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Inspection Summary


Overall summary & rating

Good

Updated 17 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Spa Medical Practice on 20 September 2016. Overall the practice is rated as good.

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

  • There were effective systems in place to monitor and maintain patient safety in the practice.
  • Staff understood their responsibilities to raise concerns and to report incidents and near misses. Incidents were regarded as opportunities for learning across the practice team and for improving patient care.
  • Patients’ needs were assessed and care delivered in line with best practice guidance.
  • Staff had received training to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients told us that they were treated with kindness, dignity and courtesy and that they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • All patients had a nominated GP, which provided continuity of care. Family members had the same nominated GP.
  • Patients said they found it easy to make an appointment with a named GP and that they appreciated the continuity of care. Patients could get urgent appointments the same day.
  • There was strong collaboration between the practice and the Patient Participation Group.
  • There was active liaison with the Worcestershire Association of Carers. 3% of patients had been identified as carers.
  • The Spa Medical Practice was the base for the town INR service (a service to monitor patients on a blood-thinning medicine).
  • A GP had initiated the diagnostic ultrasound service, which was funded by the Clinical Commissioning Group.
  • The practice proactively initiated alternative ways to improve patient outcomes. For example, it was the first in the county to employ an advanced nurse practitioner who was a qualified Acute Care Practitioner.
  • The practice was located in purpose-built premises and was well equipped to treat patients and meet their needs.
  • There was a strong and visible clinical and managerial 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 several areas of outstanding practice including:

  • The business manager had been instrumental in setting up the Social Prescribing Pilot project in the Locality. The project provided advice and support for patients with social needs or for those who had mental health issues.
  • The practice provided a minor injuries service, because the practice was situated more than five miles from the nearest A&E department. The minor injuries service was open between 8am and 6.30pm for any new injury that had occurred within the past 48hrs. This was a walk-in service for any patient.
  • A Gateway worker and a psychologist from the Primary Care Mental Health Service held clinics at the practice every Monday. Mental health counselling was also available every Thursday.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 17 January 2017

The practice is rated as good for providing safe services.

  • The system for reporting and recording significant events was effective. All incidents were fully investigated and logged on a spreadsheet. Staff understood their responsibilities with regard to raising concerns and reporting incidents and near misses. Significant events were discussed at the monthly clinical governance meetings and learning points shared at the full practice meetings.
  • Lessons learned were shared with the team at regular meetings to ensure that action was taken to improve safety in the practice.
  • When things went wrong patients received support, information, and a written apology. They were told about any actions to improve processes to prevent a recurrence.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse. All staff had received safeguarding training appropriate to their role.
  • The practice assessed risks to patients and had systems for managing specific risks such as fire safety, infection control and medical emergencies.
  • The practice engaged an external consultant firm to advise on their health and safety procedures, including their health and safety handbook, and to undertake an annual inspection. This ensured that the practice received up to date guidance in health and safety matters.
  • The practice had a comprehensive business continuity plan in place for major incidents such as power failure and loss of medical records. Mutual aid arrangements with local practices had been agreed in the event of an emergency.
  • There were sufficient staff on duty to keep patients safe and the practice was clean and tidy.
  • Recruitment procedures were followed to ensure that appropriately qualified staff were employed at the practice.

Effective

Good

Updated 17 January 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) 2014/15 showed that most patient outcomes were at or above average compared to the national average.
  • Staff assessed needs and delivered care in line with National Institute for Health and Care Excellence (NICE) and local guidelines.
  • The practice engaged with the South Worcestershire CCG Improving Quality and Supporting Practices scheme to drive improvements in clinical care.
  • Clinical audits were carried out and the findings used to improve the quality of care.
  • Staff had the skills, knowledge and experience appropriate to their roles to enable them to deliver effective care and treatment. The practice invested in staff training at both internal and external courses. GPs had time allocated for training every week.
  • We saw that appraisals were carried out on an annual basis and that personal development plans were in place for all staff. We saw that performance management plans were introduced if necessary.
  • The practice used innovative and proactive methods to improve patient outcomes and worked with other local providers to share best practice.
  • Staff worked with other health care teams to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 17 January 2017

The practice is rated as good for providing caring services.

  • Data from the National GP Patient Survey published in July 2016 showed that patients rated the practice as average or higher than others for several aspects of care.
  • Patients told us that they were treated with kindness, dignity and respect and that GPs and nurses involved them in decisions about their care and treatment. Opinions expressed on the comment cards aligned with these views.
  • Views of external stakeholders were positive about the standard of care provided. For example, the managers of four local care homes said that the standard of care was extremely high and that the GPs took care to involve the patients as much as possible in discussions about their treatment.
  • Patient information for patients about the services available was easy to understand and accessible.
  • We observed that staff treated patients with kindness and respect, and maintained patient and information confidentiality. Staff were very polite and helpful to patients both at the reception desk and on the telephone.

Responsive

Outstanding

Updated 17 January 2017

The practice is rated as outstanding for providing responsive services.

  • Practice staff reviewed the needs of its local population and worked closely with the NHS England Area Team and South Worcestershire Clinical Commissioning Group (CCG) to adapt services to suit the requirements of the local community. A GP was the Chair of the SWCCG and the business manager was a Board member for the Foundation of the South Worcestershire Federation, so they were at the forefront of discussions to improve services in the community.
  • We saw examples of innovative approaches to providing integrated patient focussed care, which recognised the link between health and social care needs. For example, the business manager had been instrumental in setting up the Social Prescribing Pilot project in the Locality.
  • The practice provided a Minor Injuries service, because the practice was situated more than five miles from the nearest A&E department. This was a walk-in service for any patient.
  • The practice had submitted a successful business case to the CCG to secure funding to set up a diagnostic ultrasound service. Patients were able to get an appointment within two weeks, compared to the average waiting time at the local hospital of more than six weeks.
  • The practice ran an INR monitoring service for patients from three local practices. 
  • Patients said they found it easy to make an appointment with their named GP and that they valued the continuity of care. Urgent appointments were available the same day and an appointment with a GP was available within 48 hours.
  • Patients could access appointments and services in a way and at a time that was convenient for them. Patients were able to book or cancel appointments via the Patient Partner option on the practice’s telephone system. This was in addition to the online facility to which patients could subscribe.
  • Extended hours were available which provided flexibility for patients who could not attend during core opening hours.
  • The practice implemented suggestions for improvements and made changes to the way in which services were delivered in response to feedback from patients and from the Patient Participation Group (PPG). For example, the practice had decided to recruit additional staff to help ease the pressure at the front desk, because patients had complained about waiting times at the front desk.
  • Data from the National GP Patient Survey published in July 2016 showed that patients’ satisfaction with accessing care and treatment was rated in line with or above local and national averages: 78% of patients found it easy to get through to the practice by telephone, which was above both the CCG and national averages of 75% and 73% respectively.
  • The practice was located in purpose-built premises, which they had been able to help design to meet their requirements. The building had good facilities and disabled access. It was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand and evidence showed that the practice responded in a timely manner to complaints. Learning from complaints was shared with staff and other stakeholders, including the PPG. 

Well-led

Good

Updated 17 January 2017

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

  • The practice had a clear vision and strategy to provide high quality care and promote the best possible outcomes for their patients. Staff were clear about the vision and their responsibilities with regard to achieving it.
  • There was a high level of constructive engagement with staff and a high level of staff satisfaction.

  • There was a clear leadership structure with strong and visible leadership from the GP partners and management team. Staff understood their roles and responsibilities and said that they felt supported by the management team, who were very approachable.
  • There was an overarching governance framework which supported the effective delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk. Monthly clinical governance meetings were held to share best practice and discuss lessons learned.
  • Coding and staffing issues affected the results for some QOF indicators in 2014/15. For example, chronic lung disease and dementia reviews. Results for 2015/16 showed an upward trend.

  • 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. We saw evidence of meetings which demonstrated that the management team shared learning outcomes not only within their own practice but also with local practices, so that the learning was widespread. Significant events were also shared with external agencies such as NHS England when necessary.
  • There was a schedule of regular practice meetings and there was a comprehensive induction process. Staff told us that they were encouraged to develop their skills. This encouragement extended to the trainee GPs, two of whom had stayed to become associate GPs, because of the support and high level of job satisfaction.
  • The practice proactively sought feedback from staff and patients, which it acted on. There was strong collaboration with the Patient Participation Group (PPG), which met regularly and contributed to practice development. A PPG is a group of patients registered with the practice who worked with the practice team to improve services and the quality of care. The PPG helped with patient surveys, submitted proposals for improvements to the management team and helped to arrange health events for patients and the PPG. The business manager was the lead for the Locality PPG and was responsible for producing the quarterly newsletter.
  • There was a strong focus on continuous learning and improvement at all levels with participation in local pilot projects.
Checks on specific services

People with long term conditions

Good

Updated 17 January 2017

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.
  • Nursing staff had oversight for several clinics for patients with long term conditions such as asthma, diabetes and chronic lung disease, and had received appropriate training.
  • Longer appointments and home visits were available when needed.
  • All these patients had 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 Spa Medical Practice was the base for the town INR service (a service to monitor patients on a blood-thinning medicine) for patients from three local practices. 500 patients were on the database. An average of 30 appointments were available every day with an anticoagulation nurse and an average of six home visits were provided for patients who were housebound. The clinic provided monitoring and adjustment of the drug warfarin and gave patients the opportunity to learn about their medicines, have their blood tests evaluated, and dose adjustment made accordingly.
  • The in-house pharmacist carried out reviews of patients with asthma and chronic lung disease, supported by the GP lead.
  • The nursing team provided healthy lifestyle advice and NHS health checks.
  • The practice website had links to support services for patients with long term conditions. For example, Asthma UK, Diabetes UK and the British Heart Foundation.
  • The practice clinical team had received additional training in long term care. For example, a GP had been trained to provide an insulin initiation service to diabetic patients.

Families, children and young people

Good

Updated 17 January 2017

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.
  • The practice’s uptake for the cervical screening programme was 82% which was slightly below the CCG average of 84% and the same as the national average of 82%.

  • Childhood immunisation rates were comparable to local and national averages.
  • Appointments were available outside of school hours with GPs and nurses. A separate area set aside for children had been decorated with a mural and a breast feeding room was provided on the second floor.
  • A GP also worked at Birmingham Children’s Hospital in the ENT department, so they could bring additional expertise to the practice in this area.
  • We saw positive examples of joint working with midwives, health visitors and school nurses. 

Older people

Good

Updated 17 January 2017

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.
  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • The practice had signed up to the admissions avoidance service, which identified patients who were at risk of inappropriate hospital admission.
  • The practice provided care for patients in seven local care homes. The patient’s nominated GP visited regularly, thus ensuring continuity of care.
  • The practice offered a range of enhanced services, for example, in dementia and end of life care.
  • A GP from the Health and Care Trust held a weekly clinic to assess frail, elderly patients. This service was funded by the Locality.
  • The practice participated in a foot care clinic run by Age UK every Thursday morning.

Working age people (including those recently retired and students)

Good

Updated 17 January 2017

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.
  • Patients could book routine GP appointments online as well as request repeat prescriptions at a time that was convenient for them.
  • Patients could also book or cancel appointments via Patient Partner, which was an option on the practice telephone system.
  • Text messages were sent to remind patients about their appointments and to invite them to attend for chronic disease management or influenza vaccinations.
  • Extended hours appointments were provided and patients could also book appointments with the GP Access Fund (previously known as the Clinical Contact Centre) service outside of the practice’s core opening hours. The GP Access Fund was open from 8am to 8pm during the week and from 8am to 12noon at weekends
  • Patients who had signed up to the Electronic Prescription Service could have prescriptions sent to the pharmacy in the premises or to a pharmacy close to their home or work.
  • General contraceptive advice was available at the practice as well as coil fittings.
  • Health promotion information was available in the waiting room and on the practice website.
  • The practice had set up a Twitter page, which was used to keep patients up to date with forthcoming events.

People experiencing poor mental health (including people with dementia)

Good

Updated 17 January 2017

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

  • 77% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was 7% below both the Clinical Commissioning Group (CCG) and national averages. We were told that this was due to coding issues, which had now been addressed. For example, a proforma was now used for home visits, which facilitated data entry and coding. Results from 2015/16 showed that this achievement rose to 79%.
  • 81% of patients with poor mental health had a care plan documented in the last 12 months, which was 8% lower than both the CCG and national averages (the number of patients on this register was 55, which was relatively small). The achievement for 2015/16 was 96%, which was 3% above the CCG average and 8% above the national average.
  • 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.
  • Patients experiencing poor mental health were given advice as to how they could access various support groups and voluntary organisations.
  • The practice had a system in place to follow up patients who had attended A&E 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.
  • A Gateway worker and a psychologist from the Primary Care Mental Health Service held clinics at the practice every Monday. Mental health counselling was also available every Thursday.
  • The business manager had been instrumental in setting up the Social Prescribing Pilot Project in the locality. The project provided advice and support for patients with social needs or for those who had mental health issues. For example, patients who were isolated or lonely could use the service. Patients could be referred into the service by their GP or self-refer. They would be given an appointment with a counsellor, who could also signpost them to external agencies like Age Concern, if appropriate. The service was open to patients from two other practices in the locality.
  • GPs could refer patients with dementia to a local dementia café, or patients could self-refer.
  • A GP was the lead for dementia care and a member of the Droitwich Dementia Awareness Group. The same GP was the CCG clinical lead for mental health services, so could share additional knowledge and experience with colleagues.

People whose circumstances may make them vulnerable

Good

Updated 17 January 2017

The practice is rated as good 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, travellers and those with a learning disability.
  • The practice had a protocol for registering homeless and vulnerable patients, which outlined the way in which these patients would be registered.
  • Vulnerable patients were flagged on the practice’s clinical computer system, so that they were immediately identifiable to staff and could be offered an appropriate level of service.
  • The practice had 58 patients on its learning disability register and had carried out annual medication reviews on 89%.
  • The practice offered longer appointments for patients with a learning disability.
  • The practice leaflet and complaints leaflet were available in an easy-read format.
  • Clinical staff 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.
  • Staff had received training in 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. There was a GP lead for safeguarding.
  • A GP had undergone training in drug and alcohol misuse. A substance misuse worker from the local alcohol and drug recovery charity centre held a weekly clinic at the practice.
  • Carers were coded on the practice’s clinical computer system. The practice had identified 273 patients as carers, which represented 3% of the practice list. This represented a 1% increase on the figure for 2014.