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Inspection Summary


Overall summary & rating

Good

Updated 26 June 2018

This practice is rated as Good overall. (Previous inspection November 2017– Requires Improvement)

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? – Requires Improvement

We carried out an announced comprehensive inspection at Wearside Medical Practice on 1 May 2018 to follow up on breach of regulations following our inspection in November 2017.

We first carried out an announced comprehensive inspection of this practice on 31 August 2016. We rated the practice then as good overall and requiring improvement for providing well-led care. This was because although the practice had some governance arrangements in place, there were areas that needed improvement. We carried out an announced focused inspection in November 2017; we rated the practice as requires improvement overall and inadequate for providing well-led care. We issued a warning notice following this inspection as we found the practices leadership, oversight and governance were not effective.

These reports can be found by selecting the ‘all reports’ link for Wearside Medical Practice on our on our website at www.cqc.org.uk.

At our previous inspection on 6 November 2017, we told the provider that they must make improvements in some areas. These included the leadership of the practice, the practice’s governance framework and the lack of focus on improvement at the practice.

At this inspection we found:

  • We saw that some improvements had been made with respect to leadership, however, they were not yet fully established or embedded into practice. When we inspected the practice, there was continuing uncertainty about the partnership at the practice that meant that we were unable to determine if the leadership and governance issues were fully resolved.
  • 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.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Most patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • The practice had developed an increased focus on continuous learning and improvement at all levels of the organisation. We saw that the lead GP was actively engaged with work to improve the practice.

The areas where the provider should make improvements are:

  • Continue to develop effective systems and processes to ensure good governance in accordance with the fundamental standards of care.
  • Review the recruitment procedures so that they are established and operated effectively to ensure only fit and proper persons are employed. In particular, to ensure the practice completes disclosure and barring check process prior to employment of new members of staff.
  • Continue work to complete the process of recording the immunisation status for non-clinical members of staff.
  • The provider should ensure that INR (international normalized ratio) results for warfarin are appropriately added to patients medical records.

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

Inspection areas

Safe

Good

Updated 26 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. 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.) Would the nurse below not be a chaperone too
  • 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 most of the appropriate staff checks at the time of recruitment and on an ongoing basis. For the most recently appointed nurse the practice had not applied for a DBS check until shortly before the nurse started work, when we inspected the practice a new DBS certificate had not yet been received. Steps had been taken to mitigate the risk to patients.
  • Since we last inspected the practice, they had implemented an effective system to manage infection prevention and 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. The practice employed a large number of locum staff through a locum agency; they ensured that appropriate checks had been carried out by the locum agency. The practice produced clear and effective information for locum staff employed by the practice.
  • 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.

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff. There was a documented approach to managing test 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 systems for appropriate and safe handling of medicines required review in some areas.

  • 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.
  • 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 practice system for recording the results of INR tests did not always include a record of when the next test was due. (INR is a blood test that needs to be performed regularly on patients who are taking warfarin to determine their required dose). After we reported this to the practice, they provided evidence to show this had been raised as a serious incident and had taken steps to minimize this from happening in the future. We found that appropriate blood test results were in place before other high-risk medicines such as lithium were issued.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues. Most of these risk assessments had been put in place since we last inspected the practice.
  • Since we last inspected the practice, they had put in place systems that monitored and reviewed activity. This helped managers 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.

  • Since we last inspected the practice, they had put in place clear systems that ensured 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. Staff told us that when things went wrong what had happened, and learning, was shared with the whole team.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 26 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.

Effective needs assessment, care and treatment

The practice did not have clear systems to keep clinicians up to date with current evidence-based practice. The lead GP and the nursing team kept up to date with current evidence based guidance; however, clinical meetings held with the long-term locum GPs did not discuss guidance. The locum staff we spoke to was aware of current evidence based guidance and took steps to keep themselves up to date. 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.
  • 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 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. They ensured that 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.

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.
  • 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 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’s performance for long-term condition indicators for 2016/2017 was comparable to national averages.

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 above the target percentage of 90% or above.
  • 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 74%, which was broadly in line with the 80% coverage target for the national screening programme.
  • The practices’ uptake for breast and bowel cancer screening was in line 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 that took into account the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances. For example, homeless people, travellers and those with a learning disability.
  • The practice offered annual health checks to patients with a learning disability.
  • 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’s performance for most mental health indicators was comparable to national averages. For one indicator their performance was below national averages. Preliminary date for 2017/2018 showed there had been no improvement. The practice were aware of the need to improve in this area, their practice development plan included work to improve performance in this area.
  • We found that the practice had an effective system to invite patients to attend review appointments.
  • 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. Long-term planning for patients with dementia was completed in secondary care.
  • The practice offered annual health checks to patients with a learning disability.

Monitoring care and treatment

The practice had a programme of quality improvement activity and reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • The most recent published Quality Outcome Framework (QOF) results for 2016/2017 showed overall, the practice achieved 96% of the total number of points available, compared to the CCG and England average of 97%. The overall exception reporting rate was 9.9% compared to the CCG average of 6.2% and the England average of 5.7% (Exception reporting is the removal of patients from QOF calculations where, for example, the patients decline or do not respond to invitations to attend a review of their condition or when a medicine is not appropriate.)
  • The practice development plan included work to sustain and improve performance in this area.
  • The practice used information about care and treatment to make improvements.

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 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.
  • Since we last inspected the practice, a staff appraisal system had been introduced.
  • 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 that 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.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • 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, tackling obesity.

Consent to care and treatment

The practice told us they 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 26 June 2018

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients about the way staff treat people was positive.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.

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.
  • 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. They had identified 143 (1.9% of the practice population) patients who were also carers.

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 26 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. They took account of patient’s needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • 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 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:

  • 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.

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 held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.
  • The practice referred patients to the local ‘move to improve’ programme for patients who suffer from long-term conditions. This is a programme of structured physical activity, such as exercise classes, that take place at several locations in the Sunderland area.

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 five were offered a same day appointment.

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.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances. For example, 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.
  • Information about various voluntary groups and support organisations was available for patients.

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.

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.
  • Since we last inspected the practice, they had put in place a system that recorded complaints made to the practice and they had updated their complaints policy.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints. It acted as a result to improve the quality of care. The practice told us they planned to review the complaints made in the last 12 months to see if they could learn from any themes or trends that were identified.

Please refer to the Evidence Tables for further information.

Well-led

Requires improvement

Updated 26 June 2018

At a previous inspection on 7 November 2017, we rated the practice as inadequate for providing well-led care, as the governance arrangements were inadequate. We issued a warning notice in respect to these issues. We found that leadership capacity was limited to due to the absence of one GP partner and the limited engagement of the remaining partner in the leadership and development of the practice. This had resulted in a lack of focus on progress with plans for improvement and a limited understanding of their regulatory responsibilities.

At this inspection, we found that most of the issues that had resulted because of these issues had been addressed. For example, we found that practice specific policies were reviewed and updated, staff records were organised and a practice development plan was in place. However, the changes to the governance of the practice had recently been implemented and were not yet fully embedded into practice. The partnership issues at the practice had not been resolved as only one of the GP partners was active in the management of the practice, the remaining partner was still absent. There was still no partnership agreement in place. Due to these continued issues, we found that the governance framework and leadership of the practice was still at an interim phase of development and could not yet fully ensure the effective leadership of the practice.

Leadership capacity and capability

The current leadership of the practice had the capacity and skills to deliver high-quality, sustainable care. However, as a partnership agreement was not yet in place at the practice it was not clear how the practice’s leadership would develop in the future.

  • Since we inspected the practice in November 2017, the lead GP had appointed an interim practice manager. The lead GP and the interim practice manger were knowledgeable about the issues and priorities relating to the quality and future of services. They understood the challenges faced by the practice and were addressing them. The lead GP had developed an active role in the leadership of the practice.
  • The current leaders were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

Vision and strategy

The lead GP and the interim practice had a clear vision and credible strategy to deliver high quality, sustainable care. However, it was not clear how the practice would sustain and embed this vision and strategy.

  • Since we inspected the practice in November 2017, the practice had developed a business development plan and associated objectives. They monitored their performance against these objectives. The GP and the practice manager developed this plan with the support of the clinical commissioning group. The practice had been unable to consult the second GP partner as they were on extended leave. The practice told us that they expected this partner to return to the practice in mid-June 2018. It was unclear if the practice would be able to continue with their current strategy when this partner returned.
  • 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 their 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.
  • 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 needed. This included appraisal and career development conversations. All staff received annual appraisals. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Staff were considered valued members of the practice team. Clinical staff 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. Some staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

The practice had developed clear responsibilities, roles and systems of accountability to support good governance and management. However, it was not clear how the practice would sustain, embed and develop these arrangements due to the ongoing partnership issues that they faced.

  • The lead GP and the interim practice manager had put in place structures, processes and systems to support good governance and management. The current 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 lead GP was engaged with and actively supported this process.
  • The practice had processes to manage current and future performance.
  • Practice leaders had oversight of national and local safety alerts, incidents, and complaints.
  • The practice had developed a clinical audit plan and we saw that clinical audit had begun to have a positive impact on quality of care and outcomes for patients. 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 used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The 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 and diverse 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 was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was an increased focus on continuous learning and improvement. The practice had responded to the concerns raised at the previous inspection and taken action to address them.
  • 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. We saw that the practice had used the support of the clinical commissioning group to lead improvements at the practice.
  • 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

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