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Inspection Summary


Overall summary & rating

Good

Updated 3 October 2018

This practice is rated as Good overall.

(A previous inspection undertaken on 9 November 2017 had rated the practice as requires improvement overall.)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Primrose Surgery on 9 November 2017. The overall rating for the practice at that time was requires improvement. The full comprehensive report on the November 2017 inspection can be found by selecting the ‘all reports’ link for Primrose Surgery on our website at

www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 23 August 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breach of regulations, that we identified in our previous inspection on 9 November 2017. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

At this inspection we found:

  • The practice had addressed all issues and areas of concern, which had been identified at the previous inspection.
  • There was evidence of good management and clinical leadership, which was supported by organised systems and processes.
  • There were noteworthy improvements in the reporting, recording and discussion of significant events. We saw evidence of learning from events and that action was taken to prevent the same thing happening again.
  • There was a clear process for dealing with complaints. All complaints to the practice were recorded and reviewed with the staff team.
  • There was regular staff engagement, through the use of appraisals and mentorship. The practice had introduced task lists for non-clinical staff which enabled leaders to undertake a weekly review of progress and target support for staff when needed.
  • There was evidence of good patient engagement, through the use of the patient participation group, a practice patient survey and engagement with the community.
  • 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.
  • On the day of inspection patients told us they found the appointment system easy to use and were very happy with the care and treatment they received.
  • There was a renewed focus on support, development and continual improvement at all levels of the organisation.

We saw areas of outstanding practice:

  • In response to a significant event in another area, the practice had developed ‘grab cards’ for clinical and non-clinical staff to be used in the event of an emergency. The cards detailed the action that each responding member of staff would take to manage the emergency efficiently. Alongside this; we saw that the emergency equipment was clearly labelled with large numbers which corresponded to charts displayed throughout the practice. This meant that in stressful emergency situations, non-clinical or unfamiliar staff could be directed to collect a piece of emergency equipment, regardless of their knowledge of what that equipment looked like.
  • The practice had introduced a dedicated pain management clinic in response to initiatives to reduce the prescription of pain medications. The consultations focused on enabling self-management of pain using alternatives to medications and also health promotion, using various resources like leaflets, social prescribing and websites.

The areas where the provider should make improvements are:

  • The provider should continue to review and take steps to improve the uptake of cancer screening at the practice, including bowel, breast and cervical screening.
  • The provider should review and improve their arrangements for patients who may wish to see a female GP.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice.

Inspection areas

Safe

Good

Updated 3 October 2018

We rated the practice as good for providing safe services.

At the inspection on 9 November 2017 we rated the practice as requires improvement for providing safe services. Breaches of the regulations of the Health and Social Care Act 2008 were found which included issues with the safe storage of vaccines, the signing of patient group directions, (PGDs), the non-compliance with an EU directive for window blinds and a lack of oversight of the immunisation status of the staff team.

At this inspection on 23 August 2018, we saw that actions had been taken and sustained to resolve those concerns.

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. Staff training had been reviewed and improved and we found that all staff had received up-to-date safeguarding training appropriate to their role. They knew how to identify and report concerns. Reports and learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a 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 had also attended Prevent training and training regarding female genital mutilation awareness, (FGM).
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. Safeguarding meetings were held with health visitors.
  • We reviewed the recruitment records of two new members of staff and found that the practice had carried out the appropriate staff checks and conducted a documented and comprehensive induction with these staff members.
  • There was an effective system to manage infection prevention and control. Actions had been taken in response to issues identified.
  • 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. The practice had conducted a telephone audit and in response to this made arrangements for an additional member of staff to answer the telephones on a morning.
  • There was an effective induction system for temporary staff tailored to their role. We saw that the necessary checks were undertaken prior to their employment with the practice.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures. The practice had developed ‘grab cards’ for clinical and non-clinical staff to be used in the event of an emergency. The cards detailed the action that each responding member of staff would take to manage the emergency efficiently. Alongside this, we saw that the emergency equipment was clearly labelled with large numbers which corresponded to a chart displayed throughout the practice. This meant that in stressful emergency situations, non-clinical or unfamiliar staff could be directed to collect a piece of emergency equipment, regardless of their knowledge of what that equipment was or looked like.
  • The practice had responded to concerns regarding the non-compliance of window blinds with the appropriate EU directive and on the day of inspection we saw that all blinds were compliant.
  • 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 and had undertaken additional training in this area.
  • 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. There was a documented approach to managing test results.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. Regular meetings with the multidisciplinary team were held and documented.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

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

  • The systems for managing and storing medicines, medical gases, emergency medicines and equipment, minimised risks. The practice had reviewed and improved their management of vaccines and we saw that this met best practice guidance.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. Following our last inspection, all patient group directions (PGDs) had been reviewed by clinicians. We saw that medicines were now administered in line with legislation and that PGDs were signed and reviewed as appropriate. (PGDs are written instructions for the supply or administration of medicines to groups of patients who may not be individually identified before presentation for treatment.)
  • The clinical team had reviewed its antibiotic prescribing and acted to support good antimicrobial stewardship in line with local and national guidance. Antibiotic prescribing at the practice was comparable to local and national averages. For some specific items, the practice prescribed less than other areas within the CCG and nationally which was positive.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.

Track record on safety

The practice had a good track record on safety.

  • There were risk assessments in place in relation to safety issues.
  • The practice monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture of safety that led to safety improvements.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. We were told that leaders and managers supported them when they did so.
  • Following our last inspection, there was a newly implemented system for the recording, reviewing and investigating of significant events. Significant events were discussed at staff meetings and all staff were aware of these. The form which had been implemented to record the event included a review of why the incident happened, changes that were made, how the incident was resolved and what had been learned. All incidents included a review date and then were closed when the issue had been resolved.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 3 October 2018

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

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 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, including their physical and mental wellbeing, were fully assessed by clinicians. Care and treatment was delivered in line with current legislation, standards and guidance, supported by clinical pathways and protocols. There was no evidence of discrimination when clinicians made care and treatment decisions.
  • Practice staff were aware of social prescribing, and signposted patients to other avenues of support as appropriate or if their condition deteriorated. An advisor was available at the practice for one session per week.

Older people:

  • The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • The practice worked with the community matrons to reduce referrals and admissions to hospital. For patients that were admitted and discharged from hospital it ensured that their care plans and prescriptions were reviewed and updated to reflect any extra or changed 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.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma. Patients were involved in the writing of asthma management plans to use at home and assist them to manage their condition.
  • The practice participated in a CCG initiative called ‘Bradford Breathing Better’ where, following a clinical review, patients were pro-actively supplied with a ‘rescue pack’ containing steroids and antibiotics to use as the care plan directed.
  • 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). Patients could use a hand-held device to assess their risk of atrial fibrillation.
  • The results of the 2018 GP patient survey showed, 72% of patients said they had enough support to manage their long-term condition within the last 12 months. (CCG average 70%, national average 79%.)

Families, children and young people:

  • Childhood immunisation uptake rates for all ages were at 94% which was in line with the target percentage of 90% or above.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation. The practice had proactively reviewed and continued to invite children, young adults and other family members for their MMR vaccination due to an ongoing increase in the number of measles cases in the city.
  • Concerns regarding children and families were discussed with the health visitor and midwives at meetings. 74% of patients registered at the practice were aged under 40 years old.

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

  • The practice’s uptake for cervical screening in 2016/2017 was 65.8%. This was better than the CCG average of 61.3% but lower than the national average of 72.1%. Uptake of screening was reviewed monthly and patients who had not attended were sent further invitations on pink paper. Unverified data from 2017/18 showed that the practice’s uptake for cervical screening had increased to 69%. However, this remained below the 80% coverage target for the national screening programme

  • The practice’s uptake for breast and bowel cancer screening was below the national average. Letters and information was sent to patients who did not respond to national invitations for bowel screening.

  • The practice had encouraged patients to register for on-line services. 33% of patients had registered and were able to book appointments and order their prescriptions electronically.
  • 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 NHS checks for patients aged 40 to 74. 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 took into account the needs of those 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. Staff were reminded that patients could register without documentation, in line with learning which occurred as a result of a significant event.
  • The practice offered and encouraged annual health checks to patients with a learning disability and had completed 38 out of 39 checks, with one person declining to attend.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule. The practice was also proactively offering flu vaccinations to patients who were obese.

People experiencing poor mental health (including people with dementia):

  • The practice routinely 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, 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. For patients who did not collect their prescriptions, this was reviewed by the pharmacist and a GP if appropriate, patients contacted if necessary, and outcomes documented on patient notes.
  • The results of the 2018 GP patient survey showed, 86% of patients felt the healthcare professional recognised or understood any mental health needs during their last general practice appointment. (CCG average 81%, national average 87%.)
  • 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.
  • Patients at risk of dementia were being proactively screened to increase prevalence and detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.

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. Where appropriate, clinicians took part in local and national improvement initiatives.

  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives. These included initiatives which were relevant to the practice population. For example; Bradford Beating Diabetes. An initiative aimed at comprehensive review of Diabetic patients.

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 attended specific training sessions or completed the relevant online sessions. Staff could demonstrate how they stayed up to date.
  • The practice understood the learning needs of staff and staff had been given clear timescales to complete their mandatory training requirements, the practice manager had effective oversight of this system and an up to date training matrix was in place. Additional training was also taking place.
  • Practice protected learning time was available to all staff and recent and ongoing appraisals included development plans for staff. Staff told us they were encouraged and given opportunities to develop.
  • The HCA at the practice had been supported to develop a wide range of skills relevant to the practice population and was being supported to work towards nurse training. In recognition of her work and skills she had received a certificate for being a finalist at the HCA Healthcare practice of the year awards.
  • The practice provided staff with ongoing support. Newly appointed staff told us that their induction had been thorough and they felt very supported by individuals and the team. Additional support for staff 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 and meeting minutes 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 including the community matron when discussing care delivery for people with long-term conditions and older people who were supported in their own homes.
  • They shared information with, and liaised with, community services, pharmacists, social services and carers for housebound patients and with health visitors and community services for children who had 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.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may need 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.
  • The practice held a number of patient engagement events to encourage individuals to manage their own health and conditions. Staff had also attended local Brownie and Scout groups, held presentations and engaged the young people in self-care activities. The staff member had also presented a workshop on how to assist in emergency situations.
  • Self-care posters made by the Brownies had been displayed in the waiting area.
  • Staff discussed changes to care or treatment with patients and their carers as necessary. The practice had significantly increased the number of people identified as carers in 2018.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity. A bi-lingual smoking cessation worker was available at the practice.
  • The practice was proactively identifying and offering flu vaccinations to patients who were obese or a carer.

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.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice complied with the Data Protection Act 1998. They showed us how they were meeting requirements in line with the new General Data Protection Regulator (GDPR) regulations.

Please refer to the evidence tables for further information.

Caring

Good

Updated 3 October 2018

We rated the practice as good for caring.

At the inspection on 9 November 2017 we rated the practice as requires improvement for providing a caring service. Feedback from patients regarding the services provided showed that patients did not always feel they were treated with compassion, dignity or kindness.

At this inspection on 23 August 2018 patients told us they were treated with dignity and respect.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients we spoke with on the day of inspection, patient comment cards and a recent patient survey 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 practices 2018 GP patient survey results were in line or slightly above local averages and comparable to national averages for questions relating to kindness, respect and compassion. For example; 85% of patients said the last time they had a general practice appointment the health professional was good at treating them with care and concern, (CCG average 79%, national average 87%).

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.
  • One member of staff was able to use British sign language to communicate with deaf patients. Several members of staff were able to speak a range of languages relevant to the patient population.
  • 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 proactively identified carers and supported them. Feedback from the carers support worker regarding the practice and their engagement with carers, was positive.
  • The GP patient survey data, 2018, showed that 87% of patients said that they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment. (CCG average 87%, national average 93%). From the March 2018 Primrose Surgery Patient survey, data showed that from 150 responses, 89% of patients said after seeing their GP they understood their health problem ‘very well’.

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. The practice had reviewed the layout of the waiting area to increase privacy for patients talking at the reception desk.
  • 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 3 October 2018

We rated the practice, and all the population groups, as good for providing responsive services.

At the inspection on 9 November 2017 we rated the practice as requires improvement for providing responsive services. Feedback from patients regarding access to the service was poor and there was a lack of response to this from the provider. We also found that the provider did not handle or learn from complaints appropriately.

At this inspection we found:

The practice was providing responsive services. The practice had undertaken a patient survey and reviewed the access to and demand for services. Feedback from patients was positive.

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. The practice had audited the demand for appointments and their capacity to meet this. In response to these audits, an additional member of staff had been employed to work on a morning to answer the busy telephones and patient’s queries.
  • The 2018 GP patient survey showed that 92% of patients felt their needs were met during their last general practice appointment. (CCG average 90%, national average 95%.)
  • Telephone GP and pharmacist consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The provider had made positive changes to the environment to improve safety and to systems; for example, medication storage and administration which met patient needs. This responsive approach helped to ensure that services were delivered in a safe manner.
  • The practice made reasonable adjustments when patients found it hard to access services. Longer appointments for patients were offered when appropriate.
  • The practice provided effective care coordination for patients who were more vulnerable or who had 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:

  • Only 2% of the practice population were aged over 75. These patients were invited for an annual health check.
  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GP and practice nurse also accommodated home visits for those who had difficulties getting to the practice due to poor mobility.
  • The practice worked with the local pharmacy to offer a medicines delivery service for housebound patients. Patients were also supported by a CCG commissioned pharmacy service which enabled older people to have their medication reviews carried out in their own home.

People with long-term conditions:

  • Care was coordinated with other health care professionals, such as district nurses, to support patients who were housebound or who had complex medical issues. Multidisciplinary meetings were held to discuss and support these patients.
  • 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.

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. Attendances were reviewed by the GPs and any concerns discussed with the multidisciplinary team.
  • All parents or guardians calling with concerns about a child under the age of 5 years old were offered a same day appointment when necessary or a telephone appointment. The practice had identified a large demand for appointments due to minor ailments in young children. Additional appointments had been made available with the advanced nurse practitioner (ANP).

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.
  • Telephone consultation appointments were available. Extended access appointments were available seven days per week.
  • The clinical pharmacist held a minor illness clinic for adults.

People whose circumstances make them vulnerable:

  • The practice had introduced a dedicated pain management clinic in response to initiatives to reduce the prescription of pain medications. The consultations focused on enabling self-management of pain using alternatives to medications and also health promotion, using various resources like leaflets, social prescribing and websites.
  • The practice had liaised closely with the local carers voluntary service and had identified an additional 48 patients as carers since January 2018. They had specific packs for carers which included information for young carers and the practice manager had attended an event regarding this issue. Carers events were held at the practice.
  • The practice had identified 1.2% of patients with a learning disability compared to the 0.8% CCG and 0.5% national average.
  • The lead GP described a special interest in learning disability patients and working alongside the HCA had completed 38 learning disability health checks from a total of 39 patients registered with this condition in 2017/2018. The last person had declined their health check. Patients with learning disabilities were also offered annual flu vaccinations.
  • Patients who did not have English as their first language could be orientated to a clinician’s room by colour coded plaques.
  • In addition; a small group of identified patients were able to request their repeat medication by telephone.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.

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 had recently introduced a protocol to encourage clinicians to try and increase the prevalence of dementia.
  • The practice held GP led mental health and dementia consultations to meet the needs of individual patients. Annual physical health reviews and medication reviews were offered. Clinicians would liaise with social services, health professionals, home care services and relatives as necessary.
  • Dossette box prescriptions were available for those who needed them.

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.
  • The practice offered Electrocardiograms (ECGs) to those patients for which it was clinically necessary. (This is a simple test that can be used to check the heart's rhythm and electrical activity). ECGs were undertaken and interpreted at the practice. Those which were urgent were carried out the same day. From 46 non-urgent ECGs carried out between April and July 2018 we saw that on average patients waited only three working days for the test. This service also reduced the need for patients to travel to the local hospital.
  • Waiting times, delays and cancellations were minimal and managed appropriately. The 2018 GP patient survey results showed that 72% of patients waited 15 minutes or less after their appointment time to be seen at their last general practice appointment. (CCG average 65%, national average 69%.) We saw that when a patient complained regarding the waiting time to see a specific clinician; that practice had responded and taken action.
  • Patients with the most urgent needs had their care and treatment prioritised. This include children under five years of age, a number of patients who were identified as vulnerable and the elderly. These patients were offered same day appointments or telephone consultations as appropriate.
  • On the day of inspection patients, we spoke with, and patient comment cards, reflected that the appointment system was easy to use. Data from the 2018 GP patient survey, showed that 60% of patients described their experience of making an appointment as good, (CCG average 58% and national average 69%).
  • During our inspection, a review of the clinical system showed that ‘on the day’ appointments were available.

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.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The practice had an identified complaint lead and had begun to capture verbal complaints.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care. Issues and outcomes were communicated to the staff team and the patient participation group.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 3 October 2018

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

At the inspection on 9 November 2017 we rated the practice as requires improvement for providing a well-led service. Breaches of the regulations of the Health and Social Care Act 2008 were found. Issues included a lack of staff training, significant events were not managed appropriately and policies and procedures were not updated as necessary or available to all staff. Meetings were held infrequently and information was not cascaded to the staff team.

At this inspection we found that the provider had reviewed these issues and improved the systems and processes required to ensure good governance of the 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 at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership. A GP partner was available each day of the week to ensure continuity of care and leadership. Staff we spoke with on the day of inspection described a supportive team environment.
  • 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.

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were committed to and understood the vision, values and strategy and their role in achieving them.
  • 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 and undertook weekly and monthly audits of activity to enable them to direct support where it was required and maintain oversight of patient outcomes, for example; the national cancer screening programme.

Culture

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

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice. There were positive relationships between staff and managers.
  • 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 practice had improved their response to and management of significant events 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 were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were improved processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular, documented annual appraisals in the last year and these included development plans.
  • The practice had introduced task lists for non-clinical staff which enabled leaders to undertake a weekly review of progress and target support for staff when needed.
  • Staff were supported to meet the requirements of professional revalidation where necessary. Clinical Staff attended peer support sessions outside of the practice and relevant training as necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • 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. The practice had reviewed the training and learning needs of the staff team and we saw that an up to date staff training matrix was in place.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended. These were up to date, relevant and available to all the staff team.

Managing risks, issues and performance

The practice had reviewed their approach to managing risks, issues and performance. There were clear and effective processes in place.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety. Managers at the practice were able to evidence the documentation required and had oversight of this.
  • The practice had processes to manage current and future performance. Practice leaders had an improved 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. We saw that all staff had completed fire training and the practice had identified and trained two fire wardens.
  • 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 and discussed with the PPG.
  • 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. For example, to improve the uptake of cancer screening.
  • 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 robust 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).
  • A patient survey had been undertaken from which an action plan was implemented. This was reviewed and discussed with the PPG. The practice had formulated an interim response to the August 2018 GP patient survey.
  • We saw a programme of regular meetings that was taking place.
  • 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.
  • Staff knew about improvement methods and had the skills to use them.
  • 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.

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

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