You are here

Archived: Glebe Surgery Good

This service is now registered at a different address - see new profile

Inspection Summary


Overall summary & rating

Good

Updated 24 November 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Glebe Surgery on 12 September 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • The practice had adopted the ‘Year of Care’ approach to care for patients with long term conditions which aimed to give patients better self-management of their condition.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice allowed a greater degree of flexibility in appointment times to elderly patients using the local public transport system as it could be infrequent.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • In 2015 the practice was awarded a ‘Pacesetter’ award for their care of children following the use of a template to assist GPs and nurses in their assessment of sick children. (The Pacesetter award programme is designed to highlight, acknowledge and celebrate the initiatives that GP practices are putting in place to provide excellent primary care to children, young people, their families and carers).

We saw one area of outstanding practice:

  • An additional 3,500 patients registered at the practice when a nearby GP practice closed. The practice showed us evidence of the comprehensive strategy they had established. This had ensured existing patients were not affected and new patients experienced a seamless transition from one practice to the other. This included innovative ways of transferring electronic patient notes because the other practice’s system was not compatible with the Glebe Surgery system. The practice told us of the commitment of their staff at this time which included working additional hours and learning new administrative roles. The practice told us they were proud that their patient survey results had continued to be significantly above national average during this time and that staff morale remained positive.

The areas where the provider should make improvement is:

  • Ensure compliance with the practice protocol for fridge temperatures when storing vaccines.

  • Ensure the legionella risk assessment is kept up to date.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 24 November 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 things went wrong patients received reasonable support, truthful information, and a 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 24 November 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 compared to the national average.

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

  • Clinical audits demonstrated quality improvement.

  • 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 other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 24 November 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care. For example;

    96% of patients who responded said the last GP they spoke to was good at treating them with care and concern compared to the national average of 85% and 97% of patients who responded said the last nurse they spoke to was good at treating them with care and concern compared to the national average of 91%.

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

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

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

Responsive

Good

Updated 24 November 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and clinical commissioning group to secure improvements to services where these were identified

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

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

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

Well-led

Good

Updated 24 November 2016

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

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

  • An additional 3,500 patients registered at the practice when a nearby GP practice closed. The practice showed us evidence of the comprehensive strategy they had established to ensure existing patients were not affected and new patients experienced a seamless transition from one practice to the other.

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

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

  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty.

    The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken

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

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

  • In 2015 the practice was awarded a ‘Pacesetter’ award for their care of children following the use of a template to assist GPs and nurses in their assessment of sick children. (The Pacesetter award programme is designed to highlight, acknowledge and celebrate the initiatives that GP practices are putting in place to provide excellent primary care to children, young people, their families and carers).

Checks on specific services

People with long term conditions

Good

Updated 24 November 2016

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

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

  • The practice offered a combined annual review appointment to patients with multiple long term conditions.

  • Performance for diabetes related indicators was in line with the clinical commissioning group (CCG) and national averages. For example, the percentage of patients with diabetes, on the register, in whom the last blood glucose level was 64 mmol/mol or less in the preceding 12 months was 77% compared with the CCG average of 83% and the national average of 78%.

  • The practices nurses visited patients with diabetes who were unable to attend the practice at home.

  • Longer appointments and home visits were available when needed.

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

  • The practice had adopted the ‘Year of Care’ approach to care for patients with long term conditions which aimed to give patients better self-management of their condition.

Families, children and young people

Good

Updated 24 November 2016

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

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.

  • 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.

  • The practice’s uptake for the cervical screening programme was 81%, which was similar to the clinical commissioning group (CCG) average of 83% and the national average of 82%.

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

  • The practice offered combined post-natal and six week baby checks with the named GP.

  • We saw positive examples of joint working with midwives and health visitors.

Older people

Good

Updated 24 November 2016

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

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

  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. A triage system was in place to assess the most suitable care for patients requiring this service.

  • The practice allowed a greater degree of flexibility in appointment times to elderly patients using the local public transport system as it could be infrequent.

  • The practice maintained a register of housebound patients.

  • Flu vaccines were offered in the homes of patients who were housebound.

  • GPs provided a weekly ward round to patients in a local nursing home.

Working age people (including those recently retired and students)

Good

Updated 24 November 2016

The practice is rated as good 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.

People experiencing poor mental health (including people with dementia)

Good

Updated 24 November 2016

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

  • The practice results for the management of patients diagnosed with dementia were in line with the local and national averages. For example 80% of these patients had received a face-to-face review within the preceding 12 months compared to the clinical commissioning group (CCG) average of 82% and the national average of 84%.

  • The practice results for the management of patients with poor mental health in line with the local and national averages. For example, 89% of their patients with severe and enduring mental health problems had a comprehensive care plan documented in their records within the last 12 months which was in line with the CCG average of 90% and the national average of 88%.

  • 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 had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

  • Staff had a good understanding of how to support patients with mental health needs and dementia.

  • The practice had good links with the memory assessment service and referred patients when appropriate.

  • A mental health liaison practitioner ran a weekly clinic from the practice.

People whose circumstances may make them vulnerable

Good

Updated 24 November 2016

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

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

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

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.

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

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

  • The practice had a named receptionist who was trained to offer help and signpost support for carers.

  • The practice offered food bank vouchers to patients and staff were trained to consider when patients may be in need of these.