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The Grange Good Also known as Dr Bankart and Partners LLP

Inspection Summary


Overall summary & rating

Good

Updated 11 May 2018

This practice is rated as Good overall.

The Care Quality Commission (CQC) have previously carried out four inspections of the practice.

We carried out an announced comprehensive inspection at The Grange on 6 June 2016. The practice was rated inadequate overall and for providing safe, effective, and well led services, and requires improvement for providing responsive and caring services. As a result of the findings on the day of the inspection, the practice was issued with a warning notice on 18 July 2016 for regulation 17 (good governance). The practice was placed into special measures for six months.

On 2 September 2016 we carried out a second inspection visit in response to information of concern about the provider who is also the registered manager and principal GP at 3Well Medical Ltd Botolph Bridge. We found the safety and leadership of systems for managing pathology and X-ray results and dealing with repeat prescriptions were not adequate. We did not rate this inspection.

A third inspection was carried out on 4 November 2016, to check on improvements detailed in the warning notice issued on 18 July 2016, following the inspection on 6 June 2016. We found the practice had reviewed their systems and strengthened their quality monitoring but could not demonstrate this was effective. A further warning notice was issued on the 22 November 2016 as appropriate systems were still not in place to assess, monitor, mitigate risks and improve the quality of the service. We did not rate this inspection.

A fourth inspection was undertaken following the period of special measures and included a follow up of the warning notice issued on 22 November 2016. It was an announced comprehensive inspection on 28 February 2017. Overall the practice was rated as requires improvement and was removed from special measures.

The full inspection reports can be found by selecting the ‘all reports’ link for The Grange on our website at .

This inspection was an announced comprehensive inspection carried out on 19 April 2018 to confirm that the practice had carried out the improvements identified at the last inspection in February 2017. Overall the practice is rated as good.

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 this inspection we found:

  • The practice had continued to make improvements to ensure they were meeting the regulations and providing safe and effective services to patients.
  • They had been able to recruit a new nursing team and pharmacist to join the practice and there had been an improvement in the retention of other staff. The provider was undertaking regular clinical sessions and regular locums were employed. Patients we spoke with and comment cards we received demonstrated they had been able to have continuity of care.
  • Practice staff we spoke with told us they worked together to implement and embed the changes. They told us they had found the changes positive and said patients were receiving better service. This was confirmed by the patients we spoke with who stated the practice was more proactive in calling them in for reviews and the practice appeared calm and welcoming.
  • The provider has another larger practice nearby and the management team had increased the use of technology to improve the clinical meetings and information sharing across both sites. This ensured all staff (most staff worked across both sites) were able to take part in the meetings.
  • Staff understood and fulfilled their responsibilities to raise concerns and to report incidents and near misses and there was evidence of learning and communication with staff.
  • The arrangements for managing medicines had been embedded to keep patients safe. The process for handling repeat prescriptions for high risk medicines ensured that patients were monitored regularly and that test results were checked before medicines were prescribed.
  • The practice had systems and process in place to record and action safety alerts and had a system to regularly runs searches for effective monitoring.
  • Risks to patients and staff which included fire, general risks and health and safety had been assessed and identified actions undertaken.
  • Appropriate recruitment and induction checks had been completed for locum staff. A system was in place for recording and monitoring that mandatory training had been completed.
  • 2016/2017 Quality and Outcomes Framework data showed patient outcomes had improved from the previous year and unverified 2017/18 data showed further improvements. Exception reporting had also significantly improved. Clinical audits had been carried out, and were driving improvements in patient outcomes.
  • We found that some reviews and record keeping for patients experiencing poor mental health needed to be reviewed and improved. Some of the records we viewed did not contain cohesive note taking to ensure that information sharing was effective.
  • The practice had a failsafe system in place for checking cervical cytology outcomes for patients and regular checks to ensure all samples were reported on.
  • The appointment system was working well and patients told us they received timely care when they needed it.
  • The practice had an active patient participation group (PPG) which included on line membership and members met with the practice on a regular basis.
  • There was a wide variety of information displayed in the practice which had been translated into a number of languages used by patients including how to give feedback or complain.
  • Governance systems had been improved, reviewed, and strengthened to ensure that the improvements could be sustained over time. The practice recognised where they needed to continue to further improve some areas and was working on these.

The areas where the provider should make improvements are:

  • Review and improve the clinical record keeping in relation to annual reviews for patients who may be experiencing poor mental health.

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

Inspection areas

Safe

Good

Updated 11 May 2018

At our previous inspection on 28 February 2018, we rated the practice as requires improvement for providing safe services because:

  • The system and process in place for handling repeat prescriptions for high risk medicines did not ensure that patients were monitored regularly and that test results were checked before medicines were prescribed.
  • The governance process for reviewing patients who may be affected by historic patient safety alerts needed to be reviewed.

These arrangements had significantly improved on this inspection. The practice is now rated as good for providing safe services.

Safety systems and processes

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

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Reports and learning from safeguarding incidents were available to staff. 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. This included locum and temporary staff.
  • There was an effective system to manage infection prevention and control. A member of the nursing team was the lead and improvement had been made. For example, the team had de cluttered the consultation rooms and put clear systems in place to manage cleaning and stock control.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

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

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods, and epidemics.
  • There was an effective induction system for temporary staff tailored to their role. This included a detailed file and check list for locums.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections, including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

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

  • Most of the care records we saw showed that information needed to deliver safe care and treatment was available to staff. However, we noted that the records we saw in relation to reviews of patients who maybe experiencing poor mental needed to be improved.
  • 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.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • There were effective protocols for verifying the identity of patients during telephone consultations.
  • The practice had employed two pharmacists who, alongside the GPs, ensured that patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.

Track record on safety

The practice had had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate, and current picture of safety that led to safety improvements.

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. We saw minutes of meetings which were detailed to ensure learning outcomes were shared with all staff.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts. There was a system in place to ensure that alerts were received, acted on, and disseminated to appropriate staff. Regular searches were undertaken for effective future monitoring.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 11 May 2018

At our previous inspection on 28 February 2018 we rated the practice as requires improvement for providing effective services as the arrangements in respect of

  • There was not an effective failsafe system in place for cervical samples.
  • There was a lack of evidence to show that checks were undertaken and documented to provide assurance of the quality of the work undertaken by locum staff and arrangements for clinical supervision needed to be improved.

We rated the practice and all of the population groups as good for providing effective services overall except for People experiencing poor mental health (including people with dementia): which we rated requires improvement.

  • We found some care records were not cohesive and did not ensure that all checks were completed or that information was easily available for clinical staff who may need it.

(Please note: Any Quality Outcomes (QOF) data relates to 2016/17. QOF is a system intended to improve the quality of general practice and reward good practice.)

Effective needs assessment, care and treatment

The practice 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. However, not all records we viewed were sufficiently detailed in a cohesive way especially in relation to patients who may experience poor mental health.
  • We saw no evidence of discrimination when making care and treatment decisions in the records we viewed.
  • The practice had a blood pressure machine in the waiting room enabling patients to take and monitor their blood pressure and for the clinicians to access to this information.
  • Staff used appropriate tools to assess the level of pain in patients.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • The practice offered home visits to all patients who were unable to attend the surgery. They visited patients in local care homes regularly.
  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • The practice followed up on older patients discharged from hospital. It ensured their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.
  • The practice worked with local pharmacies to ensure patients who needed their medicines delivered to their home received them on the same day if needed.

People with long-term conditions:

  • 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.
  • The practice nursing staff were undertaking reviews of patients with conditions such as diabetes and respiratory disease and were supported by the GPs. The nurses were being supported to advance their training and skills and they planned to be able to increase the nurse led clinics in the future. Those who were responsible for reviews of patients with long term conditions had received specific training.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • The practice had arrangements for adults with newly diagnosed cardiovascular disease including the offer of high‑intensity statins for secondary prevention, people with suspected hypertension were offered ambulatory blood pressure monitoring, and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate. The practice offered a no appointment needed service for blood pressure monitoring including the use of a blood pressure machine in the waiting room.
  • The practice was able to demonstrate how they identified patients with commonly undiagnosed conditions; for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation, and hypertension. The practice nursing staff and the management team shared their plans to further support the nurses with additional skills and training to enable more nurse led clinics in the future.

Families, children and young people:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates for the vaccines given were all above the target percentage of 90%. The practice was aware of the patients who had not attended their appointments and were investigating further ways to improve this. Due to the complex nature of the baby immunisation schedule, the practice had been proactive and all clinics were staff by two nurses. The staff we spoke with told us that this was very beneficial to both patients and staff members.
  • The practice had arrangements to identify and review the treatment of newly pregnant women on long-term medicines. These patients were provided with advice and post-natal support in accordance with best practice guidance.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.

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

  • The practice’s uptake for cervical screening was below the national and CCG average. The practice had reviewed their cervical screening processes and had implemented fail safe systems to ensure all reports were received and acted upon. They were looking at ways to further increase their uptake. They were aware of and working towards increasing their rate by encouraging patients whose first language was not English; for example, with the PPG they had been discussing a women only clinic every month to provide additional privacy.
  • The practices’ uptake for breast and bowel cancer screening was in line with the national average.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • 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:

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule. Following a significant event, the practice had implemented further measures to ensure patients medicine were managed effectively.

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

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks. However we noted that the record keeping for some annual reviews was not written in a detailed cohesive way to ensure all checks were carried out and documented.We were not assured that information was easily available to other health professionals who need to be aware of it.
  • The practice offered interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medicines.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • Performance in 2016/2017 for mental health indicators was below the CCG and national averages. Unverified data for the complete year 2017/2018 showed this had improved.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • The practice offered annual health checks to patients with a learning disability.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. The practice had implemented a programme of clinical and non clinical audits which included audits such as safe medicine prescribing, quality of locum performance and the telephone answering service. For example, an audit on the consultations of a locum staff member showed that overall the standards were high but the audit noted that the clinician could improve the detail of the record in respect of advice given should the patient symptoms change or worsen. The findings were discussed with the clinician and improvements made.

A further comprehensive audit was undertaken to ensure that the disease modifying anti-rheumatic medicines (DMARDS) prescribed to patients in the treatment of rheumatoid arthritis were prescribed and monitored as set out in the guidelines. Results from the second cycle of the audit showed that significant improvements had been made across all indicators. For example, 100% of patients were contacted at the appropriate time to ensure they had the appropriate review for their medication. Where appropriate, clinicians took part in local and national improvement initiatives.

The practice showed evidence of sustained performance and used the information collected for the Quality and Outcomes Framework (QOF) and performance against national screening programmes to monitor outcomes for patients (QOF is a system intended to improve the quality of general practice and reward good practice).

The most recent published results (2016/2017) showed the practice scored 88% of the total number of points available. This was 7% below the CCG average and national average. The overall clinical exception reporting rate was 5% which was below with the CCG average of 11% and national average of 10% (exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects). The overall performance had improved from 73% in 2015/2016 and the exception rate had decreased from 16%. The practice shared with us their unverified data for the year 2017/2018 (completed year), this showed a further improvement with an overall score of 97% and exception reporting rate of 7%.

Data from 2016/2017 showed that the practice performance in relations to patients with diabetes in some indicators was below the CCG and national average but performance shared from the unverified data showed that these areas had improved. For example,

  • The percentage of patients with diabetes, on the register, in whom the last IFCC-HbA1c was 64 moll/moll or less in the preceding 12 months, was 65%; this was below the CCG and national average of average of 80%. Unverified data showed the practice performance had improved to 73%.
  • The percentage of patients with diabetes, on the register, in whom the last blood pressure reading (measured in the preceding 12 months) was 140/80 mmHg or less was 56% which was lower than the CCG average of 75% and the national average of 78%. Unverified data showed the practice performance had improved to 70%.
  • The percentage of patients with COPD who had a review undertaken including an assessment of breathlessness using the Medical Research Council dyspnoea scale in the preceding 12 months was77% which was lower than the CCG average of 91% and the national average of 90%. Unverified data showed the practice performance had improved to 96%.

Effective staffing

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

  • The practice had made improvements to the recruitment and retention of staff. They had successfully employed two practices and two pharmacists. The staff members had been at the practice for almost 12 months. Regular GP locums were also employed and patients commented that they found continuity of care with these GPs.
  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people, and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications, and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. This included an induction process, one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The induction process for healthcare assistants included the requirements of the Care Certificate. The practice ensured the competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when deciding care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

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

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers. The practice had a low number of patients that had been affected by cancer in 2016/2017; the exception rate for this group was high but unverified data for 2017/2018 showed that only one patient (25%) had been excepted.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • The practice offered a no appointment required blood pressure monitoring service and patients had easy access to a machine in the waiting room.
  • Staff discussed changes to care or treatment with patients and their carers as necessary. Patients we spoke with told us that they had found that this had improved with the availability of regular GPs including the lead GP.
  • The practice supported national priorities and initiatives to improve the population’s health; for example, stop smoking campaigns and tackling obesity.
  • The practice had been proactive in identifying patients who may be at risk of latent tuberculous and had a poster displayed in the waiting room in several different languages. This intervention had a positive outcome for a patient.

Consent to care and treatment

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

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

Please refer to the Evidence Tables for further information.

Caring

Good

Updated 11 May 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect, and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social, and religious needs. The practice understood that, due to the high percentage of patients from a Pakistani background, service provision would need to be adapted to support these patients.
  • The practice gave patients timely support and information.
  • Data from the GP National Survey published July 2017 showed that the practice performance was comparable to other practices. Patients we spoke with and the comment cards we received confirmed this.

Involvement in decisions about care and treatment

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

  • Staff communicated with people in a way that they could understand; for example, communication aids and easy read materials were available. The practice had several display boards in the waiting rooms in other languages to ensure their patients had access to local support groups such as carers.
  • 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. The practice had identified 32 patients as carers this was 1.1% of the practice population and there was a system to ensure that this was kept up to date.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • Reception staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the Evidence Tables for further information.

Responsive

Good

Updated 11 May 2018

At our previous inspection on 28 February 2018 we rated the practice as requires improvement for providing responsive services because:

  • Information on how to complain was not easily available to patients.
  • The results showed the practice was performing below the CCG average and in line with or below the national averages in relation to access and overall experience of the practice.

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/deliver services to meet patients’ needs. It took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • Patients are able to book evening and weekend appointments with a GP or advanced nurse practitioner at the GP hub provided through the Greater Peterborough Network.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who were more vulnerable or who had complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GP and practice nurse also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability.
  • The practice worked with the local pharmacies and there was a same day medicines delivery service for housebound patients which the practice worked closely with to ensure these patients received medicines in a timely manner.

People with long-term conditions:

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

Families, children and young people:

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

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

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, the practice was able to book appointments for patients to see GPs, nurses, and phlebotomists for evening and weekend appointments at the GP hub provided through the Greater Peterborough Network.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers, and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

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

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • The staff told us they knew their patients well and those who failed to attend were proactively followed up by a phone call from a GP.

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.
  • Patients reported that the appointment system was easy to use.
  • The results from the GP national patient survey showed the practice performance was comparable to other practices.
  • Patients we spoke with and comments cards we received confirmed this.

Listening and learning from concerns and complaints

The practice had improved the system and process to provide information on how patients could complain. They 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. This information was available in several languages ensuring all their patients could understand the procedure.
  • The complaints policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and from analysis of trends. It acted as a result to improve the quality of care. For example, a complaint was received in relation to a patient not receiving their medicine. The practice investigated the situation and identified that the staff had resolved the situation but this had not been communicated effectively to the patient. The patient was apologised to and staff reminded to inform patients when actions had been taken.

Please refer to the Evidence Tables for further information.

Well-led

Good

Updated 11 May 2018

At our previous inspection on 28 February 2018 we rated the practice as requires improvement for providing well led services because:

  • Governance systems had improved, but the practice needed additional time to review, strengthen, and embed their new process to ensure that these improvements could be sustained over time.
  • The practice had a number of policies and procedures to govern activity, however these were not always followed in practice, for example the medicines management policy. Not all staff were able to find specific policies when asked.

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.
  • Since the previous inspection the practice had increased and strengthened the management team. Three managers worked across the two practices run by the provider.
  • The management team told us they had worked hard to ensure that all roles and responsibility were clear and that they worked cohesively to ensure that staff and patients were well supported.
  • Most staff we spoke with were clear about the roles and responsibility of the managers and all staff reported that they felt supported and valued by the management team.
  • 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 to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

The practice had a clear vision and credible 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. The practice developed its vision, values, and strategy jointly with patients, staff, and external partners.
  • 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 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 demonstrated that they had improved the culture within the practice to deliver high-quality sustainable care.

  • Staff stated they felt respected, supported and valued. They were proud of the achievements and improvements made and to work in the practice.
  • The practice focused on the needs of patients. Staff we spoke with told us that this had improved. For example, the practice was more proactive to contact and call patients in for their health reviews.
  • 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. 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 were considered valued members of the practice team. They were given protected time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice 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. Practice staff told us this had improved and they felt there was a whole team approach to patient care.

Governance arrangements

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

  • The governance systems and processes had been improved, and changes were implemented and embedded. For example, there were regular governance meetings held to discuss and identify any risks. All staff were represented at these meetings.
  • 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 including in respect of safeguarding and infection prevention and control.
  • Practice leaders had established proper policies, procedures, and activities to ensure safety and assured themselves that they were operating as intended.

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 practice had processes to manage current and future performance. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Practice leaders had oversight of national and local 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 implemented service developments and where efficiency changes were made this was with input from clinicians to understand their impact on the quality of care.

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 held regular meetings to discuss and monitor the quality and outcome framework performance and safe management of medicines.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • We found some record keeping, specifically for annual reviews of patients who may be experiencing poor mental health, were not cohesive enough to ensure all checks were completed and that the information was easily accessible by others that may need it.
  • 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 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 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 and diverse range of patient, 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 was evidence of systems and processes for learning, continuous improvement and innovation.

  • The practice recognised they had continued to improve their service to patients over the past 12 months since our last inspection. They were open and honest about areas they needed to monitor to ensure they continued to be effective and sustainable.
  • There was a focus on continuous learning and improvement. The practice recognised this as a need for the practice to sustain the delivery of their long term condition service. They had plans in place and staff were engaged in this development.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice 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.

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)

Requires improvement

People whose circumstances may make them vulnerable

Good