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Archived: Acton Lane Surgery Good

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Inspection Summary


Overall summary & rating

Good

Updated 17 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Acton Lane Surgery on 9 June 2016. Overall the practice is rated as good.

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

  • Some risks to patients were assessed and well managed, with the exception of those relating to Legionella infection, gaps in fire safety awareness training and fire evacuation drills. The provider addressed these issues shortly after our inspection.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Patients said they were treated with compassion, dignity and respect and the majority of patients felt the nurses involved them in their care and decisions about their treatment.
  • The practice proactively sought feedback from staff and patients. However, action taken to improve on some areas of the service that had been rated as below local or national averages by patients were not clearly outlined.
  • 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.
  • There was a walk-in clinic every morning and urgent appointments were available the same day.
  • 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 had not documented actions taken in response to patient feedback, and a risk assessment and infection control audit had not been dated to indicate when they were undertaken.
  • The provider was aware of and complied with the requirements of the duty of candour.

There are areas where the provider should make improvements:

  • Document clearly actions and processes pertaining to the running of the service are clearly documented, such as for risk assessments and infection control audits conducted, and actions taken in response to feedback from patients about the service.

  • Implement effective systems to monitor and improve the quality of the services where improvements are identified as required. Specifically, improve patient engagement and monitoring in relation to areas of high exception reporting.

  • Raise non-clinical staff awareness of the relevant consent and decision-making requirements of the Mental Capacity Act.

  • Maintain on-going training in order to protect patients from any associated risks to their health and welfare caused by insufficient training.

  • Consider displaying the mission statement so it is visible within the practice.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 17 March 2017

The practice is rated as good for providing safe services.

  • Risks to patients were assessed and well managed with the exception of those relating to Legionella infection, fire safety training and performing fire evacuation drills. The provider addressed these issues shortly after our inspection.

  • There were systems, processes and practices in place to keep patients safe and safeguarded from abuse.

  • 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.

Effective

Good

Updated 17 March 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) for 2014/2015 showed the practice achieved 87% of the QOF points available, which was below the national average of 95%. Exception reporting was high in some health indicators. Low outcomes were mainly related to performance around patients with long-term conditions. The practice was proactive in taking steps to improve outcomes in some areas.

  • Clinical audits demonstrated quality improvement.

  • There were gaps in staff training for fire safety awareness. The provider addressed this after our inspection.

  • Staff assessed needs and delivered care in line with current evidence based guidance. However, we found that non-clinical staff did not demonstrate an awareness of the relevant consent and decision-making requirements of the Mental Capacity Act.

  • 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 17 March 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed the practice was comparable to others for several aspects of care. The practice was proactive in gathering patient feedback; however, steps taken to improve patient satisfaction had not been clearly outlined.

  • Patients said they were treated with compassion, dignity and respect.

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

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

Responsive

Good

Updated 17 March 2017

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 (CCG) to secure improvements to services where these were identified. For example, the practice used the Whole Systems Integrated Care (WSIC) care pathway set up by the CCG to ensure patients with complex long term conditions and at risk of A&E admissions were kept under regular review. These patients had a social care coordinator, implemented care plans, longer appointments and access to the multi- disciplinary team.

  • The practice offered a walk in clinic every morning until 11.00am. There was a token system in place to ensure every patient who attended the walk in clinic was handed a colour coded token for the GP they wanted to see. As a result, patients said they found it easy to make an appointment with a named GP and there was continuity of care.

  • 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 17 March 2017

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

  • The practice had a number of policies and procedures to govern activity.

  • There was an overarching governance framework which supported the delivery of good quality care however, some arrangements to monitor and improve quality (in relation to some areas of clinical performance) and identify risk (in relation to Legionella infection, fire drills and fire safety training) were not effective. The provider addressed these issues after the inspection.

  • The provider had not displayed their was no mission statement displayed in the practice; however, staff shared a strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about their responsibilities in relation to this strategy.

  • The practice held regular governance meetings and there was a clear leadership structure. Staff felt supported by management.

  • 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 and they also reviewed comments left on the NHS Choices website. However, action taken to improve on satisfaction scores had not been clearly outlined by the practice.

  • The practice's patient participation group was active.

Checks on specific services

Older people

Good

Updated 17 March 2017

The provider 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 including those patients cared for in the residential home.

  • Older patients received an annual face-to-face review where their clinical medical records were updated and. Patients were offered influenza immunisations at these reviews.

  • Nationally reported data showed that the practice achieved high targets for conditions commonly found in older people. For example, data published in 2014/2015 showed the percentage of patients with atrial fibrillation who were being treated with anticoagulation therapy was 100%, above the national average of 98%.

People with long term conditions

Good

Updated 17 March 2017

The provider  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.

  • Nationally reported data showed the practice's targets for the management of patients with diabetes were mostly comparable to local and national averages. For example, the percentage of patients with diabetes on the register, who had a foot examination in the last 12 months was 95%, compared to the Clinical Commissioning Group average of 90% and national average of 88%. Where the practice had failed to achieve national average targets, steps had been taken to improve outcomes for this patient group.

  • The practice was proactive in taking steps to improve outcomes in some areas where clinical performance was below average.

  • Longer appointments and home visits were available when needed.

Families, children and young people

Good

Updated 17 March 2017

The provider  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 those who were at risk, for example, children and young people who had a high number of attendances to Accident & Emergency.

  • 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.

  • Cervical screening rates were comparable to local and national averages. For example, the percentage of women aged 25-64 who had received a cervical screening test in the last 5 years was 80%, compared to the Clinical Commissioning Group average of 78% and national average of 82%.

  • Appointments were available outside of school hours and the premises were suitable for children and babies. Young children were given priority at reception.

  • We saw positive examples of joint working with midwives.

Working age people (including those recently retired and students)

Good

Updated 17 March 2017

The provider  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.

  • Well adult NHS health checks were offered for people aged between 40-74 years of age who had no medical conditions. All new patients received health checks on the same day they registered with the practice.

People whose circumstances may make them vulnerable

Good

Updated 17 March 2017

The provider 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 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.

  • The practice offered the silent sounds service for those hard of hearing or requiring interpreters.

  • 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.

People experiencing poor mental health (including people with dementia)

Good

Updated 17 March 2017

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

  • 98% of patients diagnosed with mental health conditions had their alcohol consumption recorded in the last 12 months, compared to the national average of 90%.

  • Patients were screened for dementia as well as for alcohol and drug abuse when they registered with the practice.

  • 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 and those with memory problems were referred to the memory clinic.

  • 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 & 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. Patients with mental health problems unable to attend the surgery were offered home visits to ensure ease of access to healthcare.