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Inspection Summary


Overall summary & rating

Good

Updated 20 April 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pembroke Surgery on the 9 March 2016. Overall the practice is rated as good. The practice was rated as good for the provision of safe, effective, caring, responsive and well led services.

Our key findings across all the areas we inspected were as follows:

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. However, some patients reported having to wait sometime to see their preferred GP.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw one area of outstanding practice:

A GP in the practice had received training in ultrasound scanning and provided this service to patients of the practice. The service supported patients who were pregnant with routine and non-routine scans and assisted with the diagnosis of abdominal conditions such as gallstones. The GP worked closely with specialists and consultants at the local hospital and was able to seek advice, as required. This offered an improved service and experience for patients of the practice with a reduction in referrals and admissions, more rapid diagnosis and increased scans for pregnant women offering reassurance with early pregnancy concerns.

The areas where the provider should make improvement are:

  • Ensure the system for monitoring training is more robust and implement a more consistent approach to the recording of training documentation and dates.

  • Consider a review of the PPG virtual group and how this could be further developed to ensure enhanced engagement and involvement with the practice.

  • Review the cervical screening and breast cancer screening to increase uptake to nearer the national average.

  • Clearly display comments and compliments forms in reception.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 20 April 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events

  • Lessons were shared to make sure action was taken to improve safety in the practice.

  • When there were safety incidents, patients received reasonable support, truthful information, a verbal and written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.

  • Risks to patients were assessed and well managed.

Effective

Good

Updated 20 April 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework showed patient outcomes were at or above average for the locality and compared to the national average.

  • Staff assessed needs and delivered care in line with current evidence based guidance.

  • Clinical audits demonstrated quality improvement.

  • During the inspection, the practice was unable to evidence that all staff had received training appropriate to their role. This was because staff training was not well recorded and there were gaps in some records.

  • There was evidence of appraisals and personal development plans for all staff.

  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 20 April 2016

The practice is rated as good for providing caring services.

  • Data from the National GP Patient Survey showed patients rated the practice higher than others for several aspects of care.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • Information for patients about the services available was easy to understand and accessible.

  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 20 April 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 20 April 2016

The practice is rated as good for being well-led.

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to this.

  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.

  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.

  • The provider was aware of and complied with the requirements of the Duty of Candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for knowing about notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken

  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.

  • There was a focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions

Good

Updated 20 April 2016

The practice is rated as good for the care of patients with long-term conditions.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

  • The percentage of patients on the diabetes register, with a record of a foot examination and risk classification within the preceding 12 months (01/04/2014 to 31/03/2015) was 92% and was better than the national average of 88%.

  • Longer appointments and home visits were available when needed.

  • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

  • The lead diabetic nurse worked closely with the local community specialist diabetic nurse and consultant specialist to ensure patients were managed in line with best practice.

Families, children and young people

Good

Updated 20 April 2016

The practice is rated as good for the care of families, children and young people.

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young patients who had a high number of A&E attendances. Immunisation rates were comparable to clinical commissioning group averages for all standard childhood immunisations.
  • The percentage of patients with asthma, on the register, who have had an asthma review in the 12 months from April 2014 to March 2015 that included an assessment of asthma control using the three RCP questions, was 71%, which is slightly lower than the national average of 75%.
  • Patients told us that children and young patients were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
  • The practice’s uptake for the cervical screening programme was 77%, which was slightly below the national average of 82%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • We saw positive examples of joint working with midwives and health visitors.
  • Safeguarding was promoted as everyone’s business and all staff had a good understanding of how to identify possible signs of abuse and how to report any concerns.

Older people

Good

Updated 20 April 2016

The practice is rated as good for the care of older patients.

  • The practice offered proactive, personalised care to meet the needs of the older patients in its population.

  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

  • A systematic approach to long term condition management and review was in place.

  • Multidisciplinary working with community based nurses’ ensured patients who were housebound received high quality care and treatment.

  • Choose and book support was offered to patients who were unable to use the IT booking system.

  • All over 75’s were added to an unplanned admissions register with personalised care plans based on individual need.

  • A GP regularly visited two local residential homes for patients who had dementia, to provide care and treatment to the residents and support to relatives.

Working age people (including those recently retired and students)

Good

Updated 20 April 2016

The practice is rated as good for the care of working-age patients (including those recently retired and students).

  • The needs of the working age population, those recently retired and young families had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

  • The practice was proactive in offering as a full range of health promotion and screening that reflects the needs for this age group.

  • Extended hours appointments were available on a Thursday evening, Friday and Saturday morning.

  • Online registration, booking of appointments and ordering repeat prescriptions was available.

  • 24/7 telephone appointment booking and cancellation was available.

  • In house ultrasound and joint injections reduced the need for hospital attendance.

People experiencing poor mental health (including people with dementia)

Good

Updated 20 April 2016

The practice is rated as good for the care of patients experiencing poor mental health (including patients with dementia).

  • The percentage of patients diagnosed with dementia whose care has been reviewed in a face-to-face review in the 12 months from April 2014 to March 2015 was 88% which was higher than the national average 84%.
  • The percentage of patients with physical and/or mental health conditions whose notes record smoking status in the 12 months April 2014 to March 2015 was 96% when compared with the national average of 94%.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice carried out advance care planning for patients with dementia.
  • Patients with dementia were referred to the memory clinic and recommendations highlighted on care plans which were shared with the out of hours provider and other urgent and emergency care organisations.
  • Patients had access to talking therapies and self-help techniques.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 20 April 2016

The practice is rated as good for the care of patients whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including homeless patients, travellers and those with a learning disability.

  • The practice offered longer appointments for patients with a learning disability.

  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable patients.

  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.

  • Safeguarding was promoted as everyone’s business and all staff had a good understanding of how to identify possible signs of abuse and how to report any concerns.

  • Ongoing training was provided to staff to ensure early identification of Female Genital Mutilation (FGM).