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Woodgrange Medical Practice Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 3 February 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Woodgrange Medical Practice on 19 May 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 an effective system in place for reporting and recording significant events.

  • Risks to patients were assessed and well managed with the exception of minor weaknesses in systems to ensure the safety of electrical equipment and contents of a medicines refrigerator.
  • The practice used innovative and proactive methods to improve patient outcomes, it worked with other local providers to share best practice. 
  • Feedback from patients about their care was consistently positive and data showed that the practice was performing highly when compared to practices nationally.
  • 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 by substantially increasing GP sessions in response to a patients survey and providing daily GP cover in the reception area, re-organising the reception area, signage and queuing system to improve patients privacy and safety.
  • 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs and patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • 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.
  • 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.

We saw several areas of outstanding practice:

  • GPs had led and delivered improved outcomes and care for patients including across the local Clinical Commissioning Group (CCG) and over wide range of clinical areas including chronic obstructive pulmonary disease (COPD), mental health, dermatology, women’s health, diabetes and asthma. The practice also ran a weekly citizens advice bureau clinics for its patients that was provided by professional welfare benefit advisers.

  • The practice nurse ran various health based community groups to encourage patient’s general health, exercise and social interaction and had extended provision to other local practices. The nurse had also extended her work internationally to Kenya and attributed the success of these projects in part to the support received directly from the practice.
  • G

    Ps showed leadership and took responsibility at an organisational level to improve local child protection arrangements. For example, both a partner GP and registrar made detailed records of child protection reporting system failures that had resulted in a lack of or delayed response from allied health and social care professionals to protect children. GPs initiated internal significant events protocols and sustained escalation of concerns until they reached persons responsible for the system. The practices ongoing commitment triggered an analysis of the system to improve child protection arrangements in the local 

    area.

However there were areas of practice where the provider should make improvements:

  • Review or embed systems electrical equipment safety and medicines refrigerator checks.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 3 February 2017

The practice is rated as good for providing safe services.

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses and there was an effective system in place for reporting and recording significant events.
  • Lessons were shared to make sure action was taken to improve safety in the practice.
  • When things went wrong patients received reasonable support, truthful information, 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.
  • Practice GPs showed leadership and took responsibility at an organisational level to improve local child protection arrangements.

  • Risks to patients were generally assessed and well managed but there were minor weaknesses in checks for contents of medicines refrigerators and electrical equipment safety.
  • The practice had an effective and well embedded system for ensuring relevant safety alerts reached the right staff at the right time in accordance with their role.

Effective

Outstanding

Updated 3 February 2017

The practice is rated as outstanding for providing effective services.

  • Data showed that the practice was performing highly when compared to practices nationally. For example, data from the Quality and Outcomes Framework (QOF) showed the practice had achieved 100% of the total number of points available, with 7% exception reporting. (Exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects).
  • 86% of patients diagnosed with asthma, on the register had an asthma review in the last 12 months compared to 78% within the CCG and 75% nationally. Exception reporting for asthma care was 1% compared to 3% in the CCG and 7% nationally.
  • The percentage of patients on the diabetes register with a record of a foot examination and risk classification within the preceding 12 months was 99% compared with the national average of 88%. Exception reporting for diabetes care was 8% compared to 7% in the CCG and 11% nationally.
  • Childhood immunisation rates were above local and national averages. For example, for those given to under two year they olds ranged from 82% to 99% (CCG ranged from 82% to 94%), and five year olds from 92% to 97% (CCG ranged from 82% to 94%).

  • Clinical audits demonstrated quality improvement.
  • The practice had led improvements in patients care within the practice, local group of practices, and across the CCG in areas such as mental health, asthma, ureteric colic (an important and frequent emergency in medical practice most commonly caused by the obstruction of the urinary tract), eczema, polycystic ovarian disease and heavy menstrual bleeding.
  • The practice was a finalist in “The General Practice Awards” 2014 for its care of people with long term conditions, and specifically for its care of patients with diabetes.
  • The government Minister of State for Care and Support had written to the GP partner in 2015 to thank him personally for his leadership and work to improve mental health crisis care in Newham. The practice had worked jointly with a mental health charity and other health partners to deliver improvements.
  • Staff assessed needs and delivered care in line with current evidence based guidance and the practice had systems to continuously refresh guidance and engage relevant staff such as weekly clinical meetings attended by consultant specialists. We saw evidence to confirm that the practice used these guidelines to positively influence and improve outcomes for patients.
  • Another of the partner GPs had trained to become a specialist in dermatology, they offered clinics in practices across the CCG and were available to clinical staff in house on an immediate basis to help assess and treat patient’s skin conditions. Data showed high rates of patient satisfaction, substantial reductions in patients being referred to secondary care and faster treatment.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment and consistently told us they were supported and encouraged to learn for example through protected learning time. 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 held regular in-house educational sessions where expert speakers were invited to promote healthcare awareness and neighbouring practices were also invited to attend. Subjects covered in 2015 – 2016 included FGM (Female Genital Mutilation), Domestic and Sexual Violence, Safeguarding Adults and Children, Chronic Conditions, and Acute medical conditions.

Caring

Good

Updated 3 February 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice as comparable to others for 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.
  • The practice undertook an audit to check what support had been offered to bereaved patients and implemented several improvements as a result, including to ensure it offered counselling to bereaved patients where needed.

Responsive

Good

Updated 3 February 2017

The practice is rated as good 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. For example, it had a GP partner with a special interest in dermatology and offered clinics across the CCG. The practice had worked jointly with a mental health charity to deliver improvements in crisis care for people with mental health problems.
  • There were innovative approaches to providing integrated patient-centred care. For example, the practice nurse ran various health based community groups with on-going support from the practice to encourage a wide variety of patient’s general health, exercise and social interaction such as older people, families with toddlers and exercise groups for Muslim women who felt more comfortable attending a women only class.
  • One of the GP partners had engaged the local press to raise public awareness of mental health issues, to provide advice on where and how to access support and provide information on how to do so. T

    he practice had held psychological therapy sessions for the last 3 years and data showed patients 

    entering into treatment had increased by 50% over and the rate of patients not arriving for their appointment had decreased by 30% over the period.

  • The practice identified it had a high prevalence of patients with diabetes and a partner GP had written to patients with diabetes and asthma to personally invite and encourage them have a flu vaccine.
  • The practice consistently implemented a range of suggestions for improvements in an open and transparent way and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example the practice significantly increased the amount of appointments available and redesigned GP and reception staffing as well as improving arrangements for patient’s privacy and safety. It also published records of PPG meetings on the practice website.
  • 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.
  • The practice had a wide range of services available on site including an antenatal clinic, contraception (including coil fitting), minor surgery, a COPD clinic, a diabetes clinic and substance misuse prescribing. It had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had implemented a "You Asked, We Did" system and information sheet for patients and other stakeholders that showed eight actions it had undertaken in response to feedback including to improve patients privacy and safety.
  • The practice ran a weekly citizens advice bureau clinics for its patients t

    hat was provided by professional welfare benefit advisers

    .

  • Midwife clinics were held weekly and the practice promoted local weekly drop 

    in mother, child and baby health clinics for children up to five years old.

  • B

    aby check appointments at the practice were 30 minutes per appointment in response to patients feedback to ensure time for health promotion, mental health or safeguarding concerns, explaining the importance of immunisation, and the use of the health visitor for advice.

Well-led

Outstanding

Updated 3 February 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 but there were minor weaknesses in some safety systems.
  • 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.
  • A systematic approach was taken to working with other organisations to improve care outcomes, tackle health inequalities and obtain best value for money.

  • The strategy and supporting objectives were challenging and innovative, while remaining achievable.
  • The practice had led and delivered many improvements for patients across a wide range of areas of clinical care, both  in-house and across the CCG and had received external recognition for this work.
  • 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 gathered feedback from patients through surveys, and it had a very engaged patient participation group which influenced practice development.
  • There was a strong focus on continuous learning and improvement at all levels.
  • Practice GPs showed leadership and took responsibility at an organisational level to improve local child protection arrangements. The practice also made regular use of National Reporting and Learning System (NRLS) and local "amber alerts" to contribute to wider improvements in safety.

Checks on specific services

Older people

Good

Updated 3 February 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.
  • The percentage of patients with rheumatoid arthritis, on the register, who had had a face-to-face annual review in the preceding 12 months was 91% which is the same as 91% within the CCG and 91% nationally.

  • The practice nurse ran a “Holiday at Home” group for older people to meet at the church, reminisce, share stories, read the newspaper and do some light exercises together. Approximately eight older people registered at the practice attend this every week. We saw evidence of beneficial health outcomes such as weight and blood sugar for this group of patients.
  • For older patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

People with long term conditions

Outstanding

Updated 3 February 2017

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

  • The practice was a finalist in “The General Practice Awards” 2014 for its care of people with long term conditions, and specifically for its care of patients with diabetes. Locally held data showed the practice was currently the highest performer for diabetes care within a local group of practices. Exception reporting was 8% compared to 7% in the CCG and 11% nationally.
  • The specialist nurse held diabetes triage reviews over the telephone with advance time slots available for working age people to manage their care over the telephone or secure appointment at a convenient time if needed.
  • The practice identified and led areas for improvement and subsequently developed new local care pathways or redesigned pathways that delivered improvements for patients with asthma, chronic obstructive pulmonary disease (COPD), diabetes, and eczema.
  • Performance for diabetes related indicators for the percentage of patients on the diabetes register with a record of a foot examination and risk classification within the preceding 12 months was 99% compared with the national average of 88%.
  • The percentage of patients with hypertension having regular blood pressure tests was 86% compared to the CCG and national averages of 84%. Exception reporting for hypertension care was 2% compared to 3% in the CCG and 4% nationally.
  • The practice had a wide range of services available on site including a COPD clinic and a diabetes clinic.
  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority and longer appointments and home visits were available when needed.
  • 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.
  • One of the partner GPs was a specialist in dermatology, they offered clinics in practices across the CCG and were available to clinical staff in house on an immediate basis to help assess and treat patient’s skin conditions. Data showed high rates of patient satisfaction, substantial reductions in patients being referred to secondary care and faster treatment. 
  • A GP partner had written to patients with diabetes and asthma to personally invite and encourage them have a flu vaccine and explained he and one of the other GPs had already received the vaccine from the practice nurse.
  • The practice held regular in-house educational sessions where expert speakers were invited to promote healthcare awareness and neighbouring practices were also invited to attend. Subjects covered in 2015 – 2016 included Chronic Conditions.

Families, children and young people

Outstanding

Updated 3 February 2017

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

  • The practice identified areas for improvement and subsequently developed new care pathways or redesigned pathways that delivered improvements for patients with polycystic ovarian disease and heavy menstrual bleeding that were rolled out across the CCG. Reported improvements included more positive user experience, reduction in hospital referrals, improved patient experience and confidence in the clinician.
  • Childhood immunisation rates were above local and national averages. For example, for those given to under two year olds ranged from 82% to 99% (CCG ranged from 82% to 94%), and five year olds from 92% to 97% (CCG ranged from 82% to 95%). 
  • The practice had identified it had a relatively high population of working age women and offered a full range of contraceptive services delivered by female clinicians such as implants and coils.
  • The practice nurse ran various community health promotion clubs and attributed the progress and expansion of her local and international work in part to the practice. Local initiatives included a “Health Club” exercise class mainly for Muslim women who felt more comfortable attending a women only class and a “Baby Toddler Group” in response to Newham’s high rate of children under three years old and families living in cramped conditions.
  • 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.
  • 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 81%, which the same as CCG average of 81% and similar to the national average of 82%. Exception reporting was below average at 4% compared to 11% in the CCG and 6% nationally.
  • 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. Midwife clinics were held weekly and the practice promoted local weekly drop 

    in mother, child and baby health clinics for children up to five years old.

  • B

    aby check appointments at the practice were 30 minutes per appointment in response to patients feedback to ensure time for health promotion, mental health or safeguarding concerns, explaining the importance of immunisation, and the use of the health visitor for advice.

  • Practice GPs showed leadership and took responsibility at an organisational level to improve local child protection arrangements. For example, a partner GP and registrar made detailed records of child protection reporting system failures that had resulted in a lack of or delayed response from allied health and social care professionals to protect children. GPs initiated internal significant events protocols and sustained escalation of concerns until they reached persons responsible for the system. The practices ongoing commitment triggered an analysis of the system to improve child protection arrangements in the local 

    area.

Working age people (including those recently retired and students)

Good

Updated 3 February 2017

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

  • Data showed the practice was consistently exceeding health checks targets for health for 40 – 75 year old patients.
  • The specialist nurse held diabetes triage reviews over the telephone with advance time slots available for working age people to manage their care over the telephone or secure appointment at a convenient time if needed.
  • 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 had a wide range of services available on site including minor surgery.

People whose circumstances may make them vulnerable

Good

Updated 3 February 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 and those with a learning disability.
  • The practice offered longer appointments for patients with a learning disability and 41 of these patients (85%) had received an annual health check.
  • 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.
  • The practice had a wide range of services available on site including substance misuse prescribing.
  • The practice ran a weekly citizens advice bureau clinic for its patients t

    hat was provided by professional welfare benefit advisers

    .

  • The practice held regular in-house educational sessions where expert speakers were invited to promote healthcare awareness and neighbouring practices were also invited to attend. Subjects covered in 2015 – 2016 included FGM (Female Genital Mutilation), Domestic and Sexual Violence, and Safeguarding Adults and Children.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 3 February 2017

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

  • One hundred per cent of patients diagnosed with dementia had their care reviewed in a face to face meeting compared to the CCG average of 87% and the national average of 84%. Exception reporting for dementia care was 7% compared to 11% within the CCG and 8% nationally.

  • Performance for mental health related indicators was 100% compared to the CCG average at 87% and the national average of 93%. Exception reporting for mental health was 9% compared to 7% within the CCG and 11% nationally.
  • The practice had identified 116 patients on its register with a mental health condition requiring an annual health check and 89 of these patients (77%) had received the check.
  • The practice held quarterly meetings with the local psychiatrist and community mental health team in attendance in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice held bi-monthly clinics for people with mental health problems.
  • One of provided regular local newspaper articles on mental health to provide answers raise awareness and encourage access to mental health care services within the local community.

  • With support from the local Mental Health Trust, the practice had arranged for psychological therapy sessions to be held at the practice for the last 3 years. D

    ata between 2013 - 2016 showed patients

     rates for attendance and entering into treatment had increased by 50% over the period and the rate of patients not arriving for their appointment had decreased by 30%.

  • The Minister of State for Care and Support had written to a GP partner in 2015 in recognition of his leadership and work to improve mental health crisis care in Newham including by working jointly with a mental health charity and other health partners as well as government departmental officials.