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Inspection Summary


Overall summary & rating

Good

Updated 13 July 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Everest House Surgery on 5 October 2016. The overall rating for the practice was good. However, we identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided safe services. Consequently the practice was rated as requires improvement for providing safe services. The full comprehensive report from the 5 October 2016 inspection can be found by selecting the ‘all reports’ link for Everest House Surgery on our website at www.cqc.org.uk.

After the comprehensive inspection, the practice wrote to us and submitted an action plan outlining the actions they would take to meet legal requirements in relation to;

  • Regulation 12 Health & Social Care Act 2008 (Regulated Activities) Regulations 2014

- safe care and treatment.

The areas identified as requiring improvement during our inspection in October 2016 were as follows:

  • Ensure that patients prescribed higher risk medicines are monitored and reviewed at the required intervals.
  • Ensure that patients in whom Warfarin should be considered are prescribed it, or have the reasons for why they are not receiving it documented.
  • Ensure that at all times sufficient processes are in place and adhered to for the management and review of results received from secondary care services, for example pathology results.

In addition, we told the provider they should:

  • Ensure that all staff employed are supported by receiving appropriate supervision and appraisal and are completing the essential training relevant to their roles, including infection prevention and control and safeguarding training.
  • Ensure that the infection control lead is appropriately trained and that the infection control protocol is fully specific to the practice.
  • Ensure actions taken to resolve the risks identified by the fire and Legionella risk assessments are recorded and fully completed.
  • Implement a formal and coordinated practice wide approach to ensure the practice’s areas of below average Quality and Outcomes Framework (QOF) performance are improved.
  • Continue to support carers in its patient population by providing annual health reviews.

We carried out an announced focused inspection on 21 June 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches of regulation that we identified in our previous inspection on 5 October 2016. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

Our key finding on this focused inspection was that the practice had made improvements since our previous inspection and were now meeting the regulation that had previously been breached.

The practice is now rated as good for providing safe services.

On this inspection we found:

  • A sufficient review and recall process was in place to ensure patients prescribed higher risk medicines were monitored and reviewed at the required intervals.
  • All patients with Atrial Fibrillation were prescribed an anticoagulant medicine or had the reasons they were not receiving it recorded. (Atrial Fibrillation is a heart condition that causes an irregular and often abnormally fast heart rate).
  • A sufficient process was in place and adhered to for the management and review of clinical results received from secondary care services.

Additionally where we previously told the practice they should make improvements our key findings were as follows:

  • Staff had completed infection control and adult and child safeguarding training.
  • The infection control lead was appropriately trained and the infection control protocol was specific to the needs of the practice.
  • Most of the risks identified by the fire and Legionella risk assessments were completed and recorded. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • A programme was in place to ensure all staff received an appraisal on an annual basis and this was on schedule for non-clinical staff. We saw that the 16 applicable non-clinical staff had received fully documented appraisals within the past 12 months. The three non-clinical staff employed for less than a year at the time of our inspection were all scheduled to receive their first annual appraisals between August and October 2017.
  • Through implementing a coordinated practice wide approach, the practice had improved its Quality and Outcomes Framework (QOF) performance. (QOF is a system intended to improve the quality of general practice and reward good practice). Figures provided by the practice showed that as of 31 March 2017 the practice had achieved 100% of the total number of points available. This included achieving 100% of the points available for all of the diabetes related indicators. The practice discussed, monitored and reviewed its QOF performance at monthly clinical meetings.
  • The practice had identified inaccuracies in its carers register (those patients on the practice list identified as carers). This was due to recording anomalies. As a result, the practice had undertaken a considerable piece of work including the review of 1,157 patient records in order to ensure the carers register was accurate and fit for purpose. This work was due to be completed by July 2017. Along with this the practice had prioritised identifying carers with the most needs such as those with one or more (multiple) chronic conditions so that they received a carers’ health check as part of their nurse led review. The senior staff we spoke with told us that by that point they were confident the practice would be in a position to start offering carers’ health reviews on a routine basis.

Following our inspection on 21 June 2017 the areas where the provider should make improvements are:

  • Ensure that the infrequently used outlet at the practice is appropriately flushed on a weekly basis and that this is recorded.
  • Continue to identify and support carers in its patient population.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 13 July 2017

At our comprehensive inspection on 5 October 2016, we identified breaches of legal requirements. Improvements were needed to systems, processes and procedures to ensure the practice provided safe services. During our focused inspection on 21 June 2017 we found the provider had taken action to improve and the practice is rated as good for providing safe services.

  • A sufficient review and recall process was in place to ensure patients prescribed higher risk medicines were monitored and reviewed at the required intervals.
  • All patients with Atrial Fibrillation were prescribed an anticoagulant medicine or had the reasons they were not receiving it recorded. (Atrial Fibrillation is a heart condition that causes an irregular and often abnormally fast heart rate).
  • A sufficient process was in place and adhered to for the management and review of clinical results received from secondary care services.
  • Staff had completed infection control and adult and child safeguarding training.
  • The infection control lead was appropriately trained and the infection control protocol was specific to the needs of the practice.
  • Most of the risks identified by the fire and Legionella risk assessments were completed and recorded. (Legionella is a term for a particular bacterium which can contaminate water systems in buildings). However, we found the requirement to flush the infrequently used outlet at the practice on a weekly basis was not properly completed or recorded.

Effective

Good

Updated 13 July 2017

Caring

Good

Updated 13 July 2017

Responsive

Good

Updated 13 July 2017

Well-led

Good

Updated 13 July 2017

Checks on specific services

People with long term conditions

Good

Updated 26 January 2017

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

  • Patients at risk of hospital admission were identified as a priority.
  • 70% of patients on the asthma register had their care reviewed in the last 12 months. This was similar to the CCG average of 76% and the national average of 75%.
  • Performance for diabetes related indicators was below the CCG and national averages. The practice achieved 83% of the points available compared to the CCG average of 91% and the national average of 89%. The practice was aware of its below average performance and an action plan was in place to improve this.
  • 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 GPs worked with relevant health and care professionals to deliver a multi-disciplinary package of care.

Families, children and young people

Good

Updated 26 January 2017

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 may be at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were slightly higher compared to other practices in the local area 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 77% which was comparable to the 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.
  • There were six week post-natal checks for mothers and their children.
  • A range of contraceptive and family planning services were available.

Older people

Good

Updated 26 January 2017

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.
  • Older people had access to targeted immunisations such as the flu vaccination. The practice had 2,247 patients aged over 65 years. Of those 1,952 (87%) had received the flu vaccination at the practice in the 2015/2016 year.
  • There were six care homes in the practice’s local area. For most of these, the GPs visited as and when required to ensure continuity of care for those patients. For two of the homes for residents with increased needs there was a scheduled GP ward round once each week.

Working age people (including those recently retired and students)

Good

Updated 26 January 2017

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 offered online services such as appointment booking and repeat prescriptions as well as a full range of health promotion and screening that reflects the needs for this age group.
  • There was additional out of working hours access to meet the needs of working age patients. There were 27 hours of extended opening each month (just over six hours each week) at various times on various days depending on the GP available. However, this always included the second Saturday of each month from approximately 9am to midday.

People experiencing poor mental health (including people with dementia)

Good

Updated 26 January 2017

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

  • 75% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months. This was slightly below the CCG average of 85% and national average of 84%.
  • Performance for mental health related indicators was above the CCG and national averages. The practice achieved 100% of the points available compared to the CCG average of 96% and the national average of 93%.
  • The practice regularly worked with multi-disciplinary teams in the case management of people 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.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.
  • An NHS counsellor was based at the practice every Tuesday morning. Patients could access this service to obtain psychological and emotional counselling and advice through referral from the GPs. Patients were referred as required to mental health trust well-being workers based elsewhere.
  • There was a GP lead for mental health and dementia.

People whose circumstances may make them vulnerable

Good

Updated 26 January 2017

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 those with a learning disability. There were 72 patients on the practice’s learning disability register at the time of our inspection. Of those, 30 (42%) had accepted and received a health review in the past 12 months.
  • The practice offered longer appointments for patients with a learning disability and there was a GP lead for these patients.
  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.
  • 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.
  • Additional information was available for patients who were identified as carers and there was a nominated staff lead for these patients.
  • The practice had identified 465 patients on the practice list as carers. This was approximately 3.4% of the practice’s patient list. Although the total number of carers receiving an annual health review was low.