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North Preston Medical Practice Good

Inspection Summary


Overall summary & rating

Good

Updated 30 October 2018

This practice is rated as Good overall. (Previous rating May 2017 – Good)

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out a comprehensive inspection on 21 September 2016 when we found that patients were at risk of harm because systems and processes were not in place to keep them safe and there was no systematic approach to assessing and managing risks. The governance arrangements within the practice were insufficient and policies were not easily accessible to staff and not all were detailed enough to adequately describe the activity to which they related. There was a lack of understanding around what training was required for staff, including safeguarding training, and several staff had not had an appraisal. The practice was placed into special measures. At our re-inspection on the 10 May 2017 we found the practice had made significant improvements; they were meeting all the required regulations and we took the practice out of special measures.

We carried out a further announced comprehensive inspection at North Preston Medical Practice on 9 October 2018. This inspection was in line with our new methodology to ensure the improvements found at our inspection in May 2017 had been sustained.

At this inspection we found:

  • The practice had maintained the systems we saw at our last inspection and had further strengthened those arrangements.
  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes. Learning from incidents was shared with all staff.
  • There was a comprehensive meeting structure and support system for clinical staff.
  • Staff were given opportunities to develop and staff training was central to the practice development and sustainability.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • There was a clear management structure in place and staff had lead roles in many areas of practice service delivery. The practice team worked well together and practice governance processes were comprehensive.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw one area of outstanding practice:

  • The practice made good use of computer systems to strengthen the governance of the practice and to improve patient care. They had worked to populate an online computer system to store, share and maintain practice processes and procedures relating to many areas of the governance of the practice. They had also worked to strengthen the templates used at patient health appointments in order to follow best practice, better document consultations and share information with other services.

The areas where the provider should make improvements are:

  • Improve the management of patient urgent, two-week-wait referrals.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Safe

Good

Updated 30 October 2018

We rated the practice as good for providing safe services.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse.

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role although records of training for urgent care practitioners were not up to date for safeguarding adults training. They knew how to identify and report concerns. Learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, discrimination and breaches of their dignity and respect. Staff had trained in equality and diversity.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient safety.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was an effective induction system for temporary staff tailored to their role although the practice had not used any temporary staff for over two years.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures. We saw medicines held by the practice were comprehensive and based on best practice although there was no formal record of a risk assessment for those medicines not held by the practice. We were sent a documented risk assessment following our inspection.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals to other services in line with protocols and checked referrals had been accepted. However, the practice had no protocol in place to check appointments had been given and attended for those patients referred urgently using the two-week-wait rule. Staff told us they would put this in place following our inspection.

Appropriate and safe use of medicines

The practice had reliable systems for appropriate and safe handling of medicines.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks.
  • Staff prescribed and administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance. We saw prescribing of antibiotic medicines was in line with or lower than local and national averages.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed safety using information from a range of sources. There was a comprehensive risk assessment policy in place.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the evidence tables for further information.

Effective

Good

Updated 30 October 2018

We rated the practice and all of the population groups as good for providing effective services.

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • There was a machine in one patient area that allowed patients to self-monitor some basic health indicators such as weight and blood pressure.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • Older patients who were frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • The practice followed up on older patients discharged from hospital when it was needed. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training. Nurses were supported with clinical leads for managing patient chronic diseases.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension.
  • The practice’s performance on quality indicators for long term conditions was in line with local and national averages.

Families, children and young people:

  • Childhood immunisation uptake rates were in line with the target percentage of 90% or above except for children aged one year where uptake rates were above the World Health organisation (WHO) target of 95%.
  • The practice had arrangements for following up failed attendance of children’s appointments following referral to secondary care or for immunisation.

Working age people (including those recently retired and students):

  • The practice’s uptake for cervical screening was 73.2%, which was below the 80% coverage target for the national screening programme but above the local and national averages. Patients who did not attend for screening were contacted by the practice and encouraged to attend. Invitations were sent out on yellow paper to raise awareness.
  • The practice’s uptake for breast and bowel cancer screening was above the national average. Members of the local screening teams had attended the practice to encourage attendance.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The practice maintained links to local organisations and charities set up to help vulnerable people and signposted patients to them when it was appropriate.
  • The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

People experiencing poor mental health (including people with dementia):

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medication.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis. Staff had trained in dementia awareness.
  • The practice offered annual health checks to patients with a learning disability.
  • The practice’s performance on quality indicators for mental health was in line with local and national averages.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • Patient chronic disease registers had been reviewed by an external company to ensure they were accurate and patients previously not identified were added appropriately.
  • The practice used information about care and treatment to make improvements.
  • Staff carried out clinical audits and an audit programme was held online on the practice software system Reminders were triggered when re-audits were due.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • Reception staff had trained to become care navigators; enabling them to direct patients to the most appropriate member of the clinical team effectively.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop. At the time of our inspection, one healthcare assistant had already qualified as an assistant practitioner and one was in training. Staff told us they planned to continue training to become practice nurses in the future. The practice had employed two urgent care practitioners and these clinicians were being supported by the practice to become non-medical prescribers.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who had relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes. There was a patient self-monitoring machine in a patient area of the practice.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.

Caring

Good

Updated 30 October 2018

We rated the practice as good for providing caring services.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treated people. There were many comments relating to the helpful, friendly and compassionate nature of staff.
  • Staff understood patients’ personal, cultural, social and religious needs. Staff had trained in equality and diversity.
  • The practice chaperone service offered support to patients and patients we spoke to were aware of this service.
  • The practice gave patients timely support and information.
  • The practice’s GP patient survey results were in line with local and national averages for questions relating to kindness, respect and compassion.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available. There was a hearing loop in reception.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them. A staff member acted as carers’ champion.
  • The practice’s GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues, or appeared distressed reception staff offered them a private area or room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.
  • The practice respected patient confidentiality. All staff had trained in the new General Data Protection Regulation (GDPR) and maintained patient confidentiality appropriately.

Please refer to the evidence tables for further information.

Responsive

Good

Updated 30 October 2018

We rated the practice and all of the population groups as good for providing responsive services.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • Telephone GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered. At the time of our inspection, the practice was in discussion with the clinical commissioning group (CCG) to use funding from Preston city council to convert additional rooms at Ingol health centre for use by the practice.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who were more vulnerable or who had complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The GP and other clinical staff also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability.
  • Appointments were able to be made at Broadway surgery for those people who found it difficult to travel to Ingol health centre.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice offered blood testing with results for patients at the same time as their visit for chronic disease review.
  • The practice assistant and trainee assistant practitioners were able to do foot checks for diabetic patients.
  • There were patient drop-in sessions for taking blood at community phlebotomy clinics.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • We found there were systems 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 accident and emergency (A&E) attendances. Records we looked at confirmed this.
  • There was a weekly antenatal clinic at both surgery sites and mothers generally had the choice of where to give birth. GPs always visited after home births.
  • The practice children vaccination clinics were timed to run at the same time as the health visitor clinic.
  • One of the practice GPs with support from the trainee assistant practitioner, ran a monthly family planning clinic and made referrals to other services when indicated.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

Working age people (including those recently retired and students):

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, weekend appointments in collaboration with other local practices.
  • Telephone appointments were available for patients who were unable to attend during working hours.
  • Nurse appointments were offered until 6pm in the evening.
  • There was a community early evening drop-in clinic available to take blood.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.
  • Staff had attended cancer champion training in order to better support patients.
  • The practice made referrals to health and social care services as necessary for this patient group. This included the community drug and alcohol team and the Lancashire well-being service.

People experiencing poor mental health (including people with dementia):

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • Patients suffering from dementia and their carers referred to the local hospital were given information to help fast-track them through the clinics and provide them with support during the process.
  • A member of the local community mental health team held clinics at the practice Ingol site to see patients with mental health problems.

Timely access to care and treatment

Patients were able to access care and treatment from the practice within an acceptable timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised. The practice urgent care practitioners offered on-the-day access to appointments at Ingol health centre. Patients could be seen at Broadway if they were unable to travel to Ingol.
  • Patients reported that the appointment system was easy to use.
  • The practice’s GP patient survey results were in line with local and national averages for questions relating to access to care and treatment.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends; learning points were discussed in practice staff meetings. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 30 October 2018

We rated the practice as good for providing a well-led service.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care.

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plan to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.

Culture

The practice had a culture of high-quality sustainable care.

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • The practice focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints although actions taken as a result of safety alerts were not always available to managers.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved patients, the public, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good