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Inspection Summary


Overall summary & rating

Good

Updated 26 November 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Clarendon Surgery and Trinity Medical Centre (Branch Surgery) on 24th September 2015. Overall the practice is rated as Good.

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.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. They monitored, evaluated and changed the services they offered to suit the needs of their population, increasing resources at peak times to meet demand. This was most apparent in relation to the telephone appointment system which was monitored on a daily basis, with evidence that patient demand, and not the practice, was managing any changes.
  • The practice recorded, reported and shared significant events and complaints with the Clinical Commissioning Group (CCG), at neighbourhood meetings for peer review, support and continual improvement. They were also aware of the requirement to report necessary information to the Care Quality Commission and provided examples where this had been done.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met people’s needs.
  • 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 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.
  • The practice had a clear vision which had quality and safety as its top priority. A business plan was in place and high standards were promoted and owned by all practice staff with evidence of team working across all roles.
  • The practice became Investors in People (IPP) in March 1997 and has retained this status. The IIP is an accreditation that recognises the work an organisation does in empowering its employees to be at their best.
  • They have been a training and teaching practice for GP Registrars and medical students for over 20 years.
  • The practice aimed to build on its already developing processes such as data gathering and analysis, Plan Do Study Act (PDSA) cycles and tests of change, all of which were aimed at improving the quality of service provision for patients.

We saw several areas of outstanding practice including:

  • The practice had introduced a telephone appointment system which increased and improved the flexibility of access to appointments. The system was evaluated on a daily basis and changed to meet the demands of the patients, increasing resources at peak times. The practice could demonstrate the impact of this system showing telephone access to a GP within the hour on a daily basis. Also evidenced was a reduction in the number of unattended appointments (DNA rates) and reduced use of the GP out of hours service which was reflected in very positive patient survey results.
  • The practice had a very good skill mix which included advanced nurse practitioners (ANPs) and they were able to see a broader range of patients than the practice nurse. There was a preceptorship programme in place to support new ANPs to the practice.
  • The practice could evidence that events of significance led to changes in working practice which increased safety not only in their own environment but also throughout the CCG including other GP practices and major hospitals.
  • The practice was involved in many initiatives, local and national, around improving patient safety in general practice. These included, PRISM (around medicine safety), The Scottish Patient Safety Programme, Making Safety Visible and General Productive Practice which is designed to help the practice to support and build on quality improvements. This meant that the practice were continually reviewing the safety of their environments, their clinical practice and the services they offered to make sure that patients were treated in a safe and effective way at all times.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 26 November 2015

The practice is rated as good for providing safe services. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. The practice used every opportunity to learn from internal and external incidents, to support improvement. They could evidence that events of significance led to changes in working practice which increased safety not only in their own environment but also throughout the Clinical Commissioning Group (CCG) including other GP practices and major hospitals. Risk management was comprehensive, well embedded and recognised as the responsibility of all staff.

Effective

Good

Updated 26 November 2015

The practice is rated as good for providing effective services. Our findings at inspection showed that systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines. We also saw evidence to confirm that these guidelines were positively influencing and improving practice and outcomes for patients. Examples included guidance on investigating suspected cancer which led to an audit which is planned to be repeated. Data showed that the practice was performing highly when compared to neighbouring practices in the Clinical Commissioning Group (CCG) and the practice reviewed this data regularly, making improvements where they could. The practice used innovative and proactive methods, auditing and re-auditing, to improve patient outcomes and it linked with other local providers to share best practice.

Caring

Good

Updated 26 November 2015

The practice is rated as good for providing caring services. Data showed that patients rated the practice higher than others for almost all aspects of care. Feedback from patients about their care and treatment was consistently and strongly positive. We observed a patient-centred culture and a clear vision and strategy by all staff to go beyond clinical outcomes and support patients in a holistic sense. The practice took into account and addressed wider issues such as housing, education and other social issues and health determinants. Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. We found many positive examples to demonstrate how patients’ choices and preferences were valued and acted on. Views of external stakeholders were very positive and aligned with our findings.

Responsive

Outstanding

Updated 26 November 2015

The practice is rated as outstanding for providing responsive services. The practice had initiated positive service improvements for its patients that were over and above its contractual obligations. It acted on suggestions for improvements and changed the way it delivered services in response to feedback from the patient participation group (PPG). The practice reviewed the needs of its local population and engaged with the NHS England Area Team and CCG to secure service improvements where these had been identified.

Most patients told us it was easy to get an appointment with a named GP or a GP of choice, there was continuity of care and every patient was spoken to by a GP within an hour (sometimes sooner) of their call to the practice. Those who needed to be seen could be seen within hours if convenient to them and urgent appointments were always available. 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 the practice responded quickly when issues were raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 26 November 2015

The practice is rated as good for being well-led. There was a clear vision with quality and safety as its top priorities. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. High standards were promoted and owned by all practice staff, and teams worked together across all roles. Governance and performance management arrangements had been proactively reviewed and took account of current models of best practice. The practice carried out proactive succession planning. There was a high level of constructive engagement with staff and a high level of staff satisfaction. The practice gathered feedback from patients using new technology, and it had a very active PPG which influenced practice development.

Checks on specific services

People with long term conditions

Good

Updated 26 November 2015

The practice is rated as good for the care of people with long-term conditions. The practice identified, with the Clinical Commissioning Group (CCG), the priority diseases in the Salford area and participated in locally enhanced services for patients in these categories. This enabled them to provide care in a holistic and preventative way, encouraging and involving patients to manage their own conditions. An additional advanced nurse practitioner was recruited to manage chronic disease clinics where patients with multiple chronic diseases were reviewed during a 45-minute appointment. A dedicated member of the administration team was given a lead role to ensure that call and recall for those patients was kept up to date. One third of the patients with long term conditions had received an annual review at the time of our inspection. Patients at risk of hospital admission were identified as a priority and the practice also participated in the Salford Lung Study. Patients with asthma received a personalised asthma action plan which was regularly reviewed. Self management plans were also provided for patients with cardio obstructive pulmonary disorder (COPD) including rescue packs as appropriate.

Families, children and young people

Outstanding

Updated 26 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 such as children and young people with high attendance at accident and emergency departments. GP safeguarding leads undertook additional training in child sexual exploitation (CSE), female genital mutilation (FGM) and domestic abuse and 50% of all the staff had completed basic domestic abuse training. All reports of domestic abuse and child protection issues were READ coded (READ codes are standard clinical terminology) and the practice maintained in excess of 90% for its childhood immunisation targets which was similar to figures for the CCG. 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 and health visitors and the practice was pro-actively trying to engage school nurses in discussions regarding children over the age of five years to maximise information sharing and safeguarding opportunities.

Older people

Good

Updated 26 November 2015

The practice is rated as good for the care of older people. Nationally reported data showed that outcomes for patients were very good for conditions commonly found in older people. The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example, in dementia and end of life care. It was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs. The practice participated in the integrated care project with Salford Together with the aim to integrate health and social care for older people. They created a new patient questionnaire around sharing information which has proved helpful specifically to elderly patients enabling the practice to liaise with family members and support workers without a wory about breaching confidentiality. A number of leaflets and notices advised the elderly of other services available including support from local charities, volunteer groups and the Mavis Grundy Befriending Service. These were agencies that worked within the community to reduce the number of lonely and vulnerable people across Salford.

Working age people (including those recently retired and students)

Good

Updated 26 November 2015

The practice 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 were identified and the practice continually adjusted the services it offered to ensure they were accessible, flexible and offered continuity of care to all patients. This was evidenced by continual review of services both clinical and non-clinical through audit and re-audit. We saw specific examples where changes were made to ensure that services such as the telephone appointment system, uptake of screening programmes, quality outcomes and the safety of patients was maximised to meet patients’ needs. For example, the number of staff on duty at any particular time was quantified through patient demand, new staff were recruited to enhance services that were underachieving and staff were re-skilled to increase resources. They had collected evidence that people who were working found the system flexible and helpful as they could request a call back to fit in with their working hours, could speak to a GP when they were at work (if this was appropriate) and could pre-arrange with their employers if they needed to be seen before, after or during work following a telephone appointment.

People experiencing poor mental health (including people with dementia)

Good

Updated 26 November 2015

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia). There was a high incidence of depression, mental health issues and distress in the practice population and the practice had made themselves more accessible through the telephone appointment system with everyone able to get an ‘on-the-day’ appointment. They had quantified that improved accessibility encouraged attendance of difficult to reach populations by removing barriers and enabling better access to healthcare. 82% of people experiencing poor mental health (including people with dementia) had received an annual physical health check. The practice pro-actively worked with several multi-disciplinary teams in the case management of people experiencing mental health problems. These teams included mental health counsellors and children’s teams who were available in the building, at short notice, to provide support and advice. The practice participated in the dementia directed enhanced service and all staff had received dementia awareness training to assist with early detection. They had identified, through clinical audit, that mental health conditions masked other serious conditions and those patients were included in their long term conditions programme, ensuring annual holistic review.

People whose circumstances may make them vulnerable

Good

Updated 26 November 2015

The practice is rated as good for the care of people whose circumstances may make them vulnerable. A register of patients living in vulnerable circumstances was held and this included homeless people, travellers and those patients with a learning disability. The practice participated in the Asylum Seekers locally enhanced service, offering screening and support and one of the GPs and the practice manager attended the Refugee Healthcare Conference to increase their knowledge. Alerts were placed on patient records when required, to ensure that all staff were aware of patients in vulnerable circumstances. All staff had received equality and diversity training and staff knew how to recognise signs of abuse in vulnerable adults and children, with 50% of the staff having also completed training in domestic abuse. 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. Longer appointments were available for all patients that required them.