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Radcliffe-on-Trent Health Centre Good

Inspection Summary


Overall summary & rating

Good

Updated 30 June 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Radcliffe-on-Trent Health Centre on 11 April 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 and near misses, and we saw evidence that learning was applied.

  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the use DVDs as a form of education for patients with long term conditions and working with the local diabetes specialist nurse to improve the wellbeing of patients.

  • There was easy access to appointments for patients whose circumstances made them vulnerable, for example patients from the traveller community. They were assured of an appointment on the day when they presented to the practice without a booked appointment.

  • Feedback from patients about their care was consistently positive. Data from the GP survey was consistently high and this included confidence in care provided by GPs, where 99% of patients surveyed said they had confidence and trust in the last GP they saw or spoke to.

  • The practice planned and co-ordinated patient care with the wider multi-disciplinary team to plan and deliver effective and responsive care to keep vulnerable patients safe. This approach had impacted on unplanned hospital admissions and attendance at Accident and Emergency. 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 was actively working with the patient participation group to resolve issues regarding access to non-urgent GP appointments.
  • The practice actively reviewed complaints for trends and how they 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, and staff told us that they were well-supported and felt valued by the partners.

We saw areas of outstanding practice including:

  • The practice provided exceptional care to registered patients living in care homes, particularly those coming to the end of their life. Patients were seen every week by a nominated GP who visited the care homes with the district nursing team to ensure patient care was seamless and patients could be seen, assessed and treated (where necessary) in one visit. GPs provided urgent access telephone numbers and went the extra mile by visiting outside surgery hours to ensure that patients living in care homes received personalised end of life care.

  • Staff had innovative ways to help patients who had limited literacy skills manage long term conditions by providing them with educational DVDs rather than just written information.

  • One of the GPs had a special interest in dermatology and used their skills and knowledge to provide improve services for the wider community through offering clinics and educational sessions for colleagues in other practices, to medical students and trainees. This included an advice and guidance unpaid service offered to other practitioners. There was evidence of reduced inappropriate referrals to secondary care for dermatology care indicated by the low number of rejected referrals.

However, we also found an area where the practice needs to improve.

  • The practice should ensure that there are procedures in place for monitoring and managing risks to patient and staff safety by having robust arrangements for health and safety assessments and following up actions on legionella assessments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 30 June 2016

The practice is rated as good for providing safe services.

  • There was an open culture in which all safety concerns reported by staff were dealt with effectively, and a system in place for reporting and recording significant events

  • The practice had robust processes in place to investigate significant events and lessons were shared to make sure action was taken to improve safety in the practice.

  • When things went wrong patients received reasonable 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. There were designated leads in areas such as safeguarding children and infection control with training provided to support their roles.

  • Risks to patients were recognised by all staff and were well managed. The practice had systems in place to deal with emergencies, and arrangements for managing medicines were robust.

Effective

Good

Updated 30 June 2016

The practice is rated as good for providing effective services.

  • 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 saw evidence to confirm that the practice used these guidelines to positively influence and improve practice and outcomes for patients. For example, there were two completed audits and some ongoing audits where results indicated improved and appropriate prescribing for patients.

  • Data showed that the practice was performing consistently highly on QOF when compared to practices nationally. For example, The practice had one of the lowest outpatients’ referral rates to hospital for patients in the Clinical Commissioning Group (CCG). In addition, admissions through hospitals emergency departments were also among the lowest in the CCG suggesting that conditions were not being overlooked or treatment delayed resulting in patients attending secondary care in an emergency.

  • Staff worked effectively with multi-disciplinary teams to meet the range and complexity of people’s needs. Of particular note was the joint working between GPs and district nurses in respect of patients nearing the end of their life. A recent audit carried out by the practice showed that 80% of patients had died in their preferred place of care and 94.5% had died in the community under the care of the practice team .

  • Staff had the skills, knowledge and experience to deliver efficient care and treatment. Additional training was offered to staff on real life situations to improve their understanding of safeguarding children and vulnerable adults. A number of staff used their additional qualifications such as dermatology as specialist resources within the practice as well as actively educating colleagues in the wider community. For example, dermatology training was offered to 17 practices within the CCG, with 25 GPs attending the lectures and three clinics. A further nine practices in another CCG were offered the same training with 14 GPs attending lectures and three clinics.

Caring

Good

Updated 30 June 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care. For example, 87% of patients said the last GP they saw or spoke to was good at involving them in decisions about their care, compared to the CCG average of 84% and national average of 82%.

  • Feedback from patients, carers, care homes and community health professionals was consistently positive about the way staff treated vulnerable patients. For example, GPs often saw patients outside of their normal working hours, particularly those coming to the end of their life to attend to the patient’s wishes. They undertook visits to care homes with district nurses to ensure seamless care was provided to patients and care and treatment could start without delay.

We observed a strong patient-centred culture:

  • Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. Staff and the patient participation group (PPG) took an active role in identifying carers and providing them with support, holding events to identify and support carers. As a result the practice had identified 256 patients as carers (which was 3.1% of the practice list).

  • Patients told us they were treated with care and concern by staff and their privacy and dignity was respected. Feedback from comment cards was overwhelmingly positive about the compassionate care given by the staff.

  • Views of external stakeholders were strongly positive and aligned with our findings.

Responsive

Good

Updated 30 June 2016

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 met patients’ needs. For example, the practice had engaged with the PPG and other organisations in the local community to find suitable premises for a new purpose built building to accommodate the growing practice.

  • There were innovative approaches to providing integrated patient-centred care. For example, collaborative working with specialist diabetes nurses to manage complex patients and draw on their knowledge to improve the knowledge and skills of their own staff.

  • 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 (PPG). For example, improving the appointments system to solve problems identified with access.
  • 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

Good

Updated 30 June 2016

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

  • The practice had a clear vision with quality and safety as a 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. There was no ‘senior partner’ view, with all GPs and the practice manager sharing responsibilities across the practice and encouraging staff to take on lead roles.

  • Governance and performance management arrangements had been proactively reviewed and took account of current models of best practice. Practice policies and procedures were actively reviewed and staff had a wide range of training resources available to them.

  • The practice proactively sought feedback from staff and patients, which it acted on. The PPG worked closely with the practice to review complaints and issues pertaining to appointments access.

  • Staff with additional qualifications actively used their skills to provide additional services to the patients in the practice and the wider Rushcliffe community, as well as specialist training and advice to colleagues.

Checks on specific services

People with long term conditions

Good

Updated 30 June 2016

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, ensuring they have care plans in place. The nurses provided dedicated clinics for patients with chronic illnesses such as asthma and diabetes.

  • The practice achieved 98.9% on QOF. This was in line with the CCG average of 98.2% and 4.2% higher than the national average.

  • Nursing staff worked collaboratively with a community specialist diabetes nurse on their more complex patients with a diabetes diagnosis to improve outcomes for the patients.

  • QOF achievement on indicators for diabetes was consistently above CCG averages. For example, The percentage of patients with diabetes, on the register who had been given ablood pressure reading within the preceding 12 months was 77.3%, compared to a CCG average of 70.3% and national average of 71.2%. The exception reporting rate for the practice was 3.1%, which was lower than the CCG average of 5% and also lower than the national average of 5.2%.

  • QOF achievement on indicators for asthma and chronic obstructive pulmonary disease were broadly in line with national averages.

  • Longer appointments and home visits were available and offered when needed.

  • The practice actively managed its annual recall system and followed up non-attenders to check their health and medicines needs were being met.

Families, children and young people

Good

Updated 30 June 2016

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. All child A&E attendances were reviewed by a GP and discussed with the health visitor if appropriate.

  • The practice held quarterly meetings with the health visitor, and also reviewed any children on a child protection plan at their clinical meetings.

  • Immunisation rates were broadly in line with the CCG averages for standard childhood immunisations.

  • Appointments were available outside of school hours with urgent appointments available on the day for children and babies.

  • The practice offered family planning services including fitting of intra-uterine devices (coil) and contraceptive implant fitting.

  • The premises were suitable for children and babies. Baby changing facilities were available and the practice accommodated mothers who wished to breastfeed. Vaccination rates for children under two years old ranged from 89.2% to 96.1% compared to the CCG average ranging from 91. 1% to 96.3%. Vaccination rates for five year olds ranged from 84.5% to 94.8%, compared to the CCG average of 86.9% to 95.4%.

Older people

Outstanding

Updated 30 June 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 has a significant elderly population with 27.3% aged over 65, compared to a national average of 16.4%.

  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. Feedback from care and nursing homes indicated that the GPs went over and above what was expected of them and were often available outside of normal working hours when needed urgently to meet the needs of this group of patients.

  • They worked effectively with multi-disciplinary teams to identify patients at risk of admission to hospital to ensure their needs were met. For example, the practice coordinated care with the district nurse and community matron and did joint visits with District Nurses.

  • The practice offered annual health checks to patients aged 75 and over and performed the checks on request. They identified 1152 patients aged over 75, and 55% had received a formal health check. All over 75s have a named GP for continuity of care.

  • The practice reported the flu vaccination uptake for 2015/16 was 80.4%, compared to a CCG average of 78%, and this was achieved by offering home visits for the vaccinations.

The practice provided services for registered patients living in five care and nursing homes for the elderly, who constituted 1.48% of their list size. Each home had a designated GP who visited each week for routine and urgent appointments, doing coordinated ward rounds with the district nurses. The practice undertook an annual care home review and medication reviews were carried out in collaboration with the community pharmacists. Staff at two care homes described the practice as caring, conscientious and efficient.

Working age people (including those recently retired and students)

Good

Updated 30 June 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 and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. This included access to telephone appointments, text reminders and the availability of early morning appointments from 7am to 8am on Tuesday and Thursday mornings.

  • Appointments with the phlebotomist were available from 7.30am.

  • The practice was proactive in offering online services such as online prescription requests, appointments and test results.

  • There was a full range of health promotion and screening information in the practice and online that reflects the needs for this age group.

  • The practice’s uptake for cervical screening for eligible patients was 88.2%

People experiencing poor mental health (including people with dementia)

Good

Updated 30 June 2016

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

  • 84.47% of patients diagnosed with dementia had their care plan reviewed in a face to face meeting 2014/15. This was in line with the national average of 84.01%.

  • Staff told us that of the 127 patients on the dementia register in 2015/16 105 had care plans. This represented 82% of their register.

  • The practice achieved 98.5% for mental health related indicators in QOF, which was 0.4% above CCG average and 5.7% above national average. The practice had a significantly lower exception reporting rate of 3.6% (The exception reporting rate is the number of patients which are excluded by the practice when calculating achievement within QOF) compared to a CCG average of 8.4%.

  • Staff told us that there were 42 patients on the mental health register in 2015/16, and 52% had care plans.

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

  • 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 30 June 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 homeless people, travellers and those with a learning disability.

  • The practice proactively managed a number of patients from the travelling community with literacy challenges and multiple medical problems and had registered 27 patients on their permanent patient list and three patients as long term temporary residents.

  • The practice was creative in educating their patients in managing their conditions. For example, the use of DVDs to help a patient with a long term condition with literacy challenges to manage their insulin.

  • The practice had identified that compliance with appointments was difficult for vulnerable people, so they encouraged these patients to present to reception whenever they felt the need for medical care and an appointment was offered to them on the day.

  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing and how to contact relevant agencies in normal working hours and out of hours.

  • The practice provided good care and support for end of life patients, keeping them under close review in conjunction with the wider multi-disciplinary team. For example, we saw a case study of a patient who was diagnosed with cancer who was experiencing a decline in their condition. Their request for a home visit was responded to by the on call GP during morning surgery, and then followed up by their usual GP and the district nursing team by the afternoon. A plan was put in place to see the patient daily as needed by both teams and extra support provided to their relatives by arranging carers and night sitters. The prompt response and good teamwork resulted in avoidance of a possible admission to hospital, and the patient was cared for at home as they wished until their death.

  • There were 62 patients on the palliative care register, and 30.6% of them did not have cancer, showing that the practice included all patients with life limiting conditions to ensure they had access to high quality palliative care.

  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations. For example, the practice has a nominated Carers’ Champion who liaised with a support worker from the Carers Association to identify carers and offer them support.

  • The practice had registered patients living in two care homes for young people with complex needs. Each home has a designated GP who visits for routine and urgent appointments.

  • The practice had 21 patients on their learning disabilities register, and 90% of them had received a health review in the last year. Longer appointments including home visits were offered to them, and we saw evidence of the patients’ involvement in their care plans.

  • Staff told us they were aware of how to access interpreting and text talk services for their patients with hearing impairment, and a hearing loop was available in the practice.