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Inspection Summary


Overall summary & rating

Good

Updated 18 January 2017

Letter from the Chief Inspector of General Practice

We carried out a desk based review (an inspection where we do not need to visit a practice in order to review the evidence we need) in November 2016 at The Leys Health Centre. This was following an inspection in February 2016 where we identified improvements were required in providing responsive services. We issued a requirement notice under Regulation 17 Good Governance of the the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. There were also areas we advised the practice should make improvement and offered the provider the chance to inform us what action they had taken as a result. We have rated the responsive domain as good. This report should be read in conjunction with the previous comprehensive inspection report.

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

  • Improvements to accessibility of appointments had been made through staff recruitment.
  • Patient engagement including a survey was formulating improvement plans for the appointment system.
  • Communication with patients was used to inform them how the appointment system worked.
  • Staff had been provided with training on the legal requirements related to consent to care and treatment.
  • Information on bowel cancer screening had been purchased and displayed for patients.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 18 January 2017

Effective

Good

Updated 18 January 2017

The practice was rated good for this domain in February 2016 and this domain is not being rated as part of this inspection. At our last inspection in February 2016 we asked the provider to consider action regarding some areas where improvements should be made. These included:

  • Ensure nurses were aware of the principles and requirements of the Mental Capacity Act 2005.
  • Review means to increase in the uptake of learning disability health checks.
  • Identify how to promote better awareness of bowel cancer screening to help increase uptake on the screening programme.

In November 2016 the practice informed us that in April 2016 nursing staff and GPs had attended in house Mental Capacity Act 2005 training. They were also informed how to obtain further information or advice if uncertain about an individual patient’s capacity. The slides from the meeting were stored on a shared drive for staff to access. This training was cascaded to staff who did not attend the first meeting.

The practice implemented new invitation methods for health checks for patients with learning disabilities. Eleven patients who had not previously attended for check-ups have since attended.

The practice informed us they have obtained several different posters promoting bowel-screening.

Caring

Good

Updated 18 January 2017

Responsive

Good

Updated 18 January 2017

The practice is rated as good for providing responsive services.

At our last inspection in February 2016 we found that patients found it difficult to make an appointment. The national GP survey showed very poor feedback regarding patient access to appointments. A new appointment system had been implemented in February 2015 but no comprehensive review of the system had taken place since to deduce how well it was working for patients and to identify any improvements which were required.

At this inspection we saw that a number of channels for communicating with patients had been utilised to improve two way communication. This enabled increased patient feedback and more information being provided to patients regarding the appointment system. Recruitment had been undertaken and we saw more routine appointments were available. There were also improved outcomes in the national GP survey in July 2016 compared to January 2016.

Well-led

Good

Updated 18 January 2017

Checks on specific services

People with long term conditions

Good

Updated 6 May 2016

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

  • The practice followed guidance in the management of chronic diseases.
  • Patients at risk of hospital admission were identified and had care plans written where appropriate.
  • The practice achieved 97% on its quality outcomes framework scores (QOF) in 2015. QOF is a quality system to measure the performance and quality of patient care and treatment.
  • The care of long term conditions was audited to identify where improvements in the management of a specific condition could be made.
  • Longer appointments and home visits were available when needed.
  • There was a process to offer a periodic structured review to check patients’ health.
  • There was monitoring of patients on long term medicines.
  • 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.

Families, children and young people

Good

Updated 6 May 2016

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

  • The practice had led on a scheme to provide mentoring to young patients (16-24) who were encountering social or personal problems, potentially at risk of developing mental health issues. The practice referred patients onto the project during the initial pilot in 2015 and this has been extended due to the feedback from those involved.
  • Local schemes which the practice participated in had reduced teenage pregnancy rates in the local area.
  • Childhood immunisation rates for the vaccinations given were comparable to CCG averages. Vaccinations given to under two year olds were 90% (regional average 90%) and for five year olds they were 85% (regional average 95%).
  • Staff were aware of the circumstances and rights when gaining consent from patients under 16.
  • Baby changing facilities were available.
  • GPs worked with midwives and health visitors in the provision of care.

Older people

Good

Updated 6 May 2016

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

  • The practice offered proactive, personalised care to meet the needs of the older patients in its population.
  • Care plans were available for patients deemed at high risk of unplanned admissions.
  • Access for patients with limited mobility was good including for those with mobility scooters.
  • There were named GPs for this group of patients.
  • Screening for conditions which patients in this population group may be at risk of was provided, such as dementia

Working age people (including those recently retired and students)

Good

Updated 6 May 2016

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

  • The needs of the working age population, those recently retired and students had been identified.
  • Extended hours appointments were available including on Saturday mornings. 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.

  • Patient feedback on the availability of appointments from the national survey and on the day of inspection was poor.
  • Phone consultations were offered to patients.
  • Online appointment booking was available.

People experiencing poor mental health (including people with dementia)

Good

Updated 6 May 2016

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

  • Performance for mental health related indicators was 96% compared to the CCG average of 95% and national average of 93%.
  • 93% of patients eligible for a care plan had one in place and reviewed in 2015/16.
  • During 2014/2015, there were 231 patients assessed for dementia with 14 diagnoses.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice had led on a scheme to provide mentoring to young patients (16-24) who were encountering social or personal problems, potentially at risk of developing mental health issues. The practice referred patients onto the project during the initial pilot in 2015 and this has been extended due to the feedback from those involved.

People whose circumstances may make them vulnerable

Good

Updated 6 May 2016

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

  • Learning disability health check figures were low.
  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability.
  • The practice offered longer appointments for vulnerable patients.
  • GPs regularly worked with multi-disciplinary teams in the case management of vulnerable patients.
  • A mentoring scheme offered young people with social, emotional or potential mental health problems with support.
  • 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.
  • Staff worked with patients who they were aware had problems associated with poor housing conditions, including working with external organisations to try and improve these patients physical and mental wellbeing.
  • Staff identified that some patients did not find leaflets on their care and treatment easy to use. Therefore nurses developed pictorial guides along with written guidance on the practice leaflets for diabetes and asthma care.