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Inspection Summary


Overall summary & rating

Good

Updated 4 December 2018

This practice is rated as Good overall. (Previous rating December 2017 Requires Improvement).

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 Wilmslow Road Surgery on 14 November 2018 to follow up on areas we identified as requiring improvement at our previous inspection in December 2017. These included improving uptake of cervical cytology, consulting patients about access to the service and improving the recording and format of clinical audit. All these areas had improved and we noted that improvements made before the December 2017 inspection had been sustained and other areas of development and improvement continued.

At this inspection we found:

  • Patient feedback on the quality of care and treatment they received was positive.
  • The practice had systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice was actively implementing initiatives to improve patient attendance at their long-term health care condition reviews. This included action to improve attendance at cervical cytology.
  • The practice had invited diabetic patients to attend a two-hour group learning event. This had been well attended.
  • 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. A clinical audit plan and audit recording strategy was in place.
  • Staff involved and treated patients with compassion, kindness, dignity and respect. CQC received wholly positive feedback from five patients before the inspection and feedback received on the inspection and from comment cards was consistently complimentary.
  • In response to patient feedback the practice had adapted its appointment system from open access surgeries in a morning to on the day appointments. This had proved to be successful as patient feedback to the practice indicated they preferred this system. GPs preferred this system also as it allowed them to see patients at timely intervals
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Review and improve the system for monitoring uncollected prescriptions.
  • Implement strategies to improve the practice’s handling of personable identifiable data to protect and promote confidentiality.
  • Implement improvements to the existing system to follow up children who do not attend primary care appointments.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Safe

Good

Updated 4 December 2018

We rated the practice as good for providing safe services.

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. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Learning from safeguarding incidents was available to staff. Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (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, 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.

Risks to patients

There were 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.
  • There was an effective induction system for temporary staff tailored to their role. A locum GP information folder was available that provided comprehensive information including relevant contact details.
  • 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.
  • 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.
  • 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 generally 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.
  • Staff prescribed and administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice employed a clinical pharmacist who supported the practice to develop protocols for medicine reviews and prescription authorisations. The pharmacist also supported the practice to monitor and to review the prescribing of antibiotic and anti-psychotics. The practice team confirmed they worked closely with the clinical commissioning group (CCG) medicine optimisation team. The practice acted to support good antimicrobial stewardship in line with local and national guidance.
  • Systems to monitor the collection of prescriptions from the practice required improvement as we noted three prescriptions which were issued more than six months previously had not been collected by the patient. In addition, the systems to record who collected prescriptions issued for controlled drugs required improvement to protect patient identifiable information. The practice team confirmed they intended to take immediate action to address these issues.
  • 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 safety using information from a range of sources.
  • There was evidence that patient safety alerts were reviewed by all clinicians and we saw evidence these were actioned.

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. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons.
  • The practice acted on and learned from external safety events.

Please refer to the evidence tables for further information.

Effective

Good

Updated 4 December 2018

We rated the practice and all 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 deteriorated and where to seek further help and support.

Older people:

  • Older patients who were frail or vulnerable received a full assessment of their physical, mental and social needs. The practice worked with the community based health care support service Practice-Integrated Care Teams (PICT) to assist in supporting vulnerable patients in the community.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Housebound patients benefited from visits from the GPs and practice nurse for reviews and vaccinations.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.
  • The practice encouraged carers to identify themselves so that they could receive additional support.

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. The practice implemented a range of strategies to encourage patients to attend these reviews. They regularly monitored patient attendance and the practice performance in achieving its targets.
  • For patients with the most complex needs, the practice worked with other health and care professionals to deliver a coordinated package of care. For example, the practice had secured the services of a specialist diabetic nurse who held a weekly clinic at the practice to review patients with complex diabetes. The practice also held a two-hour patient education session on diabetes. This was so popular another larger venue had been identified for future education meetings.
  • 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.
  • 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 could demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension.

Families, children and young people:

  • Childhood immunisation uptake rates were in line with the target percentage of 90% or just below that for two indicators. The practice was aware of this and the practice nurse confirmed they spent time trying to encourage parents and carers to immunise their children.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation. However, the systems in place to follow up children who did not attend primary care appointments were not always followed up.
  • Comprehensive children’s safeguarding registers were established, monitored and updated regularly.

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

  • The national screening programme uptake for cervical screening has a coverage target of 80%. The practice’s uptake for cervical screening was 58.7%% which was below the local average of 64.8% and the England average of 72.1%. The practice was proactive in recalling patients for this test, including direct telephone calls and opportunistic screening. Evidence available using a different monitoring indicator for cervical screening showed the practice had made significant improvements in achievement from 2016/17 (68%) when compared to 2017/18 (78.9%).
  • The practice’s uptake for breast screening was comparable with the local average both of which were below 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.
  • In house smoking cessation clinics were offered to working adults at flexible times.
  • 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 considered the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, those with a learning disability and veterans.
  • 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. There was a system for following up patients who failed to attend for administration of long term medication.
  • 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 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 published data available regarding the practice’s performance on quality indicators for patients experiencing poor mental health including dementia was above local and national averages and there were no exceptions recorded. For example, 100% of patients with dementia had received a face to face review in the previous 12 months.

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.

  • Evidence showed that the practice’s performance on quality indicators for long term conditions were improving each year. Exception reporting was also lower than local and national averages. (Exception reporting is the removal of patients from the performance indicator calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects). The results for the year April 2017 to March 2018 demonstrated the practice continued to improve. The practice achieved 97.38% compared with the local average of 97.11%and national average of 97.13. Achievements in previous years were lower than both local and national averages. The practice also maintained a lower rate of clinical exception reporting (2017/18) with 4.8% compared to the CCG 11% and the England average of 10.1%.
  • 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.

  • 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 understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop. Staff told us they felt valued and were supported with opportunities to learn new skills. Staff had personal development plans in place.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This 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 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, 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.
  • 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.
  • The practice team were developing local community links to seek ways of delivering healthcare education to the local population.

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 monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.

Caring

Good

Updated 4 December 2018

We rated the practice as good for providing caring services.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treated people. We spoke with seven patients and the CQC received five calls before the inspection from patients expressing their satisfaction with the care and treatment they received at the practice.
  • Staff understood the personal, cultural, social and religious needs of the local patient demographic. Many staff could speak another language and so were able to support those patients who struggled speaking or reading the English language.
  • The practice gave patients timely support and information.
  • Patient responses in the GP patient survey showed comparable or lower levels of satisfaction for questions relating to kindness, respect and compassion when compared with local and national averages. However, the GP survey was undertaken at a time before the practice had implemented changes.

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 we spoke with had a good understanding and awareness of working with patients to deliver a patient focused service.
  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available as required.
  • 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 had a carer’s champion who encouraged patients to register as carers and signposted them to avenues of support. The practice offered carers an annual health check and flu vaccinations. The patient waiting area contained information and links to carers’ support groups.
  • The practice’s GP patient survey results were lower than local and national averages for questions relating to involvement in decisions about care and treatment. Since May 2018 (and after the GP patient survey) the practice had changed its appointment scheduling and this allowed GPs to have more time with patients instead of rushing to see all the patients that had attended the former open access surgery.

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 4 December 2018

We rated the practice, and all 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 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, including undertaking home visits.
  • 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.
  • The practice promoted continuity of care by trying to ensure patient appointments were with the same clinician.
  • The practice referred patients to the health and wellbeing services where support and signposting to a range of services was available to patients. The social prescribing organisations supported patients with guidance and information about different services available in the community.

Older people:

  • 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 held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • 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 were implemented. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child were offered a same day appointment when necessary.
  • Examples of specific support to children and families was available. For example, the practice located a pharmacist that could supply a specific prescription and they supported a family to overcome language barriers.

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. For example, telephone appointments and later evening appointments were available two evenings each week.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including asylum seekers and 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.
  • The practice provided examples where home visits had been undertaken to patients to assess their capacity. In response to the assessment outcome and with the patient consent, an appropriate support package was provided to assist with their daily living needs.

Timely access to care and treatment

Patients could 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.
  • The GP patient survey results were lower than both local and national averages for questions relating to access to care and treatment. However, since that survey, the practice had reviewed and adapted its appointment schedule to provide on the day appointments. This allowed GPs more time to review patients without the added pressure of a full waiting room of patients requiring attention. A new improved telephone system had been commissioned and was awaiting installation.

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 complaint policy and procedures were in line with recognised guidance. The practice recorded all complaints including verbal ones.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 4 December 2018

We rated the practice, and all 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 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, including undertaking home visits.
  • 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.
  • The practice promoted continuity of care by trying to ensure patient appointments were with the same clinician.
  • The practice referred patients to the health and wellbeing services where support and signposting to a range of services was available to patients. The social prescribing organisations supported patients with guidance and information about different services available in the community.

Older people:

  • 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 held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • 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 were implemented. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child were offered a same day appointment when necessary.
  • Examples of specific support to children and families was available. For example, the practice located a pharmacist that could supply a specific prescription and they supported a family to overcome language barriers.

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. For example, telephone appointments and later evening appointments were available two evenings each week.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including asylum seekers and 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.
  • The practice provided examples where home visits had been undertaken to patients to assess their capacity. In response to the assessment outcome and with the patient consent, an appropriate support package was provided to assist with their daily living needs.

Timely access to care and treatment

Patients could 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.
  • The GP patient survey results were lower than both local and national averages for questions relating to access to care and treatment. However, since that survey, the practice had reviewed and adapted its appointment schedule to provide on the day appointments. This allowed GPs more time to review patients without the added pressure of a full waiting room of patients requiring attention. A new improved telephone system had been commissioned and was awaiting installation.

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 complaint policy and procedures were in line with recognised guidance. The practice recorded all complaints including verbal ones.

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

Older 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