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Inspection Summary


Overall summary & rating

Good

Updated 14 December 2018

This practice is rated as Good overall. (Previous rating November 2017 – Good overall). The practice was rated as requires improvement for providing safe services. A breach of legal requirement was found and a requirement notice was served in relation to safe care and treatment. The full comprehensive report on the November 2017 inspection can be found by selecting the ‘all reports’ link for Mansion House Surgery on our website at www.cqc.org.uk.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Mansion House Surgery on 19 November 2018. This was to follow up on breaches of regulations and confirm the practice had met the legal requirement in relation to the breach in regulation that we had previously identified.

At this inspection we found:

  • The practice leaders had taken the findings from the previous CQC inspection to improve the services provided and patient safety and care. The breach in regulation had been addressed and all of the best practice recommendations we made at the previous inspection had been addressed. However, we identified further improvement was required in some areas.
  • The practice 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 had effective systems, processes and practices in place to protect people from potential abuse and staff had received safeguarding training appropriate to their role.
  • There were systems in place for identifying, assessing and mitigating risks to the health and safety of patients and staff.
  • The practice routinely reviewed the effectiveness and appropriateness of the care provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Some patients reported that they found difficulties with the appointment system use and that they found it stressful to access care when they needed it.
  • The practice actively worked with the patient participation group (PPG) to meet the needs of their patients and were also working towards developing a virtual PPG.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Continue to develop root cause analysis to provide sufficient detail when investigation incidents and complaints.

  • Complete the ongoing development for a written vision and strategy for the service.
  • Consider the electronic sign in screen having more than one language.
  • Take appropriate action to improve the telephone access for patients.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Safe

Good

Updated 14 December 2018

We rated the practice as good for providing safe services.

At our previous inspection in November 2017, we rated the practice as requiring improvement for providing safe service. This was because the provider had failed to do all that was reasonably practicable to mitigate risks to the health and safety of service users receiving care and treatment. Specifically: a risk assessment had not been completed to support the decision not to stock emergency medicines as recommended. Not all environmental health and safety risk assessments had been formally assessed. Staff had not received up to date essential training which included safe working practices and safeguarding.

At this inspection we saw that improvements had been made and a comprehensive risk assessment was in place for emergency medicines. We saw that action had been taken to review this risk assessment in line with updated guidance. Environmental health and safety risk assessments had been formally assessed. Staff had received up to date essential training which included safe working practices and safeguarding.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse.

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control. A comprehensive infection control audit had been carried out, with a compliance rate over 90%. Additional quarterly spot check audits on hand washing technique had been carried out. The full audit was supported with a dedicated action plan which captured all completion dates. For example, all clinical couches had been recovered, as many had been found to have small grazes and or tears in the surface. All carpets had been replaced in clinical rooms. All taps in clinical areas were now elbow operated. Monthly cleaning audits were in place and recorded. The infection control lead had requested that the practice support from external infection prevention and control audits for the oncoming year. They felt this would support ongoing improvements in quality and best practice. The practice was still considering this option at the time of our inspection.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe. The practice had recently updated its policy for staff handling of specimens, all staff we spoke with knew about the changes and how to handle specimens safely.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient safety.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics. Staff we spoke with told us that they managed this but it would be easier if they had an extra member of the team. The practice told us about their recruitment plans and that they expected to have an extra nurse and another GP soon.
  • There was an effective induction system for temporary staff tailored to their role. At the last inspection November 2017, we had made a best practice recommendation that temporary staff had a suitable induction system. Practice leaders had acted on this and a detailed and effective induction system for temporary staff was in place.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis. Staff used the electronic emergency alert process. Staff we spoke with who had used this emergency system reported, that it took seconds for help to reach them and that they had confidence in the process.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

The practice had reliable systems for appropriate and safe handling of medicines.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks. There was a dedicated insulated box with an integral thermometer to ensure that the cold chain was maintained when vaccines were administered to patients outside of the practice.
  • Staff prescribed and administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues. At the last inspection November 2017, we had made a best practice recommendation that risk assessments were completed. Practice leaders had acted on this and at this inspection we saw that comprehensive health and safety risk assessments were in place.
  • The practice monitored and reviewed safety using information from a range of sources.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so. Staff we spoke with told us that they were encouraged to raise any concerns and that practice leaders were encouraging and receptive to all concerns raised.
  • There were systems for reviewing and investigating when things went wrong. However, the root cause analysis required further work. There were some incidents in which one causative factor had not been included. This would also have enabled the practice to identify when policy or protocol required review. The practice learned and shared lessons, identified themes and took action to improve safety in the practice. Staff we spoke with told us that they were well supported when things had gone wrong and that they were comfortable to share the learning from events.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the evidence tables for further information.

Effective

Good

Updated 14 December 2018

We rated the practice and all of the population groups as good for providing effective services overall.

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication. Any frail patient that presented with a problem was offered a full assessment to reduce the stress to the patient of having to make a further appointment. There were 175 patients on the practices frailty register.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care. Patients were offered flexible appointments to support their annual review.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension).
  • The practice’s performance on quality indicators for long term conditions was in line with local and national averages.

Families, children and young people:

  • Childhood immunisation uptake rates were in line with the target percentage of 90% or above. The practice scored 94% and 91% for childhood immunisations. The practice had reviewed the arrangements for baby clinic and had reinstated a GP led clinic for women and their eight-week-old babies.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation. Children that had not been taken for appointments in secondary care were followed up appropriately. Where appropriate these non-attendances were shared with the safeguarding team.

Working age people (including those recently retired and students):

  • The practice’s uptake for cervical screening was 76%, which was below the 80% coverage target for the national screening programme. The practice was aware of this and were trying to find ways to improve on the target. Nurses were opportunistically encouraging patients to have the test done. The computer system had a flag which identified when a woman had not had this test completed; so that at any attendance the clinician could explain the importance of the test and encourage the woman to book an appointment.
  • The practice’s uptake for breast cancer screening was 68%, slightly below the regional and national average of 70%. The practice’s uptake for bowel cancer screening was 62% above the national average of 54%. The practice told us that they opportunistically spoke to women about the importance of breast screening when thy attended for other reasons.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

  • 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 was part of a forward planning initiative with the local hospice. This was a detailed plan which took account of the persons beliefs and wishes as well as treatment options and legal requirements.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability. There were 76 patients on the learning disability register and over 50% of these had received a face to face review. The practice had a plan in place to provide face to face reviews for all of its learning disability patients annually.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

People experiencing poor mental health (including people with dementia):

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medication. The practice held a joint clinic with a community mental health nurse every month.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis. The referral process included a specialist clinic which was held at the practice every week.
  • The practices performance on quality indicators for mental health was above in line with local and national averages.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • The practice used the information collected for the Quality and Outcomes Framework (QOF) and performance against national screening programmes to monitor outcomes for patients. QOF is a system intended to improve the quality of general practice and reward good practice. The most recent published results for 2017/18 showed the practice had achieved 96.2% of the total number of points available compared with the clinical commissioning group (CCG) average of 97.8% and the national average of 96%. The practice exception reporting was 12% broadly in line with the local and national averages of 12% and 10% respectively. The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity and had carried out a range of audits in the last 12 months. These were a mix of one and two cycle audits. Those with only one cycle had a second cycle planned. The two cycle audits we reviewed demonstrated quality improvement.
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.

  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice had an inclusive mix of leaders with a diverse skill set.
  • The practice was a training practice and at the time of inspection had two GP registrars. GP Registrars had allocated time scheduled each day with a GP trainer to support them in their work. GP registrars are qualified doctors who undertake additional training to gain experience and higher qualifications in general practice and family medicine.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • The practice carried out regular health and medication reviews at local care and nursing homes. They also had a nurse led proactive approach to the care of the residents which reduced the number of admissions into A&E and improved patient outcomes.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example the lead nurse for diabetes encouraged patients to form small walking groups with their friends. The practice had plans to participate in social prescribing schemes locally in the near future.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.

Caring

Good

Updated 14 December 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.

The results of the National GP patient survey, published August 2018, showed the practice was in line with local and national averages for questions relating to kindness, respect and compassion.

  • Two hundred and thirty-three surveys were sent out and 104 were returned giving a completion rate of 45%. Results showed 88% of patients who responded said the healthcare professional they saw or spoke to at their last appointment was good at treating them with care and concern; compared with the local average of 87% and the national average of 87%.
  • Eighty percent of patients who responded said the overall experience at the GP was positive, compared with the local average of 81% and the national average of 84%.
  • Ninety-nine percent of patients who responded said they had confidence and trust in the last healthcare professional they saw; compared with the local average of 96% and the national average of 96%.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.) For example, they had easy read information available. The clinical rooms were all on the ground level with flat level access. There was large clear signage to all of the clinical rooms. There was a hearing loop available within reception. Translation services were available although the electronic sign in screen was only available in English. The practice told us that they were trying to get the sign in screen adjusted so that is was more appropriate for people with visual disabilities. There was a reduced height section of the reception desk which was a suitable height for people who used wheelchairs.

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available. People needs were identified and recorded on the computer system so that staff could provide appropriate support for their appointment.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them. There were 321 carers identified on the practice register which was just over two per cent of the practice list. The practice had recently invited a member of the carers association to talk to staff members during protected learning time. This was part of the practices ongoing commitment to review what support they could offer carers. At the time of inspection, they offered influenza vaccinations to carers. They had a dedicated carers noticeboard with signposting to useful services and support.

The practices GP patient survey results were broadly in line with local and national averages for questions relating to involvement in decisions about care and treatment. Results from the national GP patient survey, published in August 2018, showed:

  • Ninety-seven percent of practice patients who responded to the national GP survey said they were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment; compared with the local average of 95% and the national average of 93%.

Privacy and dignity

  • When patients wanted to discuss sensitive issues, or appeared distressed reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.

Responsive

Good

Updated 14 December 2018

We rated the practice, and all of the population groups, as good for providing responsive services.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • The facilities and premises were appropriate for the services delivered. The purpose-built facilities provided ground floor clinical rooms for patients. A lift was in place for anyone requiring access to the first floor.
  • The practice made reasonable adjustments when patients found it hard to access services. Same day urgent home visits were triaged and available to people who needed them. The triage process determined who made the visit; visits could be made by an ANP (advanced nurse practitioner) or a GP.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice. Flexible appointments were available for people when they needed them.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme. The practice also supported older people living within religious orders locally.
  • The practice held a frailty register. Of the 175 patients on this register 167 have received face to face reviews within the last 12 months. The practice has identified that three of the remaining eight patients were seen by the district nursing service at the request of the practice. There was one who had chosen not to accept the offer of the face to review and this was recorded at the practice. Two patients were living in care and two were new to the practice.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • 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. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

Working age people (including those recently retired and students):

  • The needs of this population group 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, extended opening hours through the Primary Care Extended Access initiative. This provided appointments from 6.30pm – 8.pm on weekdays, 9am – 1pm on Saturdays, and 10am – 12 noon Sundays and Bank Holidays.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

People experiencing poor mental health (including people with dementia):

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • The practice held GP led dedicated weekly mental health and dementia clinics. Patients who failed to attend were proactively followed up by a phone call from a GP.

Timely access to care and treatment

Patients could access care and treatment from the practice within an acceptable timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was not easy to use. People we spoke with told us that on-line appointments went very quickly and that trying to get through by telephone was difficult and time consuming.

Results from the national GP patient survey, published in August 2018, showed that patients’ satisfaction with how they could access care and treatment was broadly in line with the local and national averages. Data showed:

  • Sixty-one percent of patients who responded described their experience of making an appointment as good; compared with the local average of 62% and the national average of 69%.
  • Seventy-three percent of patients who responded said they were satisfied with the type of appointment they were offered; compared with the local average of 70% and the national average of 74%.
  • Fifty-nine percent of patients who responded said they were satisfied with the general practice appointment times available compared with the local average of 60% and the national average of 66%.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 14 December 2018

We rated the practice as good for providing a well-led service.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

The practice had recently held development meetings with staff to develop a clear vision. They had not yet completed this work but they planned to support the vision with a credible strategy to deliver high quality, sustainable care.

  • The practice had a mission statement to work in partnership with their patients, to understand their needs and deliver the highest standards of medical care to the community. The practice had supporting business plans to achieve priorities.
  • Staff were aware the vision and values were being developed and that they had a role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.

Culture

The practice had a culture of high-quality sustainable care.

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • The practice focused on the needs of patients.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective.
  • Staff were clear on their roles and accountabilities including safeguarding and infection prevention and control.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care. The practice used a variety of dashboards to monitor its progress when treating people with a range of long term conditions.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved, the public, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal reviews of incidents and complaints. However, the root cause analysis process did not effectively identify all causative factors. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good