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Hannage Brook Medical Centre Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 7 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Hannage Brook Medical Centre on 16 November 2016. Overall the practice is rated as outstanding.

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

  • There was an open and transparent approach to safety and a system in place for managing significant events. Opportunities to learn from internal and external safety events were maximised and used to drive improvement.
  • The practice had clearly defined and embedded systems to keep patients safe and safeguarded from abuse.
  • Risk management was comprehensive, well embedded and recognised as the responsibility of all staff.
  • Staff were aware of current evidence based guidance and clinical audits demonstrated quality improvement.
  • The practice took a holistic approach to assessing, planning and delivering care and treatment to meet patient’s needs. Staff worked collaboratively to understand and meet the range and complexity of people’s needs.

  • The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high-quality care.

  • We observed a strong patient-centred culture and feedback from patients about their care was consistently positive. Patients said they were treated with compassion, dignity and respect and were involved in their care and decisions about their treatment.

  • The national GP patient survey results showed patients rated the practice higher than others for all aspects of care including interactions with staff and access to the service.
  • Patients found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice worked closely with other organisations and with the local community in planning and delivering services that met patients’ needs.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • There was a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

We saw several areas of outstanding practice including:

The whole team was engaged in reviewing and improving safety and safeguarding systems. Learning was shared widely with other health and social care professionals. For example:

  • Following an unexpected death, one of the GP partners had facilitated a clinical commissioning group (CCG) event which was attended by a wide range of professionals including GPs, school nursing staff and social care workers from the multi-agency team. The event was attended by 86 people and focused on strengthening the arrangements in place for working with young people using drugs, and clinicians being aware of the safeguarding thresholds and early referral pathways. The GP had also facilitated a question and answer session on drug misuse on two occasions at a local secondary school to promote awareness of the risks and services available for the young people to access. The sessions were delivered to year 11 and 12 students with 25 pupils in each group.

  • The practice was consistent in supporting people to live healthier lives through a targeted and proactive approach to health promotion and prevention of ill-health; with support from the patient participation group (PPG). For example, the practice had supported patients in setting up self-help groups for people with a diagnosis of atrial fibrillation and diabetes with patient education being a focus area at the regular meetings. The PPG has also been running an informal self-help group [Wirksworth in support of health (WISH)] for people experiencing poor mental health including depression and anxiety since October 2015. Benefits to patient care included emotional support, reduced isolation and befriending. In addition, the Quality Outcomes Framework data for atrial fibrillation, diabetes, mental health and depression were above local and national averages indicating positive clinical outcomes were also achieved for patients.

  • The practice and PPG had organised a men’s health event as part of a health promotion campaign. About 120 people attended the event which was held at the local cricket club. The practice had audited the number of appointments requested by men prior to and after the event. The results showed the number of appointments had increased by 2.5% and some men had booked appointments specifically to discuss health issues such as erectile dysfunction.

  • Benchmarking data showed the practice’s rate for emergency admissions and accident and emergency (A&E) attendances were significantly below the local and national averages. Contributory factors included good access to clinicians, effective systems in place for care planning and a strong emphasis on multi-disciplinary working to improve patient outcomes. In addition, the national GP patient survey results showed the practice performed above local and national averages in all areas relating to accessing the service and availability of GP appointments. For example, 86% of patients described their experience of making an appointment as good compared with the CCG average of 72% and the national average of 73%. Patient feedback was also overwhelmingly positive about the ease of making an appointment at a time that was convenient for them.

The areas where the provider should make improvement are:

  • Consider ways to increase the uptake rate of the meningitis C and pneumococcal conjugate vaccine (PCV) booster in children aged two years and under.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Outstanding

Updated 7 April 2017

The practice is rated asoutstanding for providing safe services.

  • The practice had an open culture in which all safety concerns raised by staff and patients were highly valued as integral to learning and improvement. A systematic approach was in place for reporting, recording and acting upon significant events.

  • Significant events were discussed with all staff and more widely with the multi-disciplinary team to drive improvement to patient care. For example, following an unexpected death one of the GP partners had facilitated a clinical commissioning group (CCG) event which focused on strengthening the arrangements in place for working with young people using drugs, and clinicians being aware of the safeguarding thresholds and early referral pathways.

  • There were comprehensive systems in place to safeguard children and adults from abuse and / or deteriorating health. A multi-agency approach was taken to protecting these patients to ensure the delivery of safe care and treatment.

  • There were systems in place to ensure the safe management of medicines and prescriptions kept on site. The practice took appropriate action in response to medicine related alerts to ensure patients were kept safe.

  • Risk management was recognised as the responsibility of all staff.

  • The practice had suitable recruitment procedures in place and staffing levels were sufficient to meet patients’ needs.

  • A team approach was taken to managing medical emergencies. This included use of a simulated training exercise with input from an emergency medicine consultant and some members of the patient participation group. The practice had shared the benefits of the training exercise at the Royal College of General Practitioners (RCGP) national conference.

Effective

Outstanding

Updated 7 April 2017

The practice is rated as outstanding for providing effective services.

  • Staff assessed patient’s needs and delivered care in line with current evidence based guidance. The practice designed bespoke clinical templates for specific long term conditions which incorporated best practice guidance and better reflected the practice’s way of working.

  • The practice used best practice guidelines to positively influence practice and improve outcomes for patients. For example, improvements were made in respect of detection, care and treatment of patients with atrial fibrillation. The learning from this project was shared widely with other local GP practices.

  • The 2015/16 Quality and Outcomes Framework showed patient outcomes were consistently better when compared with other services. The practice had achieved 99.9% of the total number of points available compared to a local average of 97.2% and national average of 95.3%. The exception reporting rate was 9.5% compared to a local average of 11.7% and the national average of 9.8%.

  • A regular programme of clinical audit demonstrated quality improvements.

  • Staff were supported to deliver effective care and treatment through supervision, appraisal, training and sharing of best practice.

  • A multi-disciplinary approach was taken to ensure patients with complex needs, including those receiving end of life care were supported to receive coordinated care. Feedback from professionals attending the monthly meetings was very positive about the level of engagement and outcomes achieved for patients.

  • Staff were consistent and proactive in supporting people to live healthier lives, with support from the patient participation group (PPG). This included facilitating a wide range of community health events and self-help groups for patients diagnosed with atrial fibrillation and diabetes.

Caring

Outstanding

Updated 7 April 2017

The practice is rated as outstanding for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for all aspects of care. For example, 91% of patients said the last GP they spoke to was good at treating them with care and concern compared to the local average of 86% and the national average of 85%.

  • Feedback from patients about their care and treatment was consistently positive. Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • We observed a strong patient-centred culture and found many positive examples to demonstrate how patient’s choices and preferences were valued and acted on by staff.

  • Views of external stakeholders were very positive and aligned with our findings.

  • Staff were fully committed to working in partnership with patients and delivering person centred care that was tailored to their needs. This included developing personalised care plans with patient input and patients with dementia being encouraged to complete “This is Me” form. The form requires the individual (with carer support if needed) to include information on family and cultural background, routines, preferences and significant events for example.

  • The patient participation group (PPG) and staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. For example, the PPG facilitated a self-help group for people experiencing poor mental health including depression and anxiety; and the practice had facilitated a community event to raise awareness of the practicalities of end of life care.

Responsive

Outstanding

Updated 7 April 2017

The practice is rated as outstanding for providing responsive services.

  • The practice offered a wide range of services that meet the needs of its population. For example, patients had access to a minor injury service and a number of clinics for long term conditions such as asthma and diabetes.
  • GPs that were skilled in specialist areas used their expertise to offer additional services to patients and acted as a resource for the team. For example, one GP with a special interest in ophthalmology assessed a range of eye conditions using a slit lamp which ensured care was delivered closer to home.
  • The practice hosted a wider range of services that enabled their patients to access care closer to home and prevented patients been referred to secondary care. This included physiotherapy, podiatry, audiology and a substance misuse service.
  • Patients found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • National GP patient survey results showed access to the service including opening hours and availability of appointments was above local and national averages. For example, 86% of patients described their experience of making an appointment as good compared to the local average of 72% and the national average of 73%.
  • Benchmarking data showed the practice’s rate for emergency admissions and accident and emergency (A&E) attendances were significantly below the national and local averages. Staff told us this was achieved through effective care planning, regular health monitoring and good access to clinicians.
  • 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 the patient participation group.

Well-led

Outstanding

Updated 7 April 2017

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

  • The practice had a clear vision with quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

  • There was a strong reflective and learning culture in the organisation and all staff had been involved in developing the practice’s self-evaluation framework (SEF). The SEF was proactively reviewed and used to inform the development of the practice’s improvement plan (PIP).

  • The practice had a strong leadership team and some of the GP partners held strategic roles within the CCG which enabled them to influence decision making and outcomes for the practice population and the wider community.

  • 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.

  • There was a high level of staff satisfaction and constructive engagement. Staff told us that they felt empowered to make suggestions and recommendations for the practice.

  • The practice gathered feedback from patients and it had a very engaged patient participation group which influenced practice development.

  • There was a strong focus on continuous learning at all levels. As well as being an approved teaching and training practice, the practice had been awarded joint hub status to develop a Training Hub with three local practices.

  • The practice had a strong focus on research and had participated in over 23 projects to date. It had achieved “Research Ready” accreditation from the Royal College of General Practitioners (RCGP).
Checks on specific services

People with long term conditions

Outstanding

Updated 7 April 2017

The practice is rated as outstanding for the care of people with long-term conditions.

  • Nationally reported data showed a 100% achievement was attained for all but one (diabetes) of the long term conditions assessed.

  • Performance for diabetes related indicators was 99.4% which was above the local average of 93% and the national average of 89.9%. This was achieved with an exception reporting rate of 13% which was comparable to the local average of 14% and the national average of 12%.

  • The practice prioritised the self-management of diabetes and atrial fibrillation through patient education. For example, in collaboration with patients, self-help groups were established in 2015; and educational sessions were periodically facilitated by one of the practice nurses and the local diabetes specialist nurses.

  • The practice used innovative and proactive methods to improve patient outcomes. For example, the practice had improved the screening and uptake rate of anti-coagulation therapy for patients with atrial fibrillation. The learning from this work had been shared widely with other GP practices in the locality.

  • Nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.

  • There was an effective system in place to recall patients for a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
  • There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health. The practice also followed up on patients discharged from hospital and ensured that their care plans were updated to reflect any additional needs.

Families, children and young people

Outstanding

Updated 7 April 2017

The practice is rated as outstanding for the care of families, children and young people.

  • The practice had emergency processes for children and young people experiencing acute problems. A flexible appointment system ensured they could be seen on the same day when this was indicated.

  • The practice worked with midwives, health visitors and school nurses to support this population group. For example, in the provision of ante-natal and post-natal care.

  • The premises were suitable for children and young people. Baby changing facilities were available and the practice accommodated young mothers who wished to breastfeed.

  • Feedback received from comment cards completed by parents showed young people were treated in an age-appropriate way and were recognised as individuals.

  • In collaboration with the health visitors, the practice had facilitated an educational event and drop in clinics for families with children aged five years and under.

  • The practice had good links with a local school and offered work experience for some of the students. Discussions were taking place to facilitate a health ambassador project and pupils taking part in this programme could count their involvement towards their Duke of Edinburgh Award.

  • The practice had comprehensive arrangements in place to safeguard this population group from abuse and deteriorating health. For example, the safeguarding lead GP facilitated regular safeguarding meetings with other professionals and systems were in place to follow up children and young people who had a high number of accident and emergency (A&E) attendances.

  • Most of the uptake rates for the vaccines given children were comparable to the CCG and national averages. For example, rates for vaccines given to five year olds from 76.8% to 98.9% compared to a local range of 72.1% to 98% and 81.4% to 95.1%. Lower values were achieved for the meningitis C and pneumococcal conjugate vaccine (PCV) booster vaccine given to children under two years old.

  • The practice undertook reflective learning following significant events when young people had ended their own lives. The learning was shared widely with health and social care professionals in the local area to raise awareness and drive improvement.

Older people

Outstanding

Updated 7 April 2017

The practice is rated as outstanding for the care of older people.

  • Nationally reported data for conditions commonly found in older people were above local and national averages. For example, the overall achievement for performance indicators linked to rheumatoid arthritis, osteoporosis and heart failure was 100%. The overall exception reporting rate for all these conditions were below local and national averages.

  • Multi-disciplinary meetings were held monthly to review frail patients and those at risk of hospital admission to ensure they received coordinated care in their own homes. Care plans for patients with complex needs were regularly updated to reflect their current care needs.

  • The practice identified at an early stage older people who may need palliative care and involved them in planning and making decisions about their care.

  • Older people were provided with health promotional advice and support to  maintain their independence for as long as possible. Influenza and pneumococcal vaccinations were offered to everyone in this population group.

  • Staff were able to recognise the signs of abuse in older people and knew how to escalate any concerns.

  • The practice was responsive to the needs of older people and offered home visits and urgent appointments for those with enhanced needs.

Working age people (including those recently retired and students)

Outstanding

Updated 7 April 2017

The practice is rated as outstanding for the care of working age people (including those recently retired and students).

  • Nationally reported data for health screening programmes and conditions commonly found in the working age population were in line with or above local and national averages. For example:

  • A total of 88% of patients with hypertension had a blood pressure reading measured in the preceding 12 months compared to the local average of 84% and national average of 83%. This was achieved with an exception reporting rate of 4% which was in line with the local and national rates.

  • The practice’s uptake for the cervical screening programme was 81.6%, which was comparable to the CCG average of 83.1% and the national average of 81.5%. Exception reporting was 1.1% which was below the local average of 4.4% and national average of 6.5%.

  • The uptake rates for breast and bowel cancer screening were above local and national averages.

  • Telephone consultations were offered daily in addition to extended hours for both GP and nursing staff appointments (on Monday evenings as well as Tuesday and Friday mornings).

  • The practice was proactive in offering online services which enabled patients to view their summary care record, book GP appointments and request repeat prescriptions. The practice also undertook electronic prescribing so that prescriptions could be sent directly to the pharmacy of the patient’s choice.

  • A text reminder service was used to help reduce non-attendance for appointments and remind patients of health promotion activities.

  • The practice was proactive in promoting patient education in collaboration with other stakeholders. For example, about 120 people had attended a men’s health event held at the local cricket club and the practice noted a 2.5% increase in appointments made by men following this event. Some men had also booked appointments specifically to discuss health issues such as erectile dysfunction.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 7 April 2017

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

  • Staff had a good understanding of how to support patients with mental health needs and worked closely with other professionals who provided support through counselling and psychological therapies.

  • Patients had access to information and guidance in respect of their mental health needs and social issues such as tenancy based support, benefits and debt.

  • The practice had effective systems in place for monitoring repeat prescribing for patients receiving medicines for mental health needs.

  • Patients who had attended accident and emergency due to a mental health crisis were followed up in liaison with the mental health teams.

  • 97% of patients experiencing poor mental health were involved in developing their care plan in preceding 12 months, compared to a local average of 93% and national average of 89%. The exception reporting rate was approximately 8% which was below the local rate of 20% and national rate of 13%.

  • Patients at risk of dementia were identified and offered an assessment. Staff held ongoing conversations with patients diagnosed with dementia as part of their wider treatment and care planning. The practice utilised a form titled “This is Me” to obtain key information about the patient and their preferences to inform the delivery of person centred care.

  • 95% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, compared to a local average of 85% and national average of 84%. This was achieved with an exception reporting rate of approximately 11% which was slightly above the local rate of 8% and the national rate of 7%.

  • The practice considered the emotional and social needs of patients with dementia. Patients were actively signposted to various support groups and organisations, including the local dementia café. The patient participation group (PPG) had created dementia memory boxes which were to be used to stimulate patients’ memories, feelings and conversation.

  • The PPG facilitated a self-help group for patients suffering from anxiety and depression on a weekly basis. The group was has been operating since 2015 and is referred to as the Wirksworth in support of health (WISH).

People whose circumstances may make them vulnerable

Outstanding

Updated 7 April 2017

The practice is rated as outstanding for the care of people whose circumstances may make them vulnerable.

  • The practice regularly worked with other health and social care professionals in the case management of vulnerable patients. For example, a worker from the Derbyshire substance misuse service facilitated a weekly clinic onsite and also participated in safeguarding meetings held at the practice.

  • Patients with palliative care needs were reviewed at a monthly multi-disciplinary team meeting and had supporting care plans in place. Feedback from community based nursing staff was very positive and staff were described as being caring and highly responsive to the needs of these patients.

  • The practice had facilitated an end of life care educational event in April 2016. About 70 people had attended and feedback received was very positive about information shared.

  • A total of 106 carers were registered with the practice and this equated to 1.2% of the patient list. Carers were signposted to the monthly carer’s clinic which was held on site by the Derbyshire carer’s association (DCA).

  • Patients with a learning disability were offered annual health checks and longer appointments when required. The practice was a designated “safe place”. The safe place scheme offers a person with a learning disability somewhere to go if they feel unwell, lost or are being bullied or just feel they need help when they are out and about in the community.

  • Staff were aware of issues related to domestic violence, female genital mutilation and “Prevent” (which aims to safeguard vulnerable people from being radicalised to supporting terrorism or becoming terrorists themselves); and could demonstrate a good understanding of how to safeguard those at risk.

  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.