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Park View Surgery Requires improvement

Inspection Summary


Overall summary & rating

Requires improvement

Updated 24 July 2018

This practice is rated as requires improvement overall. (Previous rating May 2015 - Good)

The key questions are rated as:

Are services safe? – Requires Improvement

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Requires Improvement

We carried out an announced comprehensive inspection at Park View Surgery on 12 April 2018 as part of our inspection programme.

At this inspection we found:

  • Systems were not robust enough to ensure that when incidents did happen, the practice utilised all learning opportunities and embedded the learning into practice so the risk of recurrence was minimised.
  • 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.
  • Arrangements were not in place to ensure that staff had annual appraisals. Some staff had not completed mandatory training.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • Systems and processes were in place for managing governance in the service. However these were not fully implemented and followed to ensure the delivery of high quality, sustainable care.

The areas where the provider must make improvements as they are in breach of regulations are:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

The areas where the provider should make improvements are:

  • Improve arrangements for the identification of carers in order to offer them support when needed.
  • Review the information available for locums and temporary staff.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice


Inspection areas

Safe

Requires improvement

Updated 24 July 2018

We rated the practice as requires improvement for providing safe services.

The practice was rated as requires improvement for providing safe services because:

  • Safety systems and processes were not always operated effectively.
  • Incidents were not investigated effectively to enable all opportunities for learning and to assure the practice that lessons learned were embedded into practice.

Safety systems and processes

The practice did not have clear systems to keep people safe and safeguarded from abuse.

  • The practice had safeguarding children and safeguarding policies in place. Some staff had received up-to-date safeguarding and safety training appropriate to their role. However eight of the eleven staff had not completed safeguarding adults training and six had not completed safeguarding children training. Staff knew how to identify and report concerns. Reports and learning from safeguarding incidents were not available to staff and the GP was unable to access the safeguarding register. 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 took steps, including working with other agencies, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control.
  • 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 used long term locums and they had access to local policies, procedures and clinical guidelines. However, there was no locum induction pack available for temporary staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • 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. Information on sepsis was available in the waiting area for patients.
  • 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.
  • 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, including vaccines, medical gases, emergency medicines and equipment, minimised risks. We found one medicine in a doctors bag that had expired, this was removed during the inspection.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • 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 comprehensive risk assessments 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 did not always learn and make improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • The systems for reviewing and investigating when things went wrong were not operating effectively. Analysis of incidents was not sufficiently detailed, therefore opportunities for learning and improvement were not utilised.
  • The practice identified and shared some learning but themes were not identified. Also there evidence that changes introduced following incidents had not been effective and embedded into practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts. The practice did not document records of action taken.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 24 July 2018

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

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 were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • All patients over the age of 75 had a named GP who would normally be the GP they usually saw in order to provide continuity of care.
  • Shingles and Pneumococcal vaccinations were offered to eligible patients. Patients over 65 were targeted for flu vaccinations.
  • Practice Nurses did home visits for those patients who were unable to attend the surgery for their vaccinations.
  • The practice had arranged for a Pharmacist from the community services organisation to undertake medication reviews for patients in two care homes. The pharmacist was also going to complete medication reviews for all newly registered patients at the practice that were in care homes and was liaising with the practice manager regarding how to take this forward.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication 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.
  • 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’s performance on quality indicators for long term conditions was in line with local and national averages.

Families, children and young people:

  • Childhood immunisation uptake rates were 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.

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

  • The practice’s uptake for cervical screening was 84%, which was above the 80% coverage target for the national screening programme.
  • The practice’s uptake for breast and bowel cancer screening was above the national average.
  • 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 40-74. 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 those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

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

  • The practice 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.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • The practice offered annual health checks to patients with a learning disability.
  • The practices performance on quality indicators for mental health was above local and national averages.

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.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles. However, we found that staff had not received appraisals a number of staff had not completed mandatory training.

  • 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 received specific training and could demonstrate how they stayed up to date.
  • The practice had an e learning tool for staff to use to complete mandatory and other training modules. However, we found there were gaps in the training completed, for example information governance and infection control. Up to date records of skills, qualifications and training were maintained.
  • The practice provided staff with ongoing support. This included one to one meetings, mentoring, clinical supervision and support for revalidation. No nursing or administration staff had received an appraisal in the last 12 months. There was an induction programme for new staff employed by the practice.
  • 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 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 when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have 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 took into account 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 be in need of 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.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

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. Consent forms did record that risks, benefits and alternatives that been discussed with patients. We discussed this with the GP and practice manager during the inspection.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.

Caring

Good

Updated 24 July 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients 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 GP patient survey results were in line with local and national averages for questions relating to kindness, respect and compassion.

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.
  • 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.
  • The practices GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment.

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.
  • 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 24 July 2018

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

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.
  • Telephone GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who are more vulnerable or who have 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:

This population group was rated good for responsive because:

  • 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.

People with long-term conditions:

  • 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.
  • The practice liaised regularly with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

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.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

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.
  • Online access to make appointments and order prescriptions was available.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

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.
  • Information on mental health and dementia support groups was available in the waiting area.

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.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.
  • The practices GP patient survey results were above the local and national averages for three of the four questions relating to access to care and treatment.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and we saw in the examples we reviewed they had 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. However, we received information prior to the inspection of an issue that had been raised with the practice in 2017 to which the practice manager had responded to in a telephone call. We saw no evidence that this had been logged as a complaint and investigated.
  • 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. Following a complaint all staff had completed customer care training.

Please refer to the evidence tables for further information.

Well-led

Requires improvement

Updated 24 July 2018

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

The practice was rated as requires improvement for well-led because:

  • Governance systems were not being operated effectively.

Leadership capacity and capability

Leaders did not have 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. However, there was limited evidence that they were being addressed.
  • Following the resignation of the senior GP partner at the end of March 2018 the practice told us how it was working to address the leadership capacity and skills, including planning for the future leadership of the practice.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.

Vision and strategy

The practice had a clear vision and strategy to deliver high quality, sustainable care.

  • There was a clear vision and set of values outlined in the mission statement and practice philosophy. The practice discussed its strategy with the inspection team, however at the time of the inspection this had not been documented.
  • Staff were aware of 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.

Culture

The practice had a culture of high-quality sustainable care. However, we found some issues relating to appraisals and training.

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • 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 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 some processes for providing staff with the development they need. However, we found that staff had not had appraisals and there were gaps in mandatory training. Staff were supported to meet the requirements of professional revalidation where 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 not 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, however they were not always effective. Processes to identify learning from significant events, incidents and complaints were not operated effectively.
  • 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. However, we found there gaps in training in these areas.
  • Reports and learning from safeguarding incidents were not available to staff and the GP was unable to access the safeguarding register.
  • Practice leaders had established policies and procedures to ensure safety however there was a lack of assurance that these were operating as intended.

Managing risks, issues and performance

There was a lack of clarity around processes for managing risks, issues and performance.

  • The lead GP and practice manager had identified and understood their current and future risks including risks to patient safety. They had plans in place to manage the risks however at the time of the inspection there was limited evidence that they were being addressed.
  • The practice had processes to manage current and future performance. Practice leaders had 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.
  • 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.
  • Meetings had only recently started to be held in the practice. We found that quality and sustainability were discussed and 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.
  • 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

There was some involvement by the practice of patients, the public, staff and external partners to support high-quality sustainable services.

  • The practice had undertaken a patient survey to seek views on the services delivered and the practice had mechanisms for patients to raise concerns through the complaints process. There was no patient participation group.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was limited evidence of continuous learning and improvement.

Please refer to the evidence tables for further information.

Checks on specific services

Older people

Requires improvement

People with long term conditions

Requires improvement

Families, children and young people

Requires improvement

Working age people (including those recently retired and students)

Requires improvement

People whose circumstances may make them vulnerable

Requires improvement

People experiencing poor mental health (including people with dementia)

Requires improvement