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Inspection Summary


Overall summary & rating

Good

Updated 29 June 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection of Dr Susanne Senhenn on 25 November 2015. Breaches of legal requirements were found during that inspection within the effective domain. After the comprehensive inspection, the practice sent to us an action plan detailing what they would do to meet the legal requirements in relation to the following:

  • Ensure that mandatory training for staff is completed and monitored to ensure that time frames for renewal do not lapse. This included ensuring staff had completed relevant for fire safety, infection control and information governance.

We undertook a focused inspection on 25 May 2016 to check that the provider had followed their action plan and to confirm that they now met legal requirements. The provider was now meeting all requirements and was rated as Good under the effective domain. This report only covers our findings in relation to those requirements.

  • Mandatory training for staff had been completed. The practice had a new training matrix and used calendar reminders for the renewal of staff training. Staff had completed training for fire safety, infection control and information governance.

You can read the report from our last comprehensive inspection, by selecting the 'all reports' link on our website at www.cqc.org.uk

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 28 January 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events.
  • Lessons were learned and communicated widely to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • The practice had embedded systems, processes and practices in place to keep people safe and safeguarded from abuse.
  • Risks to patients were assessed and well managed.
  • The appointment of new staff was supported by appropriate recruitment checks and all of the practice staff had received clearance from the Disclosure and Barring Service (DBS).
  • Procedures for dealing with medical emergencies were robust.
  • Staffing levels were maintained to keep patients safe. Administrative systems were responsive and ensured that incoming correspondence was dealt with in a timely and effective manner.
  • The practice had policies and procedures in place to help with continued running of the service in the event of an emergency.
  • The practice was clean and tidy and there were arrangements in place to ensure appropriate hygiene standards were maintained.

Effective

Good

Updated 29 June 2016

The practice is rated as good for providing effective services.

At our previous inspection on the 25 November 2015, we found that staff had received some training appropriate to their roles. However, further mandatory training was identified as not having been completed in the time frame set out by the practice. This included fire safety, infection control and information governance.

At this inspection, 25 May 2016, we found that all staff had completed the practices mandatory training. Included fire safety, infection control, information governance and equality and diversity. Staff had access to and made use of e-learning training modules and in-house training.

Caring

Good

Updated 28 January 2016

The practice is rated as good for providing caring services.

  • Data showed that patients rated the practice higher than others for several aspects of care.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We also saw that staff treated patients with kindness and respect, and maintained confidentiality.

Responsive

Good

Updated 28 January 2016

The practice is rated as good for providing responsive services.

  • It reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.
  • Patients said they could make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • 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 evidence showed that the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 28 January 2016

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

  • It had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to this.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • There was a high level of constructive engagement with staff and a high level of staff satisfaction.
  • The provider was aware of and complied with the requirements of the Duty of Candour. The principal GP encouraged a culture of openness and honesty.
  • The practice had systems in place for knowing about notifiable safety incidents.
  • The practice proactively sought feedback from staff and patients which it acted on. The patient participation group was active.
Checks on specific services

People with long term conditions

Good

Updated 28 January 2016

The practice is rated as good 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 structured annual review to check that their health and medicines 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.
  • For patients with more complex diabetic needs there was a fortnightly clinic with the Diabetic Specialist Nurse.
  • An associate GP was the local Clinical Commissioning Groups Palliative Care Lead and was proactive in advising care plans and promoting care.
  • The practice used a telehealth programme for chronic obstructive pulmonary disease (COPD) patients. Its use had seen a reduction in surgery visits for these patients.
  • The practice had a number of online review forms for patients including asthma, smoking and alcohol which were screened by the practice nurses and patients could be contacted to make appointments if necessary.

Families, children and young people

Good

Updated 28 January 2016

The practice is rated as good 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 average 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 patients spoken with on the day of the inspection confirmed 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.
  • Midwives linked to the practice ran weekly clinics.
  • A pregnancy care planner was accessible online.
  • Safeguarding policies and procedures were readily available to staff.
  • The practice ensured that children needing emergency appointments would be seen on the day.

Older people

Good

Updated 28 January 2016

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

  • The practice offered proactive, personalised care to meet the needs of the older people in its population.
  • It was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • The practice providing medical services for nursing homes. The GPs conducted regular weekly doctors rounds for the larger homes.
  • Elderly patients with complex care needs and those at risk of hospital admission all had personalised care plans that were shared with local organisations to facilitate the continuity of care.
  • We saw evidence that the practice was working to the Gold Standards Framework for those patients with end of life care needs.
  • 100% of people aged over 50 who have not attained the age of 75 in whom osteoporosis was confirmed, were currently treated with an appropriate bone-sparing agent. This was significantly higher than the CCG and national averages of 74.5 % and 82.8%.

Working age people (including those recently retired and students)

Good

Updated 28 January 2016

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 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 reflects the needs for this age group.
  • The practice offered advice by telephone each day for those patients who had difficulty in attending the practice and there were daily evening emergency appointments available.
  • Patients could book evening appointments until 9:30pm and weekend appointments.
  • Electronic Prescribing was available which enabled patients to order their medicine on line and to collect it from a pharmacy of their choice, which could be closer to their place of work if required.
  • The practice offered NHS health-checks and advice for alcohol, smoking and weight reduction.
  • The practice used a text messaging service, to send patients reminders of appointments and also information on health campaigns being run such as NHS Health Checks and seasonal vaccinations.

People experiencing poor mental health (including people with dementia)

Good

Updated 28 January 2016

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

  • 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 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 where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support people with mental health needs and dementia.
  • The practice invited patients suffering from dementia and their carers for an annual review. Each patient had a comprehensive health check and a care plan agreed.
  • The practice had a number of online review forms for patients including anxiety and depression which were screened by the practice nurses and patients could be contacted to make appointments if necessary.

People whose circumstances may make them vulnerable

Good

Updated 28 January 2016

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

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.

  • 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.
  • There was a learning disability lead at the practice who oversaw the care provided to patients on the learning disability register.
  • It offered longer appointments for people with a learning disability.
  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people.
  • It had told vulnerable patients about how to access various support groups and voluntary organisations.
  • Translation services were available for patients who did not use English as a first language.
  • The practice could accommodate those patients with limited mobility or who used wheelchairs.
  • The practice also provided an auditory loop in the practice and offered text messaging services to those with hearing difficulties.
  • Carers and those patients who had carers, were flagged on the practice computer system and were signposted to the local carers support team.