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Inspection Summary


Overall summary & rating

Good

Updated 25 June 2018

This practice is rated as Good overall.

(Wilderness Road Surgery is a newly registered practice and this is the first inspection of this service under this provider.)

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

We carried out an announced comprehensive inspection at Wilderness Road Surgery on 9 May 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned because the provider of the service had changed and to check whether the new provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008. We also looked at the overall quality of the service and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured care and treatment was delivered according to evidence based guidelines.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Patients found the appointment system easy to use and reported they were able to access care when they needed it. Patient feedback on the care and treatment delivered by all staff was consistently positive.

• There was a strong focus on continuous learning and improvement at all levels of the organisation.

• A firm commitment to offering continuity of care whilst enhancing the choice of GPs available to patients.

• Change management was undertaken in an inclusive manner to ensure patients services were not affected when the provider changed.

• The practice demonstrated a commitment to improve services. For example, it had identified lower than average attendance for cancer screening and immunisations and had implemented improved recall systems to follow up patients that did not attend.

The areas where the provider should make improvements are:

• Continue to develop a workflow protocol to deal with communications coming into the practice and an audit process to ensure compliance.

• Review the sustainability of improvements made on the day of inspection. For example, completing the scheduled fire drill and reviewing advice for receptionists to identify potential life threatening symptoms..

• Review the effect of updating the recall systems for cancer screening and immunisations to evaluate whether they have proven effective.

Professor Steve Field CBE FRCP FFPHFRCGP

Chief Inspector of General Practice.

Inspection areas

Safe

Good

Updated 25 June 2018

We rated the practice 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. The staff were trained to an appropriate level in safeguarding and demonstrated a clear understanding of their responsibilities to safeguard patients. The practice nurse had identified that they needed to update their level two safeguarding training prior to inspection and completed their refresher course within two days of inspection. All staff 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.
  • There was an effective system to manage infection prevention and control.
  • The practice had arrangements to ensure facilities and equipment were safe and in good working order. There was a legionella risk assessment in place and staff carried out actions to manage risks associated with legionella in the premises (legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • The arrangements in place for managing waste and clinical specimens were appropriate and 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 in place for all staff and completion of induction training was recorded.
  • 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. Reception staff had access to policies in relation to patient medical emergencies. 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.

  • The care records we saw showed information needed to deliver safe care and treatment was available to staff.
  • There was a documented approach to managing test results and we saw results were dealt with in a timely way.
  • 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. This system had been changed when the new provider took over the management of the practice and we noted that additional checks and controls had been implemented at that time to improve the system.

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 found one medicine for use in an emergency was not stocked. The practice rectified this immediately and sent us evidence confirming that this medicine was in stock the day after inspection.
  • Staff prescribed, administered 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. We saw evidence the practice had reduced antibiotic prescribing in the last 12 months. The practice was active in working with the local medicines management team in auditing the use of medicines and their prescribing regimes.
  • 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. Data showed that 80% of patients who were prescribed four or more medicines had received a medicines review in the last 12 months.
  • We found that the practice did not have an appropriate and secure means of tracking blank prescriptions. We discussed this with the practice and they implemented a tracking system within two days of the inspection taking place.
  • The practice regularly reviewed prescribing and provided an additional safety net for patients taking high-risk medicines.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to most 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. For example, the system used to review the care of patients diagnosed with diabetes had been improved when the practice recognised there were risks arising from the previous recall system.

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 evidence that the practice had taken action as a result of incidents that had led to provision of safer services.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts. There were clear lines of responsibility for taking action in relation to safety alerts and the action taken was recorded.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 25 June 2018

We rated the practice and all of the population groups as good for providing effective services overall.

(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. Although this data is related to the previous provider, systems and staffing have remained largely the same.)

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • All clinical staff had easy and immediate access to both written and online best practice guidance.
  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • 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:

  • Older patients who were frail or may be vulnerable received a full assessment of their physical, mental and social needs.
  • The practice offered a health check to patients aged over 75 where indicated. If necessary supported by an appropriate care plan.
  • 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.

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.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training. For example, the practice nurse received refresher training in respiratory medicine in 2017.
  • 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.

Families, children and young people:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. We noted that there were very low numbers of children in each of the childhood immunisation groups. Therefore if one or two children did not attend for immunisation this had a significant effect on the percentage uptake of the immunisation programme. However, the practice was able to demonstrate that they had introduced a more stringent recall system to encourage take up of childhood immunisations. It was too early to evaluate whether this would result in increased attendance for these immunisations.
  • 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.

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

  • The practice’s uptake for cervical screening was lower than the 80% coverage target for the national screening programme. However, the new provider had introduced more robust recall systems to encourage eligible patients to take up this screening programme.
  • The practices’ uptake for breast and bowel cancer screening was below the national average. There were recall systems in place to encourage greater take up of these screening programmes.

  • 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 and those with a learning disability. We noted that the register of patients diagnosed with a learning disability required review. Some patients on the register had an incorrect diagnosis. The practice commenced, on the day of inspection, this review and introducing a revised process for inviting patients for a health check.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

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, 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 medication.
  • 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.
  • The practice reviewed the care of most patients diagnosed with dementia in a face to face meeting every year.
  • Patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in their medical records and reviewed each year.
  • The practice specifically considered the physical health needs of patients with poor mental health and those living with dementia.
  • 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.

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 used information about care and treatment to make improvements. For example, there had been a two cycle audit to review compliance with prescribing of medicines for upper respiratory tract infections. The first audit showed that the appropriate antibiotics were prescribed in line with national guidance for 59% of patients. The repeat audit conducted 1 year later showed 98% of patients received the antibiotics that were included in the national guidance. Where appropriate, clinicians took part in local and national improvement initiatives and the practice had an audit programme in place. A total of 19 audits had been completed in the last 18 months.

Effective staffing

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

  • 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.
  • 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.
  • 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. We noted that patients were able to access their preferred or named GP for continuity of care.
  • The practice ensured 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.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example they offered blood pressure monitors to patients with high blood pressure so they could record levels at home, and offered smoking and alcohol advice when appropriate.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns and tackling obesity.

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.

Please refer to the Evidence Tables for further information.

Caring

Good

Updated 25 June 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 consistently positive about the way staff treated people. We saw many patient comments related to outstanding staff support. The friends and family test results for the last three months showed that 100% of patients who responded were likely or highly likely to recommend the practice to others.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • Because the practice was small and staff turnover was low, staff had developed good knowledge of patient personal circumstances. We were given many examples of where patients had been treated in an understanding and compassionate way. For example, when a patient had been discharged following an operation the GP visited them on a Saturday to assess their post-operative progress. We saw examples of a strong, visible person-centred culture.
  • The practice gave patients timely support and information.
  • The practice was consistently higher in the GP national survey than other practices in the clinical commissioning group (CCG) and national averages for questions related to kindness, respect and compassion.

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 they are given) and were aware of this standard.

  • Staff communicated with people in a way they could understand, for example, communication aids and easy read materials were available. For example, the provider had produced communication aids for patients diagnosed with a learning difficulty at their main practice in Slough. There were plans to introduce these materials at the practice.
  • 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 was similar in the GP national survey to other practices in the CCG and national averages for questions related to involvement in decisions about care and treatment.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • Reception staff knew if patients wanted to speak in private they could 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 25 June 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. It took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • Patients could email the practice with any queries.
  • 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.
  • The care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated on a personal basis by the GPs with other services. This was possible due to the small number of patients in these groups. Such care was organised as and when necessary and did not rely upon formal meetings with other local professionals.

Older people:

  • All patients had a named GP who supported them.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
  • The GPs also accommodated home visits or telephone consultations for those who had difficulties getting to the practice.

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. Consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local Community Health and Social Care 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.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.
  • The practice had reviewed their recall system and were undertaking a check on the completion of childhood immunisations to improve the take up of immunisations for children aged two.

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, extended opening hours.
  • Telephone GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The practice offered NHS health checks to patients aged between 40 and 74 years of age.

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. During the inspection the practice identified the need to review their register of patients with a learning disability to ensure that only those patients with such a condition were included on the register.
  • 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 practice dementia champion had led a project to adapt the practice to better suit patients with dementia.
  • The practice proactively identified patients at risk of developing dementia. Early dementia screening had been offered and 80% of those screened were referred to secondary care when risk was identified.

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. For example there was a three day wait for the next pre-bookable appointment.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • By working with a larger practice partnership the practice was able to access GPs from the provider practice to cover holiday and sickness absence to ensure there were enough appointments available.
  • The practice showed higher than average performance in the GP national survey than other practices in the clinical commissioning group (CCG) and national averages for questions related to access to the practice.

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 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. All patient complaints were discussed at the monthly governance meetings and shared with staff so that they could reflect on their practice. We saw that the two complaints that the practice had received in the last year were reviewed and reflected upon. When one of the complaints required re-training of staff this was given to avoid a similar complaint arising in the future.

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

Working age people (including those recently retired and students)

Good

People whose circumstances may make them vulnerable

Good

People experiencing poor mental health (including people with dementia)

Good