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Inspection Summary


Overall summary & rating

Good

Updated 29 March 2018

This practice is rated as Good overall. At our previous inspection on 22 June 2017 the practice was rated as inadequate and placed into special measures this followed our first inspection on 12 April 2016 where the practice was rated as requires improvement.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Requires Improvement

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Good

People with long-term conditions – Good

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced comprehensive inspection at Forest Hill Group Practice on 8 February 2018. This inspection was undertaken as the service was rated as inadequate at our previous inspection and placed into special measures. At our last inspection on 22 June 2017 the practice was rated as inadequate for providing services that are safe and well led and requires improvement for effective. We identified breaches of regulations 12 and 17 of the Health and

Social Care Act 2008 (Regulated Activities) Regulations 2014. Breaches related to the practice failing to adequately assess and mitigate risks associated with infection control, the management of medicines and equipment, and recruitment and monitoring. In addition, the practice’s chaperoning procedures did not ensure patients were kept safe. The practice had also not reviewed high rates of exception reporting and did not have adequate systems in place to follow up patients following a cervical screening test.

Prior to that we inspected the service on 12 April 2016 and rated the service requires improvement for providing care that was safe, effective and well led. We identified breaches of regulations 12, 17 and 18 of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. Breaches related to deficiencies in safety systems for the management of medicines, infection control, recruitment and training. There was also limited evidence of quality improvement work, lack of effective systems relating to the management of significant events and a lack of effective policies and processes. Staff also had not received an annual appraisal and there was a lack of mechanisms to ensure staff felt supported.

At this inspection we found:

That the concerns from our previous inspection had all been addressed. The practice had taken action not only to address the concerns identified on our last inspection but also to improve leadership and management to ensure that improvements made were embedded and sustained.

For example:

  • The practice now 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.

  • 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 treated patients with compassion, kindness, dignity and respect.

  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

However:

  • Although national patient survey scores were largely positive in respect of access, some patients that we spoke with on the day of the inspection found it difficult to access routine appointments or get through on the telephone and the next available routine GP appointment was four weeks. The practice had recently recruited four additional salaried GPs with a view to improving both access and continuity of care for patients and was in the process of upgrading their phone systems.

  • The practice had not met Public Health England targets related to childhood immunisations and cervical screening. Public Health England data for targets related to smoking cessation also indicated that the practice was performing below local and national averages though unverified data provided by the practice indicated that they were meeting this target.

The areas where the provider should make improvements are:

  • Work to monitor and improve access to routine appointments and to monitor and improve telephone access.

  • Work to improve the care of patients with rheumatoid arthritis and fragility fractures, increase the uptake of childhood immunisations and review higher than average exception reporting rates.

  • Improve systems and processes that support the identification and record keeping in respect of patients with caring responsibilities to enable appropriate support and signposting to be provided.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 29 March 2018

Effective

Requires improvement

Updated 29 March 2018

Caring

Good

Updated 29 March 2018

Responsive

Good

Updated 29 March 2018

Well-led

Good

Updated 29 March 2018

Checks on specific services

People with long term conditions

Inadequate

Updated 17 August 2017

The practice is rated as inadequate for providing safe and well-led services and requires improvement for the provision of effective services leading to the practice being rated as inadequate overall. The issues identified impact on the care provided to this population group.

  • GP and nursing staff had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority.

  • From the most recently available verified data we found that performance in respect of some diabetic indicators were in line with local and national averages. The number of patients with diabetes who had well controlled blood pressure was lower than local and national averages. However we saw unverified data for 2016/17 which showed improvement in this area.

  • A pharmacist and GP led diabetic clinic was held monthly.

  • The practice participated in virtual clinics for diabetes, atrial fibrillation and chronic obstructive pulmonary disease; where consultants would provide additional support and advice for the most complex patients.

  • The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs. The practice pharmacist would update any changes to patient medicines.

  • There were emergency processes for patients with long-term conditions who experienced a sudden deterioration in health.

  • All these patients had a named GP and there was a system to recall patients for a structured annual review to check their health. Medicines needs were reviewed by the practice pharmacist. 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

Inadequate

Updated 17 August 2017

The practice is rated as inadequate for providing safe and well-led services and requires improvement for the provision of effective services leading to the practice being rated as inadequate overall. The issues identified impact on the care provided to this population group.

  • From the sample of documented examples we reviewed 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.

  • Immunisation rates were comparably high for all standard childhood immunisations compared to the local average; though in three of the four areas reviewed they did not meet the national target.

  • Patients told us, on the day of inspection, that children and young people were treated in an age-appropriate way and were recognised as individuals.

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

  • The practice held a weekly health visitors clinic and hosted a local midwifery service. Health visitors were invited to attend the practice’s monthly community meetings.

  • The practice had emergency processes for acutely ill children and young people and for acute pregnancy complications.

Older people

Inadequate

Updated 17 August 2017

The practice is rated as inadequate for providing safe and well-led services and requires improvement for the provision of effective services leading to the practice being rated as inadequate overall. The issues identified impact on the care provided to this population group.

  • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

  • The practice provided GP services to a local elderly residential care home. Staff at the home said that the practice were quick to respond when the home requested that GPs attend the home or when staff needed advice. The home said that they had requested regular review meetings to discuss residents care but that these meetings had not been established as the practice were not currently able to provide these.

  • The practice offered flu immunisations to patients over the age of 65.

  • The practice provided holistic health assessment for patients over the age of 65 who were housebound or over the age of 80 years old which involved creating a care plan which focused on addressing both patient’s health and social needs.

  • A chair lift had been installed to enable patients to access treatment from clinicians based on the upper floors of the practice.

  • The practice offered proactive, personalised care to meet the needs of the older patients in its population.

  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

  • The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care.

  • The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.

  • Where older patients had complex needs, the practice shared summary care records with local care services including the Rapid Response Team and At Home Team. The practice had direct telephone access to local geriatricians for advice and support.

  • Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible.

Working age people (including those recently retired and students)

Inadequate

Updated 17 August 2017

The practice is rated as inadequate for providing safe and well-led services and requires improvement for the provision of effective services leading to the practice being rated as inadequate overall. The issues identified impact on the care provided to this population group.

  • The needs of these populations 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, telephone consultations, extended opening hours and Saturday appointments.

  • The practice promoted the minor ailments scheme and could book patients into the local extended access hub which provided care from 8 am to 8 pm 7 days per week.

  • 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 hosted a physiotherapist in the surgery which prevented these patients having to travel to their nearest secondary care facility to access this service.

People experiencing poor mental health (including people with dementia)

Inadequate

Updated 17 August 2017

The practice is rated as inadequate for providing safe and well-led services and requires improvement for the provision of effective services leading to the practice being rated as inadequate overall. The issues identified impact on the care provided to this population group.

  • The practice carried out advance care planning for patients living with dementia. These patients would be phoned in advance of their appointments to ensure attendance.

  • Of those patients diagnosed with dementia 82% had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average.

  • The practice specifically considered the physical health needs of patients with poor mental health and dementia. There was a lead for these patients who conducted annual reviews.

  • The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.

  • Performance against mental health indicators was lower than local and national averages. However unverified data from 2016/17 showed significant improvement and the practice were now performing in line with local and national averages.

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

  • Patients at risk of dementia were identified and offered an assessment.

  • The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations.

  • The practice had a system to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

  • Staff interviewed had a good understanding of how to support patients with mental health needs and dementia.

  • The practice hosted a psychologist.

People whose circumstances may make them vulnerable

Inadequate

Updated 17 August 2017

The practice is rated as inadequate for providing safe and well-led services and requires improvement for the provision of effective services leading to the practice being rated as inadequate overall. The issues identified impact on the care provided to this population group.

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

  • The practice provided GP services to a local care facility which housed five residents with learning difficulties. Staff at the home confirmed that the practice were responsive to requests for them to visit patients and that the quality of care provided to patients was high but that there had been difficulties in obtaining repeat medication and errors were frequently made.

  • 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 offered longer appointments for patients with a learning disability.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.

  • Staff in the practice had received domestic violence training.

  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations.

  • Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They 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.