for this staff member.
  • 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.
  • Arrangements for managing waste and clinical specimens kept people safe and an up to date audit was in place.
  • The practice had arrangements to ensure that facilities and equipment at the practice were safe and in good working order. However, there was no system to check the testing and calibration of medical and electrical equipment in the doctor’s bag for home visits (although, when we checked, the equipment was in good working order as it was still within a year of purchase).

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient safety, except in relation to one aspect of fire 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, which was documented in induction meeting minutes.
  • 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.
  • Evidence demonstrated that the most recent fire drill had taken place in May 2017; there was no documentation of any more recent fire drills completed by the practice. On the day of inspection, we found that some staff had not completed any fire safety training. Following the inspection, the provider sent evidence demonstrating that all staff had now completed this training.

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 and there was an effective system for managing tests and results.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

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

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • We checked medicines and found they were stored securely and were only accessible to authorised staff. We saw evidence the practice completed daily monitoring of the refrigerator temperatures.
  • The practice kept prescription stationery securely and monitored its use.
  • Staff prescribed and administered or supplied medicines to patients and gave advice on medicines in line with current national guidance.
  • We saw the practice had taken action and reduced prescribing in response to data from the CCG which evidenced high prescribing of Benzodiazepine in the practice compared to other practices within Newham.
  • 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.
  • The nurses used Patient Group Directions (PGDs) to administer medicines (PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment). PGDs had been produced in line with legal requirements and national guidance. Nurses had received appropriate training to administer the medicines referred to.

Track record on safety

The practice had risk assessments in relation to some safety issues, but not others.

  • Although the practice did not have sight of any health and safety risk assessment completed for the whole shared building (owned by NHS Property Services), one of the nurses completes a monthly health and safety risk assessment for the practice.
  • A fire risk assessment had been completed in June 2018 with the overall fire safety risk identified as ‘low’ for the premises.
  • There was an effective system for receiving and acting upon safety alerts.

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 took action to improve safety in the practice.

Please refer to the evidence tables for further information.

Effective

Good

Updated 22 October 2018

Caring

Good

Updated 22 October 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 generally positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The practice’s GP patient survey results were in line with local and national averages for questions relating to kindness, respect and compassion.

Involvement in decisions about care and treatment

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

  • The practice was aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)
  • Staff communicated with people in a way that they could understand.
  • 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 proactively identified carers and supported them. Carers were offered an annual flu vaccine. The practice was in the process of setting up a Carers Group in conjunction with Newham Carers Network.
  • The practice’s GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues or appeared distressed reception staff told us they would offer them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect.

Please refer to the evidence tables for further information.

Responsive

Good

Updated 22 October 2018

We rated the practice, and all of 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 and took account of patient preferences.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • Telephone consultations were available for 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 had signs up in the reception area advising that a hearing loop was available. However, staff told us that this had not been working for some time (since prior to January 2018). Following the inspection, the practice provided evidence that a new hearing loop had been ordered.
  • The practice provided effective care coordination for patients who are more vulnerable or who have 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.

Older people:

  • The practice was responsive to the needs of older patients, and offered home visits for those with enhanced needs or who had difficulty travelling to the practice. Appointment requests from older patients were prioritised.

People with long-term conditions:

  • Patients with a long-term condition received reviews to check their health and medicines needs were being appropriately met.
  • The practice worked with other health and care professionals to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • Appointment requests from parents attending with children were prioritised.
  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk. The practice maintained a Child Protection Register which was reviewed and discussed at clinical meetings when required.

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, telephone consultations and extended opening hours and Saturday appointments through the Newham GP Co-Op service.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances.
  • Appointment requests from vulnerable patients were prioritised.
  • People in vulnerable circumstances were able to register with the practice. The practice manager told us photographic identification was required to register as a patient, but that specific cases involving vulnerable people who did not have such identification would be discussed with the lead GP.

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 were able to access care and treatment from the practice within an acceptable 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.
  • Some patients reported that the ‘AskMyGP’ appointment system was easy to use, and had improved access, although others expressed that the new system was difficult to understand. The practice had created information leaflets and videos to assist patients, and had hired two ‘Digital Eagles’ to teach patients how to access the online system using their own devices.
  • The practice’s GP patient survey results were below local and national averages for questions relating to access to care and treatment. The lead GP and practice manager were aware of the low results regarding access to the service. The GP explained that the new ‘AskMyGP’ online system was implemented in April 2018 to help improve access and free up same-day appointments for patients who needed them. This system requires patients to log-in securely online and write a short summary of why they need an appointment. Once the form is complete it is sent to the GP; depending on the issue, the GP will email or telephone the patient, or call the patient into the surgery the same day. Patients are able to log-in and complete appointment requests 24 hours a day. There is an explanation of how to use the ‘AskMyGP’ system for appointments or queries in the practice’s leaflet and videos on the website which demonstrate how it works.
  • The GP patient survey results related to the period prior to the implementation of the new appointment system and therefore would not reflect any changes to patients’ views and experiences regarding access. We checked the appointments diary and saw that there were many appointments available for face to face GP consultations on the day of inspection, the remainder of the week and the following week, which indicated that the new online system may be having a positive impact upon appointment availability.

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 respectfully and compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 22 October 2018

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

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 at all levels were visible and approachable. They worked closely with staff and others.

Vision and strategy

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

  • There was a clear vision and set of values. The practice 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 practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.

Culture

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

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • There were positive relationships between staff and teams.
  • The practice 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 we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need, including annual appraisals. Staff were supported to meet the requirements of professional revalidation where necessary.
  • The practice promoted equality and diversity. The practice had an equality and diversity policy, a bullying and harassment policy, and a blame free culture policy. Staff felt they were treated equally.

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.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding, complaints, and infection prevention and control.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were effective processes for managing risks, issues and performance.

  • There were processes to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

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

  • A full range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The 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.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • The practice had hired two ‘Digital Eagles’ to assist and train patients on how to use the new online ‘AskMyGP’ system.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Updated 22 October 2018

Families, children and young people

Good

Updated 22 October 2018

Older people

Good

Updated 22 October 2018

Working age people (including those recently retired and students)

Good

Updated 22 October 2018

People experiencing poor mental health (including people with dementia)

Good

Updated 22 October 2018

People whose circumstances may make them vulnerable

Good

Updated 22 October 2018