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Inspection Summary


Overall summary & rating

Good

Updated 17 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Warden Lodge Medical Practice on 4 October 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed. Staff were aware of their responsibilities in helping to safeguard and protect patients.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • This is a training practice with two GPs qualified as trainers.
  • The practice worked closely with multidisciplinary teams, including community and social services to plan and implement care for their patients.
  • The practice held regular staff and clinical meetings where learning was shared from incidents and complaints.
  • The practice were part of the Home First project ensuring that patients could remain at home whilst receiving a multidisciplinary package of care.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice’s computer system alerted GPs if a patient was also a carer. The practice had identified 309 patients as carers, approximately 2.8% of the practice population.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they 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 offered extended hours appointments.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The practice had a well-established patient participation group.
  • There was an ongoing involvement with pilot project in the locality.
  • The provider was aware of and complied with the requirements of the duty of candour.

The one area where the provider should make improvement is:

  • Ensure continued analysis of data and exception reporting processes and continue to monitor patient recall systems.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 17 March 2017

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events.
  • The practice demonstrated that they were proactive in taking action to reduce the risk of recurrence following incidents.
  • Lessons learnt were shared to make sure action was taken to improve safety in the practice.
  • When things went wrong patients received support and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • Risks to patients were assessed and well managed, including those related to fire safety and health and safety.
  • The practice had a comprehensive business continuity plan in place for major incidents such as power failure or building damage. The plan included emergency contact numbers for staff and key contractors. Copies were kept off site by lead staff.
  • Annual infection control audits were undertaken and we saw evidence that action was taken to address any improvements identified as a result.

Effective

Good

Updated 17 March 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average. The most recent published results show the practice achieved 99% of the total number of points available.
  • The percentage of patients with chronic obstructive pulmonary disease (COPD) who had a review undertaken including an assessment of breathlessness in the preceding 12 months was 94% which was comparable to the CCG average of 91% and national average of 90%.
  • The practice’s uptake for the cervical screening programme was 92%, higher than the local CCG average of 83% and the national average of 81%.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • The practice had two GP trainers (one of whom was an associate trainer) with responsibility for mentoring and training the GP registrars (GPs in training).
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
  • The practice had established a training group set up through local practice managers for reception and administration staff. Staff had also undertaken equality and diversity and customer service training.
  • All staff had received and appraisal in the last 12 months.
  • Vulnerable patients and those considered to be at risk were prioritised through a flag on the clinical system.

Caring

Good

Updated 17 March 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey published July 2016 showed patients rated the practice higher than others for several aspects of care.
  • 92% of patients said the GP was good at listening to them compared to the NHS East and North Hertfordshire Clinical Commissioning Group (CCG) average of 88% and the national average of 89%.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. 88% of patients said the last nurse they saw was good at involving them in decisions about their care compared to the local CCG average of 84% and the national average of 85%.

  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
  • 94% of patients said they had confidence and trust in the last GP they saw compared to the CCG average of 92% and the national average of 91%.
  • The practice’s computer system alerted GPs if a patient was also a carer. The practice had identified 309 patients as carers (approximately 2.8% of the practice list).
  • The practice had identified a member of staff who was the Carers Champion who identified new carers and ensured support to existing carers.

Responsive

Good

Updated 17 March 2017

The practice is rated as good for providing responsive services.

  • The practice reviewed the needs of its local population and engaged with the NHS England and NHS East and North Hertfordshire Clinical Commissioning Group (CCG) to secure improvements to services where these were identified. For example, the practice offered a range of enhanced services such as avoiding unplanned admissions to hospital, pre dementia diagnosis and identifying registered patients aged 14 years and over with learning disabilities to offer support and provide them with an annual health check.

  • Patients said they 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 offered extended hours appointments from Monday to Friday mornings from 8am and on alternate Saturday mornings between 8am and 12pm for patients who could not attend during normal opening hours.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Reasonable adjustments were made and action was taken to remove barriers when patients found it hard to use or access services. For example, the practice had systems in place to support people with complex needs to be able to register with the practice for example, asylum seekers, refugees and the homeless.
  • The practice had enrolled in the Electronic Prescribing Service (EPS). This service enabled GPs to send prescriptions electronically to a pharmacy of the patient’s choice.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 17 March 2017

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

  • The practice 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 it.
  • 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 an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.
  • There was a strong focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions

Good

Updated 17 March 2017

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.
  • Performance for diabetes related indicators was comparable to the NHS East and North Hertfordshire CCG (CCG) and national averages. For example, the percentage of patients with diabetes, on the register, in whom the last blood glucose reading showed good control in the preceding 12 months, was 85%, where the CCG average was 76% and the national average was 78%.
  • The percentage of patients with chronic obstructive pulmonary disease (COPD) who had a review undertaken including an assessment of breathlessness in the preceding 12 months was 94% which was comparable to the CCG average of 91% and national average of 90%. However, exception reporting for this indicator was 24% compared to local CCG and national averages of 12%.
  • Longer appointments and home visits were available when needed.
  • All these patients had a named GP and 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.
  • The practice nurse provided home visits for phlebotomy services including flu vaccinations for housebound patients. This included health checks and reviews for patients with long term health conditions for example, diabetes, asthma and COPD (Chronic Obstructive Pulmonary Disease).

Families, children and young people

Good

Updated 17 March 2017

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 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.
  • The practice’s uptake for the cervical screening programme was 92%, which was above the local CCG average of 83% and the national average of 81%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • We saw positive examples of joint working with midwives, health visitors and school nurses. For example, the practice held a midwife clinic on a weekly basis and held monthly meetings with health visitors to discuss families that may be in need of extra support.
  • Staff had training to ensure that they were aware of how to identify child safeguarding and domestic abuse concerns.

  • The practice offered online counselling services (KOOTH.com) for young people. This is a free and anonymous online service available on mobile devices
  • The practice had high numbers of young patients recorded with obesity and would signpost families to the local ‘HELPS’ service. This local service supported and encouraged families to develop healthier lifestyles.

Older people

Good

Updated 17 March 2017

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.
  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • Warden Lodge had the largest number of patients aged 75 and over in Hertfordshire, and the practice demonstrated a number of additional services available to care for patients in this group. For example, in September 2014 the practice began offering health checks to patients aged over 75 years, since then 1,177 patients in this group had been invited for health checks and 938 (80%) had been completed.
  • The practice nurse provided home visits for phlebotomy services including flu, pneumococcal and shingles vaccinations for housebound patients. This included health checks and dementia reviewsfor elderly and frail patients.
  • The practice had access to the ‘acute in hours visiting service’ which provided home visits to patients who met specific criteria usually acute short term illness. This meant there was a lower threshold for visiting frailer housebound individuals with long term health conditions or long standing health concerns. This service is staffed by local GPs who have access to the patient’s records, giving good continuity of care.
  • The practice was able to offer the Home First service to acutely, unwell housebound patients, providing support at home from a multi-disciplinary team of nurses, therapists and carers, preventing unnecessary hospital admissions. This initiative was commissioned by the CCG and following an initial pilot it wasrolled out to all practices in Hertfordshire.

  • GPs provided weekly ward rounds to patients in a local care home providing, part of this service included health checks and medication reviews.

Working age people (including those recently retired and students)

Good

Updated 17 March 2017

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 also encouraged its patients to attend national screening programmes for bowel and breast cancer screening. Data published in March 2015 showed that: 60% of patients aged 60-69 years had been screened for bowel cancer in the preceding 30 months, where the CCG average was 59% and the national average was 58%.78% of female patients aged 50 to 70 years had been screened for breast cancer in the preceding 3 years, where the CCG and national averages were 72%.
  • Extended hours appointments were available from 8am daily and on alternate Saturdays for those patients unable to access appointment and services during normal working hours.
  • Telephone consultations were available if a face to face appointment was not required.
  • Patients could use online services to access health information; order repeat medications, view blood test results and book appointments. In addition, the practice offered a text messaging booking confirmation and reminder service.
  • The practice offers a full range of health promotion and screening programs and an extended range of contraceptive services. For example, IUD (Intrauterine Devices) and implant fittings.
  • Patients had access to appropriate health assessments and checks. The practice had invited patients aged 40 – 74 years for a health check, 210 patients had invited from January 2016 to October 2016 and 152 of these checks had been completed (72%).

People experiencing poor mental health (including people with dementia)

Good

Updated 17 March 2017

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

  • The percentage of patients with diagnosed psychoses who had a comprehensive agreed care plan in place was 95% which was comparable with the NHS East and North Hertfordshire Clinical Commissioning Group (CCG) average of 92% and the national average of 89%. However, exception reporting for this indicator was 23% compared to the local CCG and national averages of 13%.
  • Percentage of patients diagnosed with dementia whose care had been reviewed in a face to face review in the preceding 12 months was 81%, where the local CCG average was 86% and the national average was 84%. Exception reporting for this indicator was 2% compared to a CCG average of 9% and national average of 7%.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice carried out advance care planning for patients with dementia.
  • The practice had told patients experiencing poor mental health about how to access support groups and voluntary organisations.
  • The practice had a system in place to follow up patients who had attended A&E where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.
  • Pre dementia screening was incorporated into the over 75 years health checks.
  • The community psychiatric nurses from the Home First team assisted the practice in the management of patients with dementia or at risk of developing dementia.

People whose circumstances may make them vulnerable

Good

Updated 17 March 2017

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.
  • The practice had systems in place to support people with complex needs and enable them to be able to register with the practice for example, asylum seekers, refugees and homeless patients. The practice offered longer appointments for patients with a learning disability. In the last 12 months 39 patients had been offered a review of which 16 had been undertaken.
  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.
  • The practice informed vulnerable patients about how to access 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.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children and were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies out of normal working hours.
  • The practice’s computer system alerted GPs if a patient was also a carer. The practice had identified 309 patients as carers (approximately 2.8% of the total practice list).
  • Carers were offered health checks from January 2016, and to date the practice had invited 267 carers to attend and completed 16 (6%) of these checks.