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Archived: Norton Canes Practice Good Also known as Dr B. K Singh

The provider of this service changed - see new profile

Inspection Summary


Overall summary & rating

Good

Updated 30 October 2018

We previously carried out an announced comprehensive inspection at Norton Canes Practice on 13 November 2017. The overall rating for the practice was good. The practice was rated as requiring improvement in providing safe services. A breach of legal requirement was found and a requirement notice was served in relation to safe care and treatment. The full comprehensive report on the November 2017 inspection can be found by selecting the ‘all reports’ link for Norton Canes Practice on our website at .

This inspection was an announced comprehensive inspection carried out on 1 October 2018 to confirm that the practice had met the legal requirements in relation to the breach in regulation that we previously identified.

This practice is rated as Good overall.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

At this inspection we found:

  • The practice leaders had taken the findings from the previous CQC inspection to improve the services provided and patient safety and care. Each area for improvement had been actioned and our findings at this inspection showed improvements had been made and sustained.
  • 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 had effective systems, processes and practices in place to protect people from potential abuse and staff had received safeguarding training appropriate to their role.
  • There were systems in place for identifying, assessing and mitigating risks to the health and safety of patients and staff. The system for managing patient safety alerts and the monitoring of patients on high risk medicines had improved.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that 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 that they were able to access care when they needed it.
  • The practice actively worked with the patient participation group (PPG) to meet the needs of their patients and had increased the membership of the PPG.
  • The practice had hosted a range of health awareness sessions for their patients and members of the local community. The most recent session was on diabetes. Over 30 people attended and feedback was very positive.
  • Information to support patients with making a complaint was now readily available.
  • Systems had been put in place to monitor and deal with uncollected prescriptions.
  • There was a focus on continuous learning and improvement at all levels of the organisation.
  • The practice had pro-actively identified and increased the number of carers registered and were working with external partners to support their carers.

The areas where the provider should make improvements are:

  • Consider obtaining a hearing loop system to assist patients with a reduced range of hearing.

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

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Safe

Good

Updated 30 October 2018

At our previous inspection we rated the practice as requiring improvement for providing safe services. This was because the provider had failed to minimise the risks associated with the monitoring of patients on high risk medicines. Improvements were also required in the monitoring of uncollected prescriptions and improving the system for managing patient safety alerts.

At this inspection we saw significant improvements had been made and 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 and had access to internal safeguarding leads and contacts for external safeguarding agencies were readily accessible. Learning from safeguarding incidents was available to staff. We saw vulnerable patients were flagged on the clinical computer system to alert staff for example, to children on the child protection register, their parents and siblings.
  • Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (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, 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 nurse was the infection prevention and control (IPC) clinical lead and had carried out an internal audit in July 2018. An action plan had been developed to address the improvements identified in external and internal audits. The findings showed that the infection control polices and protocols were being adhered to and recommendations for improvements had been carried out promptly by the practice.
  • 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 was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures. The practice had reviewed its medicines held in the event of a medical emergency and had obtained all the suggested medicines immediately following the last inspection.
  • 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.
  • 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 and had re-designed their referral policy to ensure consistent and efficient referral processes.

Appropriate and safe use of medicines

The practice had improved their systems for appropriate and safe handling of medicines.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed and 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 and had reduced their prescribing in 2018.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Following the last inspection, the practice had reviewed the management of patients prescribed high risk medicines. Patients prescribed medicines that required close monitoring for possible side effects had their care and treatment shared between the practice and hospital. The hospital organised the assessment and monitoring of the condition and the practice prescribed the medicines required. We saw GPs now ensured they accessed patient blood test results prior to any prescribing to ensure patients were appropriately monitored at the required frequency and medicines were prescribed safely.
  • The practice kept prescription stationery securely and monitored its use. Improvements had been made to the monitoring of uncollected prescriptions and action taken where required.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed safety using information from a range of sources.

Lessons learned and improvements made

The practice learned from 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. We saw there was a policy in place for the management of incidents and staff had access to a standard recording form available on the practice’s computer system.
  • The practice learned and shared lessons, identified themes and took action to improve safety in the practice. Significant events and complaints were standing agenda items for staff meetings held and meetings recorded.
  • The practice had improved their systems for acting on external safety events as well as patient and medicine safety alerts. Following receipt of an alert, the practice maintained a log of alerts and recorded the action taken. We saw the practice now routinely carried out clinical searches for medicine related alerts to ensure that patients were not affected by the medicines involved.

Please refer to the evidence tables for further information.

Effective

Good

Updated 30 October 2018

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

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Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed patient 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 advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • Patients over the age of 75 years had a named GP.
  • Older patients who were frail or may be vulnerable were identified on the clinical system and received a full assessment of their physical, mental and social needs. The practice used an appropriate tool and had identified 569 patients aged 65 and over who were living with moderate or severe frailty and had a clinical review including a review of medication.
  • The practice followed up on older patients discharged from hospital. It 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.
  • The practice offered these patients flu and pneumonia vaccinations.
  • Adults with newly diagnosed cardiovascular disease were offered 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 it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension).
  • The practice’s performance on quality indicators for long term conditions was in line with local and national averages. However, the practice exception reporting rate was lower than the CCG and the national averages, meaning more patients had been included.

Families, children and young people:

  • Childhood immunisation uptake rates were in line with the target percentage of 90% or above. The practice had achieved between 95% to 98% for the four indicators.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.
  • Baby clinics were provided on a Wednesday morning with the nurse. Any concerns were escalated to a GP. The practice had access to health visitors based on site at the health centre.

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

  • The practice’s uptake for cervical screening was 75%, which was below the 80% coverage target for the national screening programme. The nurse told us that they actively encouraged female patients to attend for screening. Non-attenders were flagged on the woman’s record so that the screening test could be discussed opportunistically. Women were offered appointments at different times throughout the week to suit them and a female sample taker (the nurse) was available.
  • The practice’s uptake for breast cancer screening (73%) was above the national average of 70%. Bowel screening uptake was 54%, which was in line with the national average of 55%.

  • 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 new patient health checks and checks for patients aged 75 and over. 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 considered the needs of those whose circumstances may make them vulnerable. The practice attended meetings with a range of professionals to ensure those who were approaching end of life had a cohesive plan of care.
  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
  • The practice offered annual health checks to patients with a learning disability. Records showed 21 of the 34 patients registered had received a health check in the last 12 months. The practice had 69 patients on their vulnerable adult’s register.
  • 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 and 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 were fully aware of the links with the mental health crisis team and shared an example where they had kept a recent suicidal patient safe at the practice whilst urgent mental health opinion was sought.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • The practices performance on quality indicators for mental health was comparable with local and national averages. For example, published results for 2016/17 showed 96% of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the previous 12 months. This was comparable to the CCG average of 93% and the national average of 91%. The practice exception reporting rate of 0% was significantly lower than the CCG and the national averages.

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 the information collected for the Quality and Outcomes Framework (QOF) and performance against national screening programmes to monitor outcomes for patients. QOF is a system intended to improve the quality of general practice and reward good practice. The most recent published results for 2016/17 showed the practice had achieved 99% of the total number of points available compared with the clinical commissioning group (CCG) average of 98% and the national average of 97%. The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity and had carried out ten audits in the last 12 months, which demonstrated quality improvement.

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. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and 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 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 discussing 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 considered the needs of different patients, including those who may be vulnerable because of their circumstances. Meetings were held with external healthcare partners to discuss patients with complex needs.

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. In addition, the practice had also organised health awareness events. The last event held in September 2018 was on diabetes awareness and both patients and the local community were encouraged to attend.
  • 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 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. Written consent was obtained for immunisations, contraceptive implants, coils and minor surgery.
  • 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 30 October 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

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

The results of the National GP patient survey, published August 2018, showed the practice was in line with local and national averages for questions relating to kindness, respect and compassion.

  • Two hundred and fifty-six surveys were sent out and 101 were returned giving a completion rate of 39%. Results showed 83% of patients who responded said the healthcare professional they saw or spoke to at their last appointment was good at treating them with care and concern; compared with the clinical commissioning group (CCG) and the national average of 87%.
  • Eighty-seven percent of patients who responded said the healthcare professional they saw or spoke to at their last appointment gave them enough time; compared with the clinical commissioning group (CCG) average of 86% and the national average of 87%.
  • Ninety-eight percent of patients who responded said they had confidence and trust in the last healthcare professional they saw; compared with the clinical commissioning group (CCG) and the national averages of 96%.

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. However, a hearing loop system was not currently available to assist patients with a reduced range of hearing.
  • 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 had pro-actively identified and increased the number of carers registered and were working with external partners to support their carers.
  • The practices GP patient survey results for 2018 were above local and national averages for questions relating to involvement in decisions about care and treatment. Ninety-nine percent of patients who responded said they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment; compared with the clinical commissioning group (CCG) average of 94% and the national average of 93%.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues, or appeared distressed reception staff offered 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 30 October 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.
  • Telephone GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered. Although the doors to the health centre were automatic to aid access for patients with reduced mobility, the doors leading to the practice were not automatic. However, reception staff told us they provided assistance to patients where required. None of the patients attending the practice during observations required assistance.
  • 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.
  • The practice was responsive to the needs of older patients. Same day emergency appointments were available for patients in addition to home visits and telephone consultations for patients who were physically unable to attend the practice.
  • Elderly frail patients were identified and coded on the clinical system.

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 offered prevention and chronic disease health education advice and events and provided patients with information on self-help groups.
  • Pre-diabetic patients were identified and referred to the national diabetes programme to help educate patients on lifestyles to help prevent progression to diabetes.

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.
  • Parents or guardians concerned about a child were offered a same day appointment when required.
  • Antenatal clinics were held by 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 were offered with GPs and the nurse on a Monday evening from 6.30pm to 7.30pm.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The practice provided on-line services for example booking of appointments and repeat prescription ordering. An electronic prescription service (EPS) was also available.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability. The practice had worked with the learning disability specialist nurse in identifying patients with a learning disability. The specialist nurse had visited nine patients who were non-attenders to promote attendance of health checks. The practice then sent letters to the patients and their carers offering flexible appointments to suit their needs.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.
  • The practice had increased the number of carers registered and had identified 90 (2%) of the patient list as carers. The practice had a designated carer’s champion and they had liaised with local support agencies and were looking to provide a monthly carers clinic from November 2018.

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 could refer patients to a dementia consultant who conducted dementia clinics in the health centre for diagnosis and treatment.
  • Staff and a member of the Patient Participation Group were dementia friendly trained to offer advice and support and signposted patients to local self-help groups.
  • The practice had established good links with the local memory clinic and dementia support services.

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.
  • Most patients reported that the appointment system was easy to use.

Results from the national GP patient survey, published in August 2018, showed that patients’ satisfaction with how they could access care and treatment was higher than the local and national averages.

  • Eighty percent of patients who responded described their experience of making an appointment as good; compared with the clinical commissioning group (CCG) and the national averages of 69%.
  • Seventy-five percent of patients who responded said they were offered a choice of appointment; compared with the clinical commissioning group (CCG) average of 60% and the national average of 62%.
  • Seventy-eight percent of patients who responded said they were satisfied with the type of appointment they were offered; compared with the clinical commissioning group (CCG) and the national averages of 74%.

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.

  • At the last inspection we identified that information about how to make a complaint or raise concerns was not readily assessible and some of the patients we spoke with were not aware of the procedure. We saw this had since been reviewed and information was now readily accessible in the practice in addition to the provider website.
  • 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 from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 30 October 2018

We rated the practice as good for providing a well-led service.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care.

  • The practice had a clear vision in place. This was to provide high quality, safe and professional services to their patients with a focus on prevention of disease by promoting health and wellbeing and offering care and advice within a safe and friendly environment. Staff spoken with understood the vision, values and strategy and their role in achieving them. Regular meetings were held to communicate the vision, future strategies and practice performance. Meetings were recorded and readily accessible to staff.
  • Following the last inspection, the mission statement had been made accessible to patients.
  • The practice had a business plan in place to achieve priorities.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.

Culture

The practice had a culture of high-quality sustainable care.

  • The practice had an established staff team. Staff we spoke with told us they felt respected, supported and valued and 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 could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff had received an annual appraisal in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity and had a policy in place. Staff had received equality and diversity training. Staff felt they were treated equally and had received training in equality and diversity.
  • There were positive relationships between staff and teams.

Governance arrangements

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

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted 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 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 clarity around processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

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 effective 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 (PPG) that consisted of 20 core members and a small group of virtual PPG members.
  • 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 a focus on continuous learning and improvement. The practice had joined the Cannock Chase Clinical Alliance extended access to the primary care service programme, which provided patients with seven days extended access through 13 local GP practices.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • The practice was actively involved with the National Institute for Health Research to help inform future developments in health care and was currently working on two research projects to include a study examining common and rare genetic variants associated with thinness.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good