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Inspection Summary


Overall summary & rating

Outstanding

Updated 6 June 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Northam Surgery on 17 February 2016. Overall the practice is rated as outstanding.

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

  • There was open and transparent approach to safety and an effective system in place for reporting and recording significant events. All opportunities for learning from internal and external incidents were maximised.
  • The practice used innovative and proactive methods to improve patient outcomes, leading and working with other local providers to share best practice. For example they piloted an improved diagnostic pathway for patients with suspected urine infections, which had been rolled out across the CCG area.
  • There was a holistic approach to assessing, planning and delivering care and treatment to people using services.Examples included: risks to patients were assessed, well managed through the integration of teams, for example benefitting patients with learning disabilities. Robust audit of demand and capacity took place to determine appropriate staffing resources and skills needed to deliver services safely for patients. The practice invested heavily in its staff providing advanced training opportunities such as nurse prescribing qualifications and supported other staff across the health and social care sector to extend their skills for the benefit of patients.
  • Feedback from patients who used the service, family members and carers, and stakeholders was continuously positive about the way staff treated them and other patients. Patients said staff went the extra mile to support patients and the care they received exceeded their expectations. Feedback from all 69 patients about their care was consistently and strongly positive.

  • Patients needs and preferences were central to the planning and delivery of tailored and flexible services. Examples included: male patients from the practice were able to attend a Friday evening and Saturday morning vasectomy clinic.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group, including: use of social media to reach younger people, effective and responsive review of the appointments system and improved online services.

  • Information about services and how to complain was available and easy to understand.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

We saw areas of outstanding practice:

  • Northam Surgery has taken a systematic approach to working with other organisations to improve care outcomes, tackle health inequalities and obtain best value for money.Examples seen included: piloting improved care and treatment pathways and sharing learning across the locality. The practice has streamlined monitoring patients with long term conditions through the concept of polyclinics (Polyclinics are intended to offer a one stop shop for patients where all of their chronic diseases are monitored in one consultation), providing extended length appointments and ongoing continuity by named GPs.

  • The practice strategy and supporting objectives are stretching, challenging and innovative. There were several examples of this, including the approach taken in recognition of the link between social isolation and heightened health risks. Innovative communitarian initiatives such as a Sunday afternoon tea club were soon to start at practice, with a GP and nurse available to see patients.Health promotion was key for patients at the practice and across the locality, with a nurse helping to deliver diabetic education sessions for patients in North Devon for newly diagnosed patients.

  • The practice was caring and extremely patient centred with a strong community presence. Thirty nine patients we spoke with, and comments received in the 30 comment cards, said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.The practice had a taxi fund, which it used to support vulnerable patients enabling them to get to and from appointments safely when needed. In support of carers a GP partner held a key role in a charity, raising funds with staff to take disadvantaged, disabled children and young people from the practice area on an annual holiday.

  • The practice had audited patients who had limb amputations following clinical commissioning group reports. Actions taken by the practice had seen wound healing rates for patients reduce from around 12 months to under six months and the number of appointments needed to support patients had reduced from 21 down to nine.

  • The practice had listened and acted on feedback from patients and other stakeholders about access to appointments particularly during Winter months when there was more pressure. Several changes were made, including: introducing changes to leave arrangements; increasing appointment sessions and numbers of GPs and nurses during peak times every day; having a nurse led minor illness clinic; amending call answering protocols and improved customer care through training for staff; GPs answered incoming calls at 8am to better understand better patient needs and conducted demand audits so that effective proactive rostering was arranged every month.

The areas where the provider should make improvements are:

  • Audit patient records to ensure that clinical findings are documented in a consistent way to support decisions about treatment pathways.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 6 June 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 unintended or unexpected 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 6 June 2016

The practice is rated as good for providing effective services.

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

  • Nurses led the management of patients with chronic conditions, carrying out reviews of patients with respiratory conditions or diabetes.

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

  • Clinical audits demonstrated quality improvement. However, some of those seen were not completed because a second audit had not yet taken place.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • 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

Outstanding

Updated 6 June 2016

The practice is rated as outstanding for providing caring services.

  • Data from the National GP Patient Survey showed patients rated the practice similarly to others for almost all aspects of care. For example, 93.3% of patients said the GP was good at listening to them compared to the Clinical Commissioning Group (CCG) average of 92% and national average of 88.6%). 93.5% of patients said the GP gave them enough time (CCG average 90.9% and national average 86.6%).  95.6% of patients said they had confidence and trust in the last GP they saw (CCG average 97.2% and national average 95.2%).

  • Feedback from patients about their care and treatment was consistently and strongly positive.

  • We observed a strong patient-centred culture.

  • Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this.

  • We found many positive examples to demonstrate how patient’s choices and preferences were valued and acted on.Patients shared with us examples demonstrating that when they had needed to be referred to a specialist their GP had discussed all the options available and acted on the patients wishes.

  • Views of external stakeholders were very positive and aligned with our findings.

Responsive

Outstanding

Updated 6 June 2016

The practice is rated as outstanding for providing responsive services.

  • All 11,610 patients had a named GP, but could also choose who they wished to see at each appointment.

  • Northam Surgery demonstrated a strong commitment to the community with several examples seen. These included medicals for lifeboat personnel were provided free of charge for patients and non-patients at the practice and practice staff supported charities which impacted on their patients such as children needing a holiday.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs. Examples seen included out of hours vasectomy clinics for men, in house dermatology reviews for rapid diagnosis and treatment of skin conditions, including low risk cancer lesions. A nurse delivering education sessions for newly diagnosed diabetics four Saturdays per year for patients in North Devon.

  • There are innovative approaches to providing integrated person-centred care. Polyclinics for patients with long term conditions were available with appointments of Advanced skills of clinical staff meant that services normally seen in hospital were available for patients some of which were unfunded. Examples included: a re-catheterisation service for people with long term conditions. Ring pessary (a device for holding back a prolapse) fitting for women. The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example, the whole appointment system was overhauled and 69 patients involved with the inspection gave positive feedback about these changes.

  • Monthly audits about the way appointments were being used influenced decision making about staffing resources and skills needed. For example, the practice had noticed there was a greater demand for appointments for ear irrigation. In response the practice had funded accredited training so that three health care assistants were able to carry out ear irrigations. The practice was in the process of increasing the number of appointments available for patients to reduce waiting and improve hearing for patients.
  • Patients could access appointments and services in a way and at a time that suited them. For example, extended hours two days a week were provided and a range of early/late opening times each day with GP, nurse, HCA and phlebotomy appointments available for working patients.
  • The practice had purpose built facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand, and the practice responded quickly when issues were raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Outstanding

Updated 6 June 2016

The practice is rated as outstanding 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.

  • As a training practice, Northam Surgery provided a positive experience for GP registrars and medical students. Through a good reputation of support with trainees and an approachable and dynamic leadership team. The practice had no difficulties recruiting new staff when staff retired.

  • There was a strong leadership structure, which incorporated a business manager and seen as a vital element in the future development of the practice.

  • Staff felt supported by management and told us that the culture was positive and family orientated.

  • 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 practice had a number of policies and procedures to govern activity and held regular governance meetings, which were inclusive with all staff groups represented by senior staff.

  • 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. Examples included: improving on line service for ease of access to booking appointments and requesting repeat prescriptions. Using social media websites to communicate news and obtain feedback from younger patients.

  • Northam Surgery had a strong focus on continuous learning and improvement at all levels and staff were encouraged to develop their skills for the benefit of patients. For example, practice nurses were supported to extend their skills to be nurse practitioners and nurse prescribers and Health Care Assistants were supported to extend their roles to improve services for patients.
Checks on specific services

People with long term conditions

Outstanding

Updated 6 June 2016

The practice is rated as outstanding for the care of people with long-term conditions.

  • Innovative and intuitive clinics for patients with long term conditions were developed over time and refined after being evaluated by patients and staff. Patients could access tailored appointments of at least 20-30 minutes with a GP during which their health and welfare was reviewed in a polyclinic. A significant percentage of the 69 patients who gave feedback at the inspection had experienced these clinics and were positive about the success of these in improving or maintaining their health.
  • There were several near patient services which the practice continued to provide because of the benefits for patients, including a catheter replacement service normally available at the hospital.

  • Achieving quality of life and health was at the heart of the services available for patients with chronic diseases. For example, a nurse practitioner assisted in running a course on four Saturdays a year for patients newly diagnosed with diabetes to a raise their awareness about living healthily with their condition. Anecdotally this approach helped reduce the prevalence of patients developing complications associated with diabetes.

  • Best practice risk profiling was used so that any patients with long term or chronic conditions at risk of hospital admission were identified as a priority.

  • Performance for diabetes related indicators was higher to the Clinical Commissioning Group (CCG) and national average. For example, 84% patients with diabetes had an HBa1C blood test in the previous 12 months (CCG average 79.2% and national average 77.54%)

  • 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.

Families, children and young people

Outstanding

Updated 6 June 2016

The practice is rated as outstanding 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 people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.

  • The percentage of patients with asthma, who had an asthma review in the preceding 12 months that includes an assessment of asthma control was 80.7% slightly above the CCG and national averages (CCG 75.7% and national 75.4%).

  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

  • Social media was being used to encourage young people to be involved with the virtual Patient Participation group. Initiatives with the local college were also seeking to encourage young people to be involved in improving access to healthcare for this group.

  • The practice’s uptake for the cervical screening programme was 83.8% which was higher than h the CCG average of 77% and the national average of 81.8%. There was a policy to offer telephone reminders for patients who did not attend for their cervical screening test. The practice demonstrated how they encouraged uptake of the screening programme by using information in different languages and for those with a learning disability and they ensured a female sample taker was available. The practice also encouraged its patients to attend national screening programmes for bowel and breast cancer screening.

  • 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, health visitors and school nurses.

Older people

Outstanding

Updated 6 June 2016

The practice is rated as outstanding for the care of older people.

  • The practice offered proactive, personalised care to meet the needs of the older people in its population. All of the patients had a named GP and appointments were co-ordinated to facilitate good continuity of care for people.As a result, staff knew patients well and understood the support they needed and made sure this happened.For example, the taxi fund was regularly used for instances such as an upset bereaved elderly patient needing to get home following their appointment.

  • Initiatives such as a Sunday afternoon tea club was being set up at the practice and was due to start soon to reduce the impact of social isolation on patients health and wellbeing.

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

  • Orders for repeat prescriptions were co-ordinated so that older patients were able to telephone once and arrangements made for a pharmacy of their choice to deliver their medicines to them.Close working relationships were established with the community matron for patients over the age of 75 with complex healthcare needs to ensure joint care and treatment was provided.

Working age people (including those recently retired and students)

Outstanding

Updated 6 June 2016

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

  • The needs of the working age population, those recently retired and students 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 online services as well as a full range of health promotion and screening that reflects the needs for this age group.

  • Extended pre-bookable appointments were available twice a week. Some services were provided outside of the normal opening hours. For example, vasectomy clinics were held on Friday evenings and Saturday mornings for working men.

  • The practice offered free medicals for any local people who were volunteers for the Appledore Lifeboat.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 6 June 2016

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

  • Performance for mental health related indicators was much higher than the CCG and national averages. For example, 97.4% patients with complex mental health needs who had a comprehensive, agreed care plan in the preceding 12 months (CCG average 87% and national average 88.3%).

  • Staff were proactive and consistent in supporting people to live healthier lives. For example, patients with complex mental health needs were supported to achieve recovery through regular monitored contact and maintenance of their depot treatment plan.

  • The percentage of patients diagnosed with dementia who were reviewed in the previous 12 months was 96.8% which was much higher than the CCG 86.1% and national 84.01% averages.

  • 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. The practice set up a three monthly review system for all of these patients, where GPs completed a standard review template with the patient and their carer to check their wellbeing and ensure the treatment was appropriate.

  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. Access to talking therapies was brought closer to home for patients who were able to attend weekly clinics held by the NHS Depression and Anxiety Service in the practice.

  • 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 and were ‘Dementia Friends’.

People whose circumstances may make them vulnerable

Outstanding

Updated 6 June 2016

The practice is rated as outstanding for the care of people who circumstances may make them vulnerable.

  • The practice was compassionate about helping patients in deprived circumstances. There were several examples including a taxi fund used to help patients at times of need, charitable work including making donations to the local food bank, fundraising and taking vulnerable and disabled children on holidays.

  • 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, person centred appointments for patients with a learning disability. Two community learning disability nurse specialists were enabled to lead review appointments with patients having been mentored by Northam Surgery to complete the practice nurses course.

  • The practice reflected upon data for the Northern locality of the clinical commissioning group (CCG) highlighting that higher numbers of patients were presenting late with symptoms and having to undergo lower limb amputations compared to national statistics. Northam Surgery then carried out audits and reviewed their wound care pathway.

  • 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. The team went the extra mile to reduce the risks of social isolation for vulnerable people. For example, a Sunday afternoon tea club was due to start at the practice for vulnerable people.

  • 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.