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Inspection Summary


Overall summary & rating

Good

Updated 15 November 2018

This practice is rated as good overall. This is the second inspection of Stowhealth, at our last inspection 24 February 2015 the practice was rated as outstanding.

The key questions are rated as:

Are services safe? – Requires improvement

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 Stowhealth on 4 October 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had 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 worked within a partnership of 11 practices and an electronic centralised reporting system was in place to ensure shared learning and changes were made to the benefit of the population of the Suffolk Primary Care partnership.
  • The practice had reliable systems for appropriate and safe handling of medicines within the dispensary. The practice did not have reliable systems in place for the handling of vaccines. Immediately following the inspection, the practice took action to implement a safe system and to ensure no patients had received medicines that may have been compromised.

  • The practice had not ensured that all medical records were summarised in a timely manner. Immediately following the inspection, the practice submitted their plan to address the issues found.
  • The practice had not carried out an appropriate risk assessment to identify all emergency medicines that it should stock. During the inspection the practice undertook a risk assessment and ordered the additional medicines.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines. The practice showed evidence of a comprehensive audit and quality management programme that was undertaken throughout the year.
  • The practice had recognised that there was a lack of specialist mental health services to support patient experiencing poor mental health but did not meet the criteria for referral. The practice employed mental health nurse (CPN) to support their patients through a difficult time. On the day of the inspection the nurse was no longer working at the practice but now through the Suffolk Primary Care these nurses will be available in the practice and across all 13-member practices.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • The data from the GP patient survey showed the practice consistently was in line or above the CCG and national averages.
  • Patients found the appointment system easy to use and reported that they were able to access care when they needed it. The practice operated a telephone consultation appointment system. All patients were spoken to by a clinical staff member and appointments for either acute or follow up care were arranged by the GP. Patients we spoke with told us they had easy and appropriate access to appointments.
  • The reception team had been trained as care navigators and the whole practice team had worked together to ensure patients spoke to the right person at the right time. Patients and staff had told us that this had increased the positive experience for patients.
  • The practice demonstrated a patient focused approach to providing health care. They were proactive in offering other services for the benefit of the patients, including those provided by the NHS and others from private providers. For example, NHS services included an oncology service giving chemotherapy on site, the papworth sleep clinic and Onelife Suffolk weight management and smoking cessation clinics. Private providers included a fully equipped gym where GPs could refer patients for a number of free sessions, podiatry and exercise classes.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The area where the provider must make improvements as they are in breach of regulations is:

  • Ensure care and treatment is provided in a safe way to patients.

The areas where the provider should make improvements are:

  • Review and improve the recording of carers to ensure they receive appropriate support.
  • Review and improve the system to ensure medical records are summarised in a timely manner.
  • Review the system to ensure the practice has clear oversight of actions identified in risk assessments to keep patients and staff safe.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas

Effective

Good

Updated 15 November 2018

We rated the practice as good for providing effective services overall and across

all population groups.

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.
  • The practice embraced new technology and had recently used a touch pad facility to screen for an atrial fibrillation. They had used this during a recent flu clinic and had identified fifteen patients as requiring further investigation. The practice also used a mobile application to help patients monitor their health and well-being.
  • The practice had a blood pressure monitoring machine available in the waiting area, the results were added to the patient’s medical records and patients were reviewed as appropriate.
  • 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 medicines.
  • The practice followed up on older patients discharged from hospital. It ensured their care plans and prescriptions were updated to reflect any extra or changed needs.
  • The practice clinical pharmacist undertook frailty reviews and visited care homes to review patient’s medicines.
  • 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.
  • 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 could demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension). The practice used a touch screen electronic system to screen patients for atrial fibrillation. This had successfully used during a recent flu clinic and patients were reviewed where necessary.
  • The practice’s performance on quality indicators for long term conditions was above or in line local and national averages.

Families, children and young people:

  • Childhood immunisation uptake rates were above the target percentage of 90%.

  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.
  • The practice team includes a nurse who had received training in paediatrics. This nurse also worked as part of the minor illness team.

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

  • The practice’s uptake for cervical screening was 76%, which was above the CCG average of 74% and the national average of 72%. It was below the 80% coverage target for the national screening programme.
  • The practice’s uptake for breast and bowel cancer screening was above the national average.
  • 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 including NHS checks for patients aged 40-74. These appointments were available on a Saturday morning and additional appointments were available for patients at weekends and evenings via the GP+ service. 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 used hand held care notes (yellow folders) which the patient held in their homes to ensure other visiting professionals had easy access to important information.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • 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.
  • To protect patient’s confidentiality, privacy and dignity the practice called the appointments for patients with dementia to be reviewed ‘Wednesday appointments’. This enabled patients to access appropriate appointments easily.
  • There was a system for following up patients who failed to attend for administration of long term medicines.
  • 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 practice offered annual health checks to patients with a learning disability.
  • The practices performance on quality indicators for mental health was in line 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 performance in relation to the quality and outcome framework was 100%; the practice shared their data for 2017/2018 which since the inspection has been verified and published and this had been maintained at 100%.
  • The practice exception reporting was 4%; this was below the CCG average of 5% and the national average of 6%. The data for 2017/2018 showed the practice had reduced their exception reporting to 3%. Since the inspection the data for 2017/2018 has been verified and published.
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. The practice had a comprehensive programme of audits and searches throughout the year to monitor their quality and performance. 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 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. The practice had a comprehensive pack for locum staff to ensure they were fully aware of the practice processes and procedures.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.
  • Dispensary staff were appropriately qualified and their competence was assessed regularly. They could demonstrate how they kept up to date.

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.
  • 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.
  • The practice ensured that end of life care was delivered in a coordinated way which considered the needs of different patients, including those who may be vulnerable because of their circumstances.

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 through social prescribing schemes.
  • 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.
  • The Patient Participation Group (PPG) worked closely with the practice to ensure patients were made aware of the opportunities that were locally available to them.
  • The GPs were able to refer patients to a gym that was in the same building. Patients could be seen for six sessions free of charge at times that were convenient to them.

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 decide.
  • The practice monitored the process for seeking consent appropriately.
  • The practice obtained written consent for patients receiving minor surgery procedures.

Please refer to the evidence tables for further information.

Caring

Good

Updated 15 November 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 practices GP patient survey results were in line with the local and national averages for questions relating to kindness, respect and compassion. The practice regularly reviewed feedback from patients including that received via NHS choices and Healthwatch Suffolk.

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.)

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • 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 but they recognised their recording on patients who were carers needed to improve as it was inaccurate on the day of the inspection. The practice took immediate action to remedy this and found that some of the inaccuracies were due to external agencies but addressed those incorrectly coded by their own staff.
  • The practices GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment.

Privacy and dignity

The practice respected patients’ 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 15 November 2018

We rated the practice as good for providing responsive services overall and across

all population groups.

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 practice was proactive and hosted a number of services for the patients including services such as an ultrasound clinic, the oncology team giving chemotherapy on site, a vascular surgery and rheumatology clinic.
  • Other private services were hosted including a gym to which GPs could refer patients for six free sessions of one to one fitness coaching, podiatry, counselling and hearing care.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who were more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.
  • The practice provided dispensary services for people who needed additional support with their medicines; for example, a delivery service, weekly or monthly blister packs and large print labels.

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 was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. The practice paramedic assisted with home visits ensuring patients were seen in a timely manner.
  • There was a medicines delivery service for housebound patients.
  • The practice provided care to a number of patients living in care homes. At the request of one of the care homes the practice had invested in the provision of medicines within a specific monitored dose system (Biodose). The practice told us this investment would benefit many patients that were eligible to use the dispensary service at the practice.
  • During the severe weather conditions in March 2018, the practice undertook a search of patients aged 85 and who had not been seen by the practice recently and contacted those not seen to ensure that they were safe and well.

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.
  • The practice offered a range of sexual health and family planning services. For example, long acting contraceptive services and free condoms to young people.

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 and Saturday appointments.
  • NHS health checks were available on Saturday mornings to enable those patients who worked to have easy access.

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.
  • Staff had previously recognised there was sometimes delays or complications with carers or relatives obtaining medicines for patients receiving end of life care and had worked proactively to improve the system. The secretaries developed a system to coordinate the medicine charts required by the community team along with the prescription and checked the medicine was available at the dispensary or local pharmacy. They telephoned the carer or relative and gave the details of where to collect the medicine to avoid the patient having to make multiple trips.

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 follows up patients on the serious mental health register at least annually. Patients who failed to attend were proactively followed up by a phone call from a GP.
  • The practice had piloted the employment of a nurse who was a specialist in the care of patients who maybe experiencing poor mental health. On the day of the inspection, the nurse was no longer employed by the practice but through the wider partnership of Suffolk Primary Care partnership, specialist nurses will be available across the thirteen practices.

Timely access to care and treatment

Patients were able to 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 the appointment system was easy to use. The practice had been operating a telephone first appointment system for the past three years. All patients requesting an appointment spoke with a member of the clinical team first and then appointments were booked as appropriate.
  • For patients who wished to see a GP of choice, a telephone call was arranged and the GP booked the appointment as required with the patient.
  • The practice had trained the reception team as care navigators and the whole practice team had been involved in developing the system to ensure patients spoke with the right person at the right time. This had been beneficial for patients and staff; for example, patients who required advice and guidance on their hospital appointments were directed to the secretarial team.
  • The practice GP patient survey results were above the national averages for questions relating to access to care and treatment. For example, 97% of patients reported they found it easy to get through to the GP practice by phone, this was above the CCG average of 79% and the national average of 70%.

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.

Checks on specific services

People with long term conditions

Good

Families, children and young 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