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Inspection Summary


Overall summary & rating

Outstanding

Updated 22 April 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Clare House Surgery on 21 January 2016. Overall the practice is rated as outstanding.

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.
  • There were innovative approaches to providing person centred care with risks to patients assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Eighty four patients expressed high levels of satisfaction about all aspects of their care and treatment at the practice during the inspection. They said they were always treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said staff responded immediately to their request and found it easy to make an appointment with a named GP for continuity of care, with urgent appointments available the same day.
  • The practice facilities had been refurbished to a high standard and was well equipped to meet their needs.
  • There was a strong leadership structure and staff said they 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.
  • The leadership, governance and culture of the practice put quality and safety as its top priority in delivering person centred care and treatment. We saw many examples of this throughout the inspection, which was a common thread seen in the areas of outstanding practice.

We saw four areas of outstanding practice:

  • Patients individual needs and preferences were central to the planning and delivery of tailored services.Following feedback from patients, the practice altered the appointment system.This is completely flexible and set up in a way that suits patients so they have autonomy to decide when to have a face to face appointment with a GP or nurse as opposed to a telephone consultation.

  • A systematic approach is taken to working with other organisations to improve care outcomes, tackle health inequalities and obtain best value for money for people living in Tiverton. Clare House Surgery has embraced the concept of living well and is facilitating the integration of services to specifically bring care and treatment closer to home for patients and we saw many examples of this. For example, there were several GPs with specialist interest qualifications enabling the practice to provide extended dermatology and surgical services normally seen in hospitals.

  • The practice takes a truly holistic approach to assessing, planning and delivering care and treatment to people who use services. The whole practice team is given a verbal handover every day so that the needs of vulnerable older patients and those with mental and chronic health conditions are known.This daily monitoring of these patients andco-ordination across the team aimed to reduce the risk of unplanned hospital admissions for these patients.

  • A respiratory disease nurse specialist is a member of the British Lung Foundation and works collaboratively with a nearby practice in Tiverton to deliver a hospital based rehabilitation programme for patients with long term respiratory diseases.Patients experienced an integrated service with a rolling programme of referrals, continuity of treatment and expertise from these nurses on the rehabilitation course.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 22 April 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events

  • Lessons were shared to make sure action was taken to improve safety in the practice.

  • When there were unintended or unexpected safety incidents, patients received reasonable support, truthful information, a verbal and 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.

  • Risks to patients were assessed and well managed.

Effective

Good

Updated 22 April 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 for the locality and compared to the national average.

  • Nurses led the management of patients with chronic conditions, carrying out reviews of patients with respiratory conditions or diabetes.

  • Staff assessed needs and delivered care in line with current evidence based guidance.

  • 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 multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 22 April 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.

  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Outstanding

Updated 22 April 2016

The practice is rated as outstanding 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 patients needs were met. For example, the nursing team instigated the setting up a respiratory rehabilitation group and worked closely with another practice to support this at the local hospital.

  • There are innovative approaches to providing integrated person-centred care. Advanced skills of clinical staff meant that services normally seen in hospital were available for patients.

  • There were a range of appointments and walk in services available; same day service for patients needing to be seen urgently and late appointments Monday to Friday were available for working patients and those with minor illness.

  • Patients remarked positively about improvements to the appointment system. The practice had worked collaboratively with the patient participation group to improve patient experience, carrying out an appointment demand audit and using this to inform the setting up a new system. In January 2016, an extra 182 appointments were accessible to patients above the national standard expected for the number of registered patients.

  • Clare House was commissioned to provide extended surgical and dermatology services. GP with Special Interest delivered these, so patients were able to access rapid diagnosis and treatment for conditions such as low risk skin cancer closer to home.

  • All 10,440 patients registered at the practice had a named GP and experienced continuity of care with their own GP if they were admitted to Tiverton hospital, where the practice provided medical cover.

  • The practice had refurbished the building to a high standard and was well equipped to treat patients and meet their needs. For example, there was a fully equipped operating theatre on site and reasonable adjustments such as portable hearing loops could be used in every consultation room and reception.

  • Named staff were responsible for maintaining recall registers to ensure patients attended follow up appointments. An example was the structured recall system and weekly searches to identify any female patients prescribed contraceptives by injection which were overdue to help reduce the risk of any unplanned pregnancies for these patients.
  • 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 22 April 2016

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

  • The practice had a strong vision with quality and safety as it’s top priority in delivering person centred care and treatment for patients. This focussed on providing an integrated service, which enabled patients to live well to the best of their abilities by bringing services closer to home. We saw several examples of this, which included the development of extended surgical services. These developments brought clinical expertise to the practice so that patients could access services avoiding having to travel 25 miles to the main hospital in Exeter.

  • High standards were promoted and owned by all practice staff and they worked together across all roles. Innovative approaches were taken when recruiting new staff using role play and observation of interaction styles to promote a good experience for patients. This ensured a high calibre of staff was employed and their skills and knowledge were relevant to local patient needs.

  • Governance and performance management arrangements had been proactively reviewed and took account of current models of best practice.

  • There were high levels of staff satisfaction. Staff were proud to work at Clare House Surgery. Staff told us that the culture was positive and retained a family orientated atmosphere, in which every member was encouraged to engage in development of patient centred services.

  • Clare House Surgery provided placements for GP registrars, qualified doctors training to be GPs and medical students. Feedback from trainees and students demonstrated this was a popular placement and they wanted to return to work there permanently.

  • 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 knowing about 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. The patient participation group was active. Developments were underway to obtain focussed feedback from groups of patients, for example from carers and patients with specific health needs such as chronic respiratory conditions to ensure that their needs were met.

  • Leadership drove continuous learning and improvement at all staff levels with innovation, funding and support being given so that staff extended their skills for the benefit of patients.

Checks on specific services

People with long term conditions

Outstanding

Updated 22 April 2016

The practice is rated as outstanding 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.

  • Heath promotion was strongly advocated through rehabilitation aimed at enabling patients to achieve the best quality of life possible. For example, the nursing team was instrumental with another practice in developing the pulmonary care group run at the community hospital and continued to provide expertise and support with this. Patients experienced continuity of care as a result.

  • 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.

  • The practice prescribing team worked on a one to one basis with patients. Patients were contacted in whatever way was appropriate for them with reminders to attend for blood testing or reviews. For example, patients with

    rheumatoid arthritis who were prescribed DMARDs (Disease-modifying anti rheumatic medicines) were contacted every month to ensure that any potential risks to their health were reduced by being regularly reviewed. No prescriptions could be generated until blood tests had been completed.

Families, children and young people

Outstanding

Updated 22 April 2016

The practice is rated as outstanding 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.

  • The percentage of 73.18% of patients diagnosed with asthma, on the register, who had an asthma review in the last 12 months was comparable with the national percentage of 75.35%.

  • 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. For example, the child and parent/s were invited to a post asthma review meeting to discuss the outcome and given further advice about using inhalers to help reduce the risk of an asthma attack.

  • The practice’s uptake for the cervical screening programme was 79.62% which was comparable with the CCG average of 77.0% and the national average of 81.83% in 2014/15. However, the whole team had been involved in raising public awareness of health promotion with an open event which included the value of cervical screening. The results from this campaign were not yet known as to whether the uptake had increased the number of female patients having a cervical smear.

  • Appointments were available outside of school hours, for example, flu clinics had been run during the school holidays and on Saturdays. The premises were suitable for children and babies. The practice had listened to feedback and created play areas within the waiting rooms for children.

  • We saw positive examples of joint working with midwives, health visitors and school nurses.

  • The practice was engaging with young patients through email, online booking and use of social networking sites. The Patient Participation Group was proactive in trying to attract young patients to become members.

Older people

Outstanding

Updated 22 April 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. For example, a named member of staff on the prescriptions team provided personalised support for older people with their medicines. Orders for repeat prescriptions were co-ordinated so that the patients were able to telephone once and arrangements made for home delivery to anyone who was housebound or a chemist of their choice. Close working relationships were established with the community matron for patients over the age of 75 with complex healthcare needs.

  • Every patient had a named GP, who provided continuity of care for them including if they were an inpatient at Tiverton hospital.

  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. There was proactive management of patient needs, which was risk rated and closely monitored. The practice respected patients requests for home visits without first triaging these and GPs made at least 20 home visits per week to patients at home.

  • The entire team were made aware with a verbal handover on a daily basis of any patient whose needs had changed and the support they might need from the practice that day.

Working age people (including those recently retired and students)

Outstanding

Updated 22 April 2016

The practice is rated as outstanding 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.

  • Clare House surgical service offered late evening vasectomy appointments for working men.

  • Extended hours contraception (Coil & IUD Fitting) clinics were planned for 2016.

  • 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.

  • A travel advice and vaccination service was accessible for patients.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 22 April 2016

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

  • 77.59% of patients diagnosed with dementia who had had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the national average of 84.01%.

  • The percentage of patients with complex mental health needs that had a comprehensive, agreed care plan documented in the record, in the preceding 12 months was 93.1% which was higher than the national average of 88.47%.

  • The practice helped patients focus on recovery with support and well managed treatment plans, which could include injectable medicines. Staff were responsive to patients needs enabling them to be seen at the practice whenever they presented there, which had a positive impact on maintaining their mental wellbeing.

  • 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.

  • 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.

People whose circumstances may make them vulnerable

Outstanding

Updated 22 April 2016

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

  • The practice held registers of patients living in vulnerable circumstances including homeless patients, travellers and those with a learning disability.

  • All relevant team members were updated on a daily basis about any vulnerable patients and were responsive to information about changing needs enabling patients to be seen or contacted without delay.

  • The practice offered longer appointments of a minimum of 30 minutes for patients with a learning disability. When patients had an annual review, the time was allocated according to the person’s needs.

  • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable patients.

  • 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.

  • Reasonable adjustments were in place to ensure that patients with communication needs were fully involved in decisions about their care and treatment. For example, during the refurbishment of the building the practice purchased portable hearing loops to be used in consultation and waiting rooms.