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Urban Village Medical Practice Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 20 August 2015

Letter from the Chief Inspector of General Practice

We inspected Urban Village Medical Practice on the 23 June 2015 as part of our comprehensive inspection programme.

From all the evidence gathered during the inspection process we have rated the practice as outstanding.

Specifically, we found the practice to be outstanding for providing safe, caring, responsive, effective and well led services. They were outstanding for providing services to most of the population groups, specifically those who were vulnerable.

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. Opportunities for learning were maximised.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice and meet the needs of the most vulnerable of patients, particularly homeless patients.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided in ways to help patients understand the care available to them.
  • 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 Virtual Patient Participation Group (VPPG).
  • The practice had good facilities and multi-skilled staff and was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand
  • The practice had a clear vision which had equality, quality and safety as its top priority. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

We saw several areas of outstanding practice including:

  • The practice had provided primary care services to homeless people in Manchester for over 15 years, with over 700 homeless patients currently registered with the practice. The practice had developed a wide range of services for patients to improve their health outcomes including access to weekly multidisciplinary drop-in clinics. Additional to these in house primary and secondary care services the practice had also established The Manchester pathway (Mpath) a hospital in-reach service at Manchester Royal Infirmary (MRI).
  • The practice ran a campaign during October 'Socktober' in which they encouraged donations of socks that they gave to the homeless who attend the practice.
  • The practice had the largest substance misuse shared care service in place with Manchester drug and alcohol service ‘RISE’ with approximately 200 patients in treatment.
  • The practice had flexibility within their appointment system to ensure all patients requiring on the day emergency appointments were seen.
  • We reviewed the most recent data available for the practice on patient satisfaction. This included information from the national patient survey 2014/15 and the friends and family test. The evidence from all these sources showed patients were very satisfied with how they were treated and that this was with compassion, dignity and respect. For example, data from the national patient survey showed 96% of respondents described their overall experience of this surgery as good and 98% said the last appointment they got was convenient
  • The practice had achieved Gold, the highest award in the NHS ‘Pride in Practice’ award from the Lesbian, Gay, Bisexual and Transgender Foundation.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Outstanding

Updated 20 August 2015

The practice is rated as outstanding for providing safe services. This practice was safer than other similar practices in meeting the needs of the most vulnerable of patients and was improving consistently. 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. 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 enough staff with a good skill mix to keep patients safe.

Effective

Outstanding

Updated 20 August 2015

The practice is rated as outstanding for providing effective services. Our findings at inspection showed that systems were in place to ensure that all clinicians were up to date with National Institute for Health and Care Excellence guidelines and embraced the ‘Standards for commissioners and service providers’ produced by the Faculty of Homeless Health in 2011 (revised 2013). They were actively working to meet all the standards for primary care services for homeless people. We also saw evidence to confirm that these guidelines were positively influencing and improving practice and outcomes for all patients. Data showed that the practice was performing highly when compared to neighbouring practices in the Clinical Commissioning Group. They provided a range of shared care services such as a substance misuse service and leg ulcer clinics. They were innovative and proactive in improving patient outcomes and it linked with other local providers to share best practice.

Caring

Outstanding

Updated 20 August 2015

The practice is rated as outstanding for providing caring services. Data showed that patients rated the practice higher than others for almost all aspects of care. Feedback from patients about their care and treatment was consistently and strongly positive. We observed a patient-centred culture. Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. We found many positive examples to demonstrate how patients’ choices and preferences were valued and acted on. Views of external stakeholders were very positive and aligned with our findings.

Responsive

Outstanding

Updated 20 August 2015

The practice is rated as outstanding for providing responsive services. The practice had initiated positive service improvements for its patients that were over and above its contractual obligations. It acted on suggestions for improvements and changed the way it delivered services in response to feedback from patients, external partners and the virtual patient participation group (VPPG). The practice reviewed the needs of its local population and the homeless population they supported, taking business cases forward and engaging with NHS England Area Team and Clinical Commissioning Group (CCG) to secure service improvements where these had been identified.

Patients told us it was easy to get an appointment, and in non-emergency situations with a named GP or a GP of choice, there was continuity of care and urgent appointments available on the same day. 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 20 August 2015

The practice is rated as outstanding for being well-led. The practice had a clear vision with equality, 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. The practice carried out proactive succession planning. There was a high level of constructive engagement with staff and a high level of staff satisfaction. The practice gathered feedback from patients using new technology, and it had a virtual patient participation group (VPPG) and homeless patient participation group.

Checks on specific services

People with long term conditions

Outstanding

Updated 20 August 2015

The practice is rated as outstanding for the care of people with long-term conditions. Each chronic disease area had a clinical lead who kept the practice up to date with latest guidelines. Nursing staff had lead roles in chronic disease management with a practice nurse trained with an extended role in diabetes including insulin initiation.

Patients at risk of hospital admission were identified as a priority. Care plans and named GPs were in place for those patients with complex, long term conditions. Patients who were on the unplanned admissions register were contacted following admissions to identify any changes to care and treatment required and reviews of care were discussed at practice meetings. The practice worked closely with neighbourhood teams such as district nurses, community matrons, social workers, and respiratory teams holding monthly multidisciplinary meetings to review patients’ needs.

The practice had an electronic register of patients with long term conditions and a recall system in place to ensure patients were called for a review annually so their condition could be monitored and reviewed. For homeless patients with long term health conditions the practice worked as a team with the support of the homeless case managers and the networks they had established across the city to find people. This involved letters to hostels, the nurse attending day centres and outreach sessions to ensure wherever possible homeless patients had the same access to annual reviews as any other patients.

The practice monitored the needs of those patients with a cancer diagnosis and/or those on the palliative care register. A pathway was in place as part of the cancer improvement scheme to enable appropriate referrals and support packages for patients at the end stages of life. Multi-disciplinary palliative care review meetings were held monthly with other health and social care providers.

The national Quality Outcome Framework (QOF) 2013/14 showed, that the majority of clinical and public health outcomes had been achieved to the same level or above the local CCG and national average. For example 100% of outcomes for patients with asthma and 95% of outcomes for patients with Chronic obstructive pulmonary disease (COPD) had been achieved.

Families, children and young people

Outstanding

Updated 20 August 2015

The practice is rated as Good for the population group of families, children and young people. Systems were in place for identifying and following-up vulnerable families who were at risk.

Staff told us that children and young people were treated in an age-appropriate way and were recognised as individuals. We saw evidence to confirm this such as asthma plans in place for children, using the template developed by Asthma UK. Children were provided with two copies of the plan, one of which they were to take into school and pass to teachers assisting schools to support children in managing their asthma. Appointments were available outside of school hours and the premises were suitable for children and babies. All of the staff were very responsive to parents’ concerns and ensured parents could have same day appointments for children who were unwell.

We saw that staff dealing with young people under 16 years of age without a parent present were clear of their responsibilities to assess Gillick competency.

Sexual health, contraception advice and treatment were available to patients including young people. Enhanced family planning clinics were available to all residents of Manchester which included contraceptive implant and coil fitting.

We saw good examples of joint working with midwives, health visitors and school nurses. Weekly baby immunisation and child health surveillance clinics were held at the practice and community midwives ran the antenatal clinic. Non-attenders were discussed as part of weekly safeguarding meetings and followed up by practice nurses/GPs and where appropriate home visits arranged

Staff were knowledgeable about child protection and proactive in raising concerns with the safeguarding lead to follow up on any identified. Dedicated safeguarding childrens clinicians’ and administration leads were in place. Weekly safeguarding meetings took place with nurse leads and GP leads reviewing all children’s out of hours contacts, A&E attendances and discharge summaries to detect early any safeguarding concerns. Where patients were suspected to be victims of domestic violence, this was recorded within patient records and staff were vigilant and made appropriate referrals where necessary. Staff were also aware of the needs to protect children from exploitation and provided examples of joint working to protect vulnerable young people.

Older people

Outstanding

Updated 20 August 2015

The practice is rated as outstanding for the population group of older people. Nationally reported data showed the practice had better than average outcomes for conditions commonly found amongst older people. The practice had a register of all patients over the age of 75 and those patients had a named GP.

The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example dementia, shingles vaccinations and end of life care. The care for patients at the end of life was in line with the Gold Standard Framework. This meant they worked, as part of a multidisciplinary team and with out of hours providers to ensure consistency of care and a shared understanding of the patient’s wishes. Speaking with a district nurse and the Manchester North Cancer lead for MacMillan they told us the whole practice embraced good quality end of life care and were proactive in ensuring patients and their relatives needs were regularly reviewed and needs met.

The practice was responsive to the needs of older people,. GPs, nurses and health care assistants provided home visits and rapid access appointments for those with enhanced needs. Clear alerts were placed on the appointment system highlighting vulnerable patients to ensure reception staff acted in a timely manner and allocated same day appointments or home visits. Staff routinely contact patients by telephone to remind them of appointments.

We saw care plans were in place for patients at risk of unplanned hospital admissions, and those aged 75 and over who were vulnerable, had care plans in place with a named care coordinator. Monthly multidisciplinary meetings were held to discuss care of these patients, and included neighbourhood teams such as district nurses, community matrons, social workers and respiratory teams.

The practice were proactive in immunisation campaigns such as influenza, shingles and pneumonia vaccinations and achieved 69% up take of seasonal flu vaccinations for patients over 65 years of age and 47% for carers.

Working age people (including those recently retired and students)

Good

Updated 20 August 2015

The practice is rated as good for the population group of the working-age people (including those recently retired and students). The practice was proactive in offering online services such as appointment booking, prescription ordering, viewing medical records, and a full range of health promotion and screening which reflected the needs for this age group. The practice also had Facebook and Twitter pages in which they provided details of services and healthy lifestyle information.

Appointments and prescriptions could be booked online in advance. On the day emergency appointments were available as were home visits and telephone consultations to patients who could not attend the practice.

New patient medical assessments and NHS health checks were offered to patients. These were used to gather detailed information from patients enabling the practice to offer timely interventions, treatment and education to prevent deterioration in patients’ health and manage any long term conditions identified. Patients were able to access minor surgery at the practice with a specialist GP offering monthly clinics.

Patients were provided with a range of healthy lifestyle support including smoking cessation with referrals available to external agencies to support people in leading healthier lifestyles.

The practice achieved good uptake of flu vaccinations, 47% in line with national averages. The practice offered meningitis enhanced services to students, and encouraged uptake of chlamydia screening .

The practice had a system in place to identify carers, to enable them to provide appropriate support and referrals.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 20 August 2015

The practice is rated as outstanding for the population group of people experiencing poor mental health (including people with dementia). The practice maintained a register of patients who experienced mental health problems. The register supported clinical staff to offer patients an annual appointment for a health check and a medicine review. Multidisciplinary meetings were held with community psychiatric nurses (CPNs) and local mental health services to meet the needs of those patients with poor mental health.

The practice also held a register of patients with dementia to enable regular reviews of care. The practice worked with multidisciplinary teams in the case management of people with dementia. The practice had in place care planning for patients with dementia where required for example where patients were at risk of unplanned hospital admissions. They actively screened patients who were displaying signs or at risk of dementia using a professionally recognised tool.

The practice had sign-posted patients experiencing poor mental health to various support groups and voluntary organisations and made referrals to mental health services via the Mental Health Gateway Service (Single point of access). Patients also had access to an onsite counselling service.

For patients who experienced difficulties attending appointments at busy periods they would be offered appointments at the beginning or end of the day to reduce anxiety.

People whose circumstances may make them vulnerable

Outstanding

Updated 20 August 2015

The practice is rated as outstanding for the population group of people whose circumstances may make them vulnerable.

The practice has provided primary care to homeless people in Manchester for over 15 years, with over 700 homeless patients currently registered with the practice. The practice have developed a wide range of services for patients to improve their health outcomes including access to weekly multidisciplinary drop-in clinics, drug workers, homeless case managers, leg ulcer clinics and infectious disease clinic to facilitate access to Hepatitis C and Blood borne virus treatment. Additional to these in house primary and secondary care services the practice had also established The Manchester pathway (Mpath) a hospital in-reach service at Manchester Royal infirmary (MRI) based on the work done by London Pathway who pioneered work in this field. Staff from the homeless team visited MRI, to assess homeless patients who were frequent attenders at Accident and Emergency (A&E) or current inpatients. They ensured that they were discharged with a package of care, housing, engagement with primary care services and so did not re-attend A&E unnecessarily. Initial evaluations of the mpath services showed 43% reduction in A&E attendance and 39 % reduction in hospital admission rates.

The practice had the largest substance misuse shared care service in place with Manchester drug and alcohol service ‘RISE’ with approximately 200 patients in treatment. There were two full time drug workers based at the practice. The GPs and practice nurse offered flexible and opportunistic appointments to support their work and provided holistic care packages, as well as opportunistic health screening to ensure those vulnerable patients had easy access to primary care alongside support from key workers. All patients were given access to a full range of drug services including counselling, substitute prescribing and detoxification services. All patients who received substitute prescribing undertook an initial health check which particularly focused on cardiovascular screening, the identification of chronic disease particularly COPD and full bloodborne virus testing. All patients in treatment received an annual health check as well as a six month general practitioner review in combination with their regular contact with their drugs worker.

The practice also offered a range of shared care provisions within the practice which included leg ulcer clinics and a fortnightly specialist led infectious disease clinic to facilitate access to Hepatitis C and bloodborne virus treatment.

The practice had a GP learning disabilities lead that focused on the patient as a whole looking at their physical, emotional and social needs. Patients were offered annual reviews and provided with written care plans.

For patients where English was their second language, or were hard of hearing the practice had close links with interpreter services and easy access to language line. The practice were also developing an email access system for patients with hearing difficulties.

All clinical rooms had a clear notice of adult safeguarding contacts and access to links/forms via an intranet. Adult safeguarding cases were regularly discussed at practice meetings in order to protect vulnerable patients. The practice regularly worked with multidisciplinary teams in the case management of vulnerable people.

We saw a well-established practice team who know the patients well and would actively seek to help a patient should there appear to be concern for their wellbeing.