The Eaglescliffe Medical Practice

Updated 19 November 2015

The practice Eaglescliffe Medical Practice is located in a residential area of Eaglescliffe. There are 9181 patients on the practice list and the majority of patients are of white British background. There are a higher proportion of patients under the age of eighteen years and those over 65 years on the patient list compared the practice average across England. The practice is a training practice managed by a principal GP (female), with a further four GP partners (male and female), one salaried GP (female) and one GP registrar. There is one nurse practitioner, a practice nurse, health care assistant, phlebotomist (all female), a practice and assistant manager, reception and administration staff. The practice is open 08.00 to 18.00, the earliest appointment is 08.00 and the latest is 17.20 Monday to Friday with extended hours once a week until 21.00 on an alternate Monday and Thursday evenings. Patients requiring a GP outside of normal working hours are advised to contact the GP out of hour’s service provided by Northern doctors via the NHS 111 service. The practice has a General Medical Service (GMS) contract.

Updated 19 November 2015

We carried out an announced comprehensive inspection on 11 August 2015. Overall the practice is rated as outstanding.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time.

Our key findings across all the areas we inspected were as follows.

Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

• There is a holistic approach to assessing, planning and delivering care and treatment to patients who use the services. The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example the practice joined with a neighbouring practice to improve the care and treatment of patients in older peoples care homes they visited by producing standards of care and with measurable outcomes.
• Staff actively engaged in activities to monitor and improve quality and outcomes. Opportunities to participate in benchmarking, peer review and accreditation are proactively pursued.
• The continuing development of staff skills, competence and knowledge is recognised as integral to ensuring high-quality care.
• Patients said they were treated with compassion, dignity and respect and staff went the extra mile when patients required extra support. Information was provided to help patients understand the care available to them. The practice had produced detailed care plans for patients.
• The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they were meeting the needs of their patients. The practice reviewed the Joint Strategic Needs Analysis (JSNA) and local census information to understand and plan services to meet the needs of their patients.
• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG).
• The systems to manage and share the information that is needed to deliver effective care are coordinated across services and support integrated care for people who use the services.
• The practice had good facilities and was well equipped to treat patients and meet their needs. The building was designed to meet the needs of patients. Information about how to complain was available and easy to understand.
• The practice had a clear vision which had quality and safety as its top priority. A business plan was in place, was monitored and regularly reviewed and discussed with all staff. High standards were promoted and owned by all practice staff with evidence of team working across all roles.
• There was a high level of constructive engagement with staff and a high level of staff satisfaction. Staff are proud of the organisation as a place to work and speak highly of the culture. Staff at all levels are actively encouraged to raise concerns and ideas.
• There is a systematic approach taken to working with other organisations to improve care outcomes, tackle health inequalities and obtain best value.
• The leadership drives continuous improvement and staff are accountable for delivering change. There is a clear practice approach to seeking out and embedding new ways of providing care and treatment.

We saw several areas of outstanding practice including:

• The practice had a very good skill mix which included a nurse practitioner and was able to see a broader range of patients than the practice nurse. There was a preceptorship programme in place to support practice nurses employed in the practice.
• The practice had produced detailed care plans for certain conditions such as those with mental illness, older people and other long term conditions. These plans advised clinicians on what they should be monitoring, questions they should ask patients about their condition and when they should refer patients to a consultant or acute care. We saw data that indicated the number of patients accessing mental health out patient’s services had decreased since the care plan had been put in place.
• The practice used a screening tool to reduce polypharmacy and the prescribing of medicines that may cause side effects in older people. We saw that there was a reduction in admissions of older people to acute services from the previous year.
• The practice, in collaboration with a neighbouring practice developed Clinical Standards for the care delivered in the care homes they visited. The standards set out what care the patient and staff in the homes should expect and how they would monitor their effectiveness.
• The practice developed a range of templates and guidance for staff in the management of patients not included in Quality Outcome Framework (QOF). Examples of these were the care of patients suffering from coeliac disease, splenectomy and those patients taking novel oral anticoagulants. The templates also provide evidence based information on how these patients should be effectively supported.
• The practice provided a dermatoscopy service. Two GPs had undertaken training to deliver this service. The practice continually reviewed and audited the process to improve in house referrals and the photographing of skin lesions as an accurate record into the patients notes.
• The practice had developed a Memorandum of Understanding for mutual aid and this was updated in 2015. The document describes how the design of primary care estate can improve the resilience of GP provision when challenged. This was developed by the practice and seen as best practice and was adopted widely across practices in the North East and other strategic health authorities as part of the pandemic influenza preparedness plan during 2009/10.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Updated 19 November 2015

The practice is rated as outstanding 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. Longer appointments and home visits were available when needed. All these patients had a named GP and a structured annual review to check that their health and medication needs were being met. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care. The practice consequently had low admission and prevalence rates compared with the locality for such conditions such as asthma, chronic heart disease, stroke and diabetes.

Updated 19 November 2015

The practice is rated as outstanding for the care of families, children and young people. There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations. 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. Appointments were available outside of school hours and the premises were suitable for children and babies. We saw good examples of joint working with midwives, health visitors and school nurses. The practice was also working with NHS England, the Royal College of GPs (RCGP) and the sepsis trust to develop a structured approach to the recording of physiological findings and features of sepsis. This will be rolled out nationally in the autumn together with advice to parents on what to look out for.

Updated 19 November 2015

The practice is rated as outstanding for the care of older people. The practice had introduced a number of initiatives to improve the care of older people. They had identified an increasing number of older people and organised care to better meet their needs. The practice had initiated a system to address polypharmacy in older people. The practice also used a tool to calculate Anti-Cholinergic Burden Score for each patient over 75. This alerts clinicians to the use of inappropriate medicines for this age group. The Anticholinergic Cognitive Burden Scale alerts clinicians to medicines that should be avoided which may worsen pre-existing conditions such as dementia. The practice was able to demonstrate that this intervention had led to a reduction in the prescribing of certain medicines and the associated side effects.

The practice provided regular ward round visits to the local care homes as part of a scheme initiated by the CCG. In addition to this, the practice worked with a neighbouring practice to devise a Care Home Quality Standard. Measurable outcomes had been agreed to monitor the effectiveness of the agreed quality standards. For example reviewing the percentage of patients who had had a multi-disciplinary follow up assessment after admission within eight weeks. The document also stated what patients and staff in the care home should expect and promotes the best interests of the patient.

The practice had systematically implemented emergency health care plans, avoiding admission plans and do not attempt resuscitation DNAR to reduce burdensome interventions and unnecessary admission to acute care. We saw the information was evidence based and provided guidance to clinical staff. An example of this was when to refer patients for further investigations. We saw evidence of reduced inappropriate admission to acute care for this patient group. The practice also worked collaboratively with community matrons who managed patients in their own homes.

Updated 19 November 2015

The practice is rated as outstanding 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 reflected the needs for this age group. The practice had recently provided out of area registration for those patients who wished to remain registered with the practice but had moved out of the area.

Updated 19 November 2015

The practice is rated as outstanding for the care of people experiencing poor mental health (including people with dementia). Of the 9181 patients registered with the practice the aim is to provide 550 patients with poor mental health with an individual   care plan developed specific to their needs. The practice has offered this to 178 patients, of which139 have had an individual care plan developed specific to their needs. We saw the practice had developed their own detailed care plans for specific mental health conditions and this included advice, guidance and what help and support was available locally for each condition. We saw that patients were being managed well and there was a marked decrease of patients accessing mental health outpatient services this year. Patients experiencing poor mental health had received an annual physical health check and regular reviews. The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. It carried out advance care planning for patients with dementia. The rates for dementia diagnosis were 88.5% above the national average of 83.8%.

The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. It had a system in place to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health. Staff had received training on how to care for people with mental health needs and dementia.

Updated 19 November 2015

The practice is rated as outstanding 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. It had carried out annual health checks for people with a learning disability and 60% of these patients had accepted the invitation. It offered longer appointments for people with a learning disability. We saw the practice staff had recently undergone training to improve the management of those patients with learning disabilities.

The practice regularly worked with multi-disciplinary teams and the community matron in the case management of vulnerable people. It had told vulnerable patients about how to access various support groups and voluntary organisations. Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.