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Inspection Summary


Overall summary & rating

Good

Updated 18 February 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hailey View Surgery on 5 January 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.
  • The practice had developed its own treatment templates to ensure staff assessed patients' needs and delivered care in line with current evidence based guidance.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • 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.
  • The practice had adopted a system of all patients having a usual GP. This provided continuity of care and the GP took responsibility for all correspondence for these patients.
  • Urgent same day appointments were available in addition to telephone consultations and routine appointments which could be booked up to four weeks in advance.
  • 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.

The areas where the provider should make improvements are:

  • Ensure staff receive training in infection control at a level that is appropriate to their role.

  • Review the chaperone policy to include the outcome of the risk assessment regarding non-clinical members of staff performing chaperone duties.

  • Update the health and safety poster with details of the identified health and safety lead so staff know who to refer to.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 18 February 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.

  • There were appropriate recruitment checks undertaken for all staff.

Effective

Good

Updated 18 February 2016

The practice is rated as good for providing effective services.

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

  • The practice had developed its own treatment templates to ensure staff assessed patients’ 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 multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 18 February 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.

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

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

  • The practice had an identified carer’s champion.

Responsive

Good

Updated 18 February 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.

  • Pre-bookable appointments with a usual GP were available up to four weeks in advance 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 18 February 2016

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

  • The practice had a clear vision to deliver high quality care and promote good outcomes for patients.

  • 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 practice 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 practice demonstrated through their significant events and complaints management that they were aware of and complied with the requirements of the Duty of Candour.

  • 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.

Checks on specific services

People with long term conditions

Good

Updated 18 February 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.

  • Performance for diabetes related indicators was better than the CCG and national average. The practice achieved 94% of available points compared to the CCG average of 89% and the national average of 89%.

  • 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

Good

Updated 18 February 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.

  • The practice’s uptake for the cervical screening programme was 88%, which was better than the CCG average of 83% and the national average of 82%.

  • Urgent same day appointments were available for pregnant women and children.

  • 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 and health visitors.

Older people

Good

Updated 18 February 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.

  • The practice carried out weekly visits to a local care home.

  • Annual health checks were available for patients over the age of 75 years.

Working age people (including those recently retired and students)

Good

Updated 18 February 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.

  • Extended hours appointments were available outside of normal work hours.

  • Telephone consultations were available.

  • 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 18 February 2016

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

  • 91% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which was above the national average.
  • Performance for mental health related indicators was better than the CCG and national average. The practice achieved 100% of available points 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.

  • The practice had access to an onsite counsellor and psychotherapist. Discretionary funding was provided for patient in financial need to enable them to attend appointments with the psychotherapist.

  • 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.

People whose circumstances may make them vulnerable

Good

Updated 18 February 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 those with a learning disability.

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

  • 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.

  • There was a lead GP for safeguarding children and vulnerable adults.