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Inspection Summary


Overall summary & rating

Good

Updated 15 November 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Kingston Health Centre on 9 August 2016. Overall the practice is rated as Good.

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

  • Overall, risks to patients were assessed and well managed; however, there were some areas where procedures should be more robust. For example, we observed that the room where medicines were kept was not always locked, and there was no process in place for monitoring the expiry dates for Patient Group Directions (the legal paperwork required for some staff to administer medicines); a new process was implemented by the practice immediately after the inspection, and we saw evidence that all necessary legal documents were immediately put in place.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • 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 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, having identified gaps in the community services commissioned by the CCG, they had successfully campaigned for additional services to be provided, these included the provision of a paediatrician to be part of the eating disorders team in order to address the physical needs of these patients, and for the provision of a complex dressing service for patients with challenging wound care needs.
  • Feedback from patients about their care was consistently positive.
  • 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, following feedback from patients they had introduced Saturday morning appointments.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result. Information about making a complaint was available on the practice’s website and a complaints leaflet was available; however, there was no poster in the reception area informing patients about how they could complain.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. The practice had a flexible approach to appointments; reception staff could over-ride the appointments system where necessary to meet demand and staff felt that clinical staff trusted their judgement on this.
  • The practice had strong and visible clinical and managerial leadership and governance arrangements.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw two areas of outstanding practice:

The practice was proactive in assessing the needs of their patient population and in adapting their service to meet the needs of their patients. For example, they had tailored their service to patients with learning difficulties by producing information in “easy read” for patients with learning difficulties, this included a “friends and family test” questionnaire and a care plan template, which allowed the patient to identify their support needs. They also worked closely with a local charity which supported homeless people, and as a result had developed a reputation for providing good quality and tailored service to these patients; they had registered 48 homeless patients in the past 12 months.

The practice had taken the initiative in several areas to provide services that were not available elsewhere in the locality, which in some cases involved staff undertaking additional training and completing further qualifications. For example, GPs at the practice had completed a diploma in mental health in order to offer an enhanced level of care to patients with mental health needs and to bridge the gap between the demand for counselling for patients with mental health needs and the limited provision available through the local community mental health team (CMHT); in particular, one of the GPs had qualified to offer psychosexual counselling, which was not available via the CMHT, and had provided this service to 31 patients in the past three years, with each patient receiving 6-8 sessions of 45-60 minutes each. This service is entirely funded by the practice and delivered outside of normal clinical hours.

The areas where the provider should make improvement are:

  • Ensure that the new system for monitoring the use of PGDs is robust and effective, and ensure that arrangements for the safe storage of medicines are adhered to.
  • They should review how patients with caring responsibilities are identified and recorded on the clinical system to ensure that all of these patients are identified so that information, advice and support can be made available to them.
  • They should ensure that they are advertising to patients prior to their appointment that chaperones and translation services are available. They should also display information about their complaints procedure in the patient waiting area.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 15 November 2016

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.
  • The practice used every opportunity to learn from internal and external incidents, to support improvement. Learning was based on a thorough analysis and investigation.
  • 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.
  • Information about safety was highly valued and was used to promote learning and improvement.
  • Overall, risks to patients were assessed and well managed; however, the arrangements for the secure storage of medicines were not robust.

Effective

Good

Updated 15 November 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average.
  • Our findings at inspection showed that 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. In addition, the practice had created their own internal guidance for areas where the external guidance was insufficient or out dated.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • 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 partners had also undertaken additional training to meet the needs of patients in areas where there was insufficient provision locally; for example, one of the partners had trained to be able to provide psychosexual counselling.
  • The practice used innovative and proactive methods to improve patient outcomes and worked with other local providers to share best practice. For example, they invited consultants from a local hospital to attend to provide training on specialisms such as dermatology, gastroenterology, ophthalmology and hypertension and invited neighbouring practices to attend these sessions.

Caring

Good

Updated 15 November 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.
  • 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; however, the practice had not advertised the availability of chaperones, or the translation service in the waiting area.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 15 November 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 meet patients’ needs. For example, they had a large number of homeless patients registered; they had developed an information pack tailored to the needs of these patients, and worked with local charities to support them. They had also introduced a scheme to encourage Hepatitis B and C testing for patients who had recently moved to the UK from countries with a high prevalence of these conditions.
  • The practice was also the only practice in the CCG to have achieved Kingston Integrated Sexual Health accreditation, which recognised excellence in sexual health provision. As part of this service they provided HIV testing, which was provided as a walk-in service and was provided to all, regardless of whether they were registered as a patient at the practice, the updake was on average 20 patients per month.
  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified. For example, they had identified the need for the CCG to commission specialist wound care provision, and successfully made a case to the CCG for this to be provided.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. GPs reviewed the allocation of appointments daily to ensure that demand was met.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice produced their own patient information leaflets relating to areas relevant to their patients, and in reaction to current events, such as the zika virus. They provided leaflets, and their “Friends and Family Test” form in easy read format for patients with learning disabilities.
  • The practice had introduced designated members of staff to provide training to patients on how to use their IT services for booking appointments and requesting prescriptions. They provided around 15 face to face sessions and 25-30 telephone support sessions per month.
  • The practice provided information sessions for patients on topics such as treating minor ailments in children, managing back pain, mindfulness, support available for carers, and managing stress (an evening session aimed at commuters). They also hosted an annual “Jingle Mingle” mince-pie party for patients. These sessions were also used as an opportunity to tell patients about the PPG and to encourage patients to become members or to sign up for the virtual PPG.
  • Information about how to complain was available and easy to understand, however, there was no poster about the complaints process in the waiting area. Evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Outstanding

Updated 15 November 2016

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

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
  • 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.
  • High standards were promoted and owned by all practice staff and teams worked together across all roles. The practice recorded positive events as part of their significant event reporting, which highlighted areas that staff had excelled in.
  • 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 and identify risk.
  • There was a high level of constructive engagement with staff and a high level of staff satisfaction. Staff said that they felt that the partners respected their opinions, and that their roles were tailored to reflect their skills and interests. The practice had gathered information from staff about their skills and special interests, and was developing each individual’s job role to reflect this. For example, one of their receptionists had expressed an interest in promoting sexual health, and had therefore been trained to administer HIV tests.
  • 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 proactively sought feedback from staff and patients, which it acted on; for example, they had started opening on Saturday mornings in response to patient feedback. The patient participation group was active.
  • There was a strong focus on continuous learning and improvement at all levels. The practice had taken the initiative in several areas to provide services that were not available elsewhere in the locality, which in some cases involved staff undertaking additional training and completing further qualifications. For example, GPs at the practice had completed a diploma in mental health in order to offer an enhanced level of care to patients with mental health needs and to bridge the gap between the demand for counselling for patients with mental health needs and the limited provision available through the local community mental health team (CMHT); in particular, one of the GPs had qualified to offer phychosexual counselling, which was not available via the CMHT. The practice also invited consultants from a local hospital to attend to give talks to staff on specialist areas to ensure that they were kept up to date on current research and treatments available.
Checks on specific services

People with long term conditions

Good

Updated 15 November 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.
  • GPs at the practice had special clinical interests in areas such as diabetes, dermatology and cardiology.
  • Performance for diabetes related indicators were mixed compared to CCG and national averages. Overall the practice achieved 83% of the total QOF points available, compared with an average of 92% locally and 89% nationally. Their exception reporting rate for diabetes related indicators was 12%, which was comparable to the CCG average of 13% and national average of 11%.
  • Longer appointments and home visits were available when needed.
  • All these 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.

Families, children and young people

Good

Updated 15 November 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. Immunisation rates were relatively high for all standard childhood immunisations.
  • 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.
  • Cervical screening had been carried-out for 81% of women registered at the practice aged 25-64, which was comparable to the CCG average of 83% and national average of 82%.
  • The practice was approved by the ‘You’re Welcome’ scheme (a quality criteria for young people friendly health services).
  • 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.

Older people

Good

Updated 15 November 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 people in its population. For example, the practice had designated members of staff to provide training to patients on how to use their IT services for booking appointments and requesting prescriptions.
  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • The practice liaised with community services such as district nurses, the local rapid response team, and palliative care team to provide a complete package of care to these patients.

Working age people (including those recently retired and students)

Good

Updated 15 November 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. In response to patient feedback , the practice had begun providing a Saturday morning clinic for pre-booked appointments. Comments received via the CQC comment cards noted that patients found it easy to access early morning appointments, which allowed them to arrive at work on time.
  • 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 was a registered travel clinic, and also accredited by the Kingston Integrated Sexual Health scheme to provide a comprehensive sexual health service, including contraceptive implants, a fast-track contraception service and immediate HIV testing for any individual regardless of whether they were registered at the practice. “On the spot” HIV testing was provided to an average of 20 patients per month.
  • The practice sent appointment reminders and results by text message.

People experiencing poor mental health (including people with dementia)

Good

Updated 15 November 2016

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

  • The practice had 32 patients diagnosed with dementia and 90% of these patients had had their care reviewed in a face to face meeting in the last 12 months, which was better than the CCG average of 83% and national average of 84%.
  • The practice had 55 patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses, and had recorded a comprehensive care plan for 93% of these patients, compared to a CCG average of 92% and national average of 88%.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice carried-out advance care planning for patients with dementia.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • GPs at the practice had also completed diplomas in mental health in order to deliver better care to patients with poor mental health, in particular those whose conditions were difficult to manage but did not meet the criteria for hospital treatment. One of the partners had completed training in order to offer psychosexual counselling to patients, which was not available locally.
  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support patients with mental health needs and dementia and we saw evidence of reception staff putting special arrangements in place to support these patients, for example, they had a system of telephoning some patients with dementia on the day of their appointment to remind them to attend.

People whose circumstances may make them vulnerable

Outstanding

Updated 15 November 2016

The practice is rated as outstanding 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. They had registered 48 homeless patients in the past 12 months, and worked closely with local charities to support these patients.

  • The practice offered longer appointments for patients with a learning disability. The practice conducted annual reviews of their patients with learning disabilities; they had 14 patients on their learning disability register and had completed reviews of seven of these patients in the past 12 months. They had created an “easy read” template to help these patients to understand the care package that was in place for them.

  • 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. They had also created their own patient information leaflets for vulnerable patients. They had an information pack for homeless patients which was given to them when they registered at the practice. They had also produced several leaflets and forms in “easy read” for the benefit of patients with learning disabilities and those who did not speak English as a first language.
  • 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.