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Inspection Summary


Overall summary & rating

Outstanding

Updated 5 October 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Larwood Surgery on 26 and 27 July 2016. Overall the practice is rated as outstanding.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the practice was proactive in developing templates and protocols to assist in implementing best practice guidelines and they shared these with other practices.
  • Feedback from patients about their care was consistently positive.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. For example, the practice was leading on a pilot for a “primary care home” model of multidisciplinary care.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example, they had changed the telephone access system in response to the outcomes of the National GP patient survey.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice actively reviewed complaints and how they a

    were managed and responded to, and made improvements as a result.

  • The practice had 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.
  • The practice had strong and visible clinical and managerial leadership and governance arrangements. The practice had been awarded the Royal College of General Practitioners (RCGP) quality practice award in 2012.

We saw several areas of outstanding practice including:

  • The practice had excellent systems to ensure learning from significant events was shared with the whole practice team and staff were involved in the analysis of significant events. For example, records showed significant events were discussed at meetings across the practice and this included a multidisciplinary meeting. A six monthly significant event newsletter was provided to all staff with a detailed list of the significant events and the action taken. An annual significant event meeting involving all staff was held. This involved staff taking part in mixed staff team workshops to analyse a number of significant events and review the actions taken to assess if any improvements in the process were required. Staff told us they found these meetings an excellent environment for learning and they felt involved in the in improvements to the service.

  • There were excellent systems in place for sharing information about safeguarding concerns and identifying children at risk. These included early intervention multidisciplinary safeguarding meetings called “Think Family”. The practice had led on the pilot for these meetings and the format and principles had been rolled out to other practices in the Bassetlaw CCG area and shared with the wider community. The practice had also developed templates for assessing patients requesting contraception. These templates assisted staff to identify child sexual exploitation and to assess the patients competency to make decisions.

  • A programme of continuous clinical and internal audit was used to monitor quality and to make improvements. The practice had a detailed programme of clinical audit which included auditing some areas annually to ensure continued improvement in areas such as prescribing practice and they had made significant savings in this area. They took account of and monitored good practice developments through their extensive audit systems, developing templates and protocols to support and improve practice. The practice shared this learning and their developments with local practices.

  • The practice had excellent systems to manage staff training ensuring staff completed the required training. The practice had supported staff to obtain a wide range of clinical and management qualifications relevant to their role. 

  • The Bassetlaw District General Hospital was situated very close to the main site Larwood Surgery (5 minutes’ walk) and the practice had identified this as a cause for their patients high attendance figures at the accident and emergency (A and E) department. In response to this, the practice had developed an urgent care walk in service at the main site in 2010. This service was popular with patients and 20 - 24,000 patients had been seen annually since implementation. Records showed patient A and E attendance had steadily reduced (despite the practice list size increasing). A patient survey showed the majority of patients rated the service as very good or excellent and 50% of the patients said they would use this service rather than go to A and E. Data showed the patients waiting times at the service were usually below 15 minutes and we observed patients were seen promptly. Patients told us they liked the service because they knew they could be seen the same day. Due to the success of the service this model had been extended to one of the other practice sites in 2013.

  • Care was provided by integrating the primary, secondary and social care workforces. Larwood and Bawtry was one of the fifteen test sites across England to have been chosen to develop and test a new enhanced primary care approach. The provider Larwood and Village Surgeries were part of the multidisciplinary team leading this project. The pilots had a combined focus on the personalisation of care and providing better coordinated care that is closer to home. Almost 70 networks of GPs, health and social care staff had submitted expressions of interest to be the first sites for the development of this model outlining their innovative ideas for transforming local health and community services. The successful 15 sites were chosen following a rigorous process, involving key health and social care partners, patient representatives and an evaluation workshop attended by all shortlisted applicants.

There were areas of practice where the provider should make improvements:

  • Review the security and storage arrangements for the vaccines held in the fridge at Lakeside surgery.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Outstanding

Updated 5 October 2016

The practice is rated as outstanding for providing safe services.

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

  • The practice used every opportunity to learn from internal and external incidents, to support improvement. The practice had excellent systems to ensure learning from significant events was shared with the whole practice team and staff were involved in the analysis of significant events. For example, a six monthly significant event newsletter was provided to all staff and an annual significant event meeting involving all staff was held.

  • Information about safety was highly valued and was used to promote learning and improvement.

  • Risk management was comprehensive, well embedded and recognised as the responsibility of all staff.

  • There were excellent systems in place for sharing information about safeguarding concerns and identifying children at risk.

Effective

Outstanding

Updated 5 October 2016

The practice is rated as outstanding for providing effective services.

  • Our findings at inspection showed that excellent systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines.

  • We also saw evidence to confirm that the practice used these guidelines to positively influence and improve practice and outcomes for patients. The practice had extensive auditing processes to monitor performance and were proactive in developing tools to promote consistent application of best practice.

  • Data showed that the practice was performing highly when compared to practices nationally.

  • Performance for diabetes related indicators was 97% which was the same as the CCG average and 8% better than the national average.

  • Performance for mental health related indicators was 100% which was 5% better than the CCG average and 7% better than the national average.

  • The practice had also achieved 100% in the majority of areas related to long term conditions and in the remaining areas data showed they had achieved above 97%.

  • The practice used innovative and proactive methods to improve patient outcomes and working with other local providers to share best practice.

  • Staff were proactively supported to acquire new skills and training was encouraged and supported.

Caring

Good

Updated 5 October 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice as in line with others for most 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 saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Outstanding

Updated 5 October 2016

The practice is rated as outstanding for providing responsive services.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs and there were innovative approaches to providing integrated patient-centred care. For example, Larwood and Bawtry was one of the fifteen test sites across England to have been chosen to develop and test a new enhanced primary care approach. The provider Larwood and Village Surgeries were part of the multidisciplinary team leading this project.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. The practice had changed its telephone system in response to feedback from patients.

  • Patients could access appointments and services in a way and at a time that suited them. The practice offered daily urgent care walk in clinics at two sites and evening and Saturday appointments at three sites for working patients.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • Information about how to complain was available and easy to understand, and the practice responded quickly when issues were raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Outstanding

Updated 5 October 2016

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.

  • 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 constructive engagement with staff and a high level of staff satisfaction.

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

Checks on specific services

People with long term conditions

Outstanding

Updated 5 October 2016

The practice is rated as outstanding 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 97% which was the same as the CCG average and 8% better than the national average.

  • The practice also achieved 100% in the majority of areas related to long term conditions and in remaining areas data showed they had achieved above 97%.

  • 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 provided data to show increasing and above average uptake for flu vaccinations for at risk groups . For example, for 2015/16 the practice had achieved 74% uptake in at risk groups compared to the CCG average of 42% and practice rates in 2012/13 of 48%.

Families, children and young people

Outstanding

Updated 5 October 2016

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

  • There were excellent 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 other than for measles, mumps and rubella (MMR) vaccines but the practice had systems in place to manage this.

  • 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 84%, which was comparable to the CCG and the national average 82%.

  • 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 and health visitors.

Older people

Outstanding

Updated 5 October 2016

The practice is rated as outstanding 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.

  • The practice had excellent systems to ensure continuity and safe care for patients in care homes. The practice had named GPs and dedicated administration teams for each home to aid consistency for patients and staff. Reviewed and updated monthly medication lists were sent to the care homes to ensure patients were receiving appropriate medicines.

Working age people (including those recently retired and students)

Outstanding

Updated 5 October 2016

The practice is rated as outstanding 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 reflected the needs for this age group.
  • The practice offered urgent care walk in clinics at two sites and evening and Saturday  appointments at three sites for working patients.
  • The practice provided near patient testing for patients who required routine/urgent electro cardiogram (ECG), pregnancy tests and screening for deep vein thrombosis (DVT).

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 5 October 2016

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

  • 92% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which was 6% higher than the CCG average and 8% better than the national average.

  • Performance for mental health related indicators was 100% which was 5% better than the CCG average and 7% better than the national average.

  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. They hosted counselling services for patients at the practice.

  • The practice 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.

  • The practice 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 patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Outstanding

Updated 5 October 2016

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

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.

  • The practice offered longer appointments for patients with a learning disability. The practice had a GP with the role of learning disability practice champion. The practice had developed a template to assist in the assessment of the health and social care needs of patients with a learning disability. These templates had been shared with other practices in the CCG.

  • Practice nurses had received training from a clinical complex case manager for mental health and learning disabilities to develop their skills and knowledge when seeing patients. The practice had illustrated clinical tools to help to communicate with patients.

  • 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 various 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.