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Dr P A A Wood and Partners Good

Inspection Summary


Overall summary & rating

Good

Updated 6 October 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr P A A Wood and Partners on 28 June 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. All opportunities for learning from internal and external incidents were maximised and shared within the practice and the locality.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. For example; The practice had worked with four other practices in the locality to implement and fund a community based service that enabled direct referrals for patients with gynaecology, musculoskeletal problems and diabetes to receive assessment and care by a consultant in their community instead of travelling to hospital. Patients were usually seen by a consultant within three weeks of referral and had undergone the relevant tests in preparation for their initial appointment. The core principles of the initiative was to provide a more cost effective service which was also more responsive in terms of speed of assessment and treatment for patients.
  • The practice actively reviewed complaints for trends and how they were managed and responded to, and made improvements as a result.
  • Risks to patients were assessed and well managed.
  • The practice regularly reviewed policies and made changes to practice based on audits and updates.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Feedback from patients about their care was consistently positive and data from the GP patient survey was consistently high. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients said they found it easy to make an appointment and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had strong and visible clinical and managerial leadership and governance arrangements, and staff told us that they were well-supported and felt valued by the partners.
  • The practice’s senior partner used his leadership role within the CCG to keep the practice informed of new developments and opportunities

We saw several areas of outstanding practice:

  • There was a practice initiative whereby the practice had developed an enhanced package of care for residential and care homes aligned to them which had resulted in a 9.1% reduction in visits to A/E department and a reduction of 22% in unplanned admissions to hospital in the preceding 12 months. This was funded by the practice.
  • The practice had worked collaboratively with four local practices to implement a direct referral service so that patients could be seen by a consultant more quickly in their locality rather than travelling to hospital. This was initially funded independently by the practices and is currently being commissioned by the CCG on an ongoing basis and extended to a further seven practices locally.
  • The practice actively contacted patients who did not attend for their cervical screening test and where patients did not respond to the third letter, a face to face appointment was made with the practice nurse to discuss their decision. This provided an opportunity to allay patients’ anxiety and provide additional information to help them make their decision. This resulted in an uptake for the cervical screening programme of 91% which was 10% higher than the CCG and national averages Exception reporting for this indicator at 2% was lower than both the CCG and national averages.
  • The practice actively followed up patients who did not attend their hospital breast screening appointment by sending a letter to the patient advising of the importance of the test and providing them with the hospital telephone number and their breast screening number so that they could more easily make a new appointment. This had resulted in achieved an attendance rate of 85% for breast cancer screening which was 7% higher than the CCG average and 13% higher than the national average.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 6 October 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events, and lessons learned were shared throughout the practice at regular meetings. Learning was also shared with other practices in their locality. When there were unintended or unexpected safety incidents, patients received a verbal and written apology. They were told about any actions to improve processes to prevent the same thing happening again.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse and staff had received training relevant to their role. The practice had conducted an audit on their management of safeguarding concerns and found that staff complied with policy and guidelines and were well informed about all aspects of safeguarding
  • Risks to patients were assessed and well managed. Infection prevention and control procedures were completed to a satisfactory standard. There were effective systems in place to manage safety alerts, including medicines alerts which were acted upon.
  • There was a robust process for managing incoming mail including test results which were acted upon on the same day if required.
  • There were enough staff to keep people safe.

Effective

Good

Updated 6 October 2016

The practice is rated as good for providing effective services.

Our findings showed that systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) and other locally agreed guidelines, and clinicians used these as part of their work.

  • Audits and reviews were undertaken and improvements were made to enhance patient care. For example; an audit relating to medicines conducted over three cycles showed that new guidelines were being adhered to.
  • Patients’ needs were assessed and care was planned and delivered in line with current legislation. This included assessing capacity and promoting good health. Staff had received training appropriate to their roles and any further training needs had been identified and appropriate training planned to meet these needs.
  • There was evidence of appraisals and personal development plans for staff. Most staff had received an appraisal in the preceding 12 months, and those remaining were scheduled for July. The appraisal process had recently been updated to enable more comprehensive appraisal discussions and development plans for staff.
  • Staff worked closely with multidisciplinary teams to plan, monitor and deliver appropriate care for patients. The teams included midwives, health visitors, the community matron, district nurses and the mental health team.
  • The practice worked very closely with eight residential and care homes aligned to them and had developed a package of care that included regular structured ward rounds, dedicated time for direct telephone access to a GP daily, and regular communication with relatives. This had resulted in a significant reduction in the number of patients being admitted to hospital from the residential or care home. This had also enabled 99% of these patients receiving end of life care to die in their preferred place.
  • The practice had enabled direct referrals for gynaecology, musculoskeletal problems and complex diabetes and receive care in their community instead of travelling to hospital. This meant that patients were seen by a consultant within three weeks of referral and had undergone the relevant tests in preparation for their initial appointment.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average. They had achieved 96% of their available points compared to the CCG average of 97% and the national average of 94.8%.

Caring

Good

Updated 6 October 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care. For example 92% of patient described their overall experience of the practice as good or fairly good. This was 6% higher than the CCG average and 7% higher than the national average.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
  • There was a carers champion and a carers policy that outlined how all clinical staff were to identify patients who may be carers opportunistically, whenever patients attended for an appointment. This had resulted in registering 2.6% of their practice list as carers. These were then signposted to various support resources with help from the carers champion and the care coordinator.

Responsive

Outstanding

Updated 6 October 2016

The practice is rated as outstanding for providing responsive services.

  • They were aware of the practice population and engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified. For example; by providing an enhanced package of care for patients in residential and care homes; by recruiting a GP specially to look after the 260 patients in care homes; by recruiting an additional nurse to treat patients with chronic illness and to receive specialist training in this area to enable a nurse to treat patients with chronic illness in their own homes; and by enabling direct referrals for patients to see a consultant quickly within their locality rather than travelling to hospital.
  • Patients told us they were satisfied with the appointment system and said they found it easy to make a routine appointment which was usually available the next day. Urgent appointments were always available the same day. Telephone consultations and home visits were also available.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. The premises were suitable for patients who were disabled and there were baby changing facilities.

  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and annual complaints meetings were held to reflect on learning from the preceding year and to ensure that any changes to practice had been embedded.

Well-led

Good

Updated 6 October 2016

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

  • There was a clear vision and strategy which was shared with staff who were clear about their responsibilities in relation to this. There was a clear leadership structure and staff felt supported by management. High standards were promoted and owned by all practice staff and teams worked together across all roles. There were systems in place to monitor and improve quality and identify risk.
  • The practice had a succession plan to address future needs when existing staff may retire which enabled staff to develop into potential roles for the future.
  • The practice had developed a number of flexible roles that increased capacity and skill mix within the workforce and enabled personal development for staff. This meant that staff were able to perform a number of different roles and were able to step into another role when required to avoid interruptions to services due to sickness.
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group (PPG) was working with the practice to develop this role.
  • Staff had received inductions, annual performance reviews and attended staff meetings and training opportunities. There was a high level of constructive engagement with staff and a high level of staff satisfaction.
  • Staff gave examples of how the practice had provided support for staff during times of personal and health difficulties. Staff also told us about social events and charity events organised by the practice.
  • 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 and appropriate action was taken
Checks on specific services

People with long term conditions

Good

Updated 6 October 2016

The practice is rated as good for the care of people with long-term conditions.

  • The practice had a higher than average prevalence of some long term conditions.
  • Nursing staff had received advanced training in the management of long term conditions and had lead roles in chronic disease management. Further training was planned for one of the nursing staff to provide management of chronic diseases in patients own homes for housebound patients
  • Future care planning was prioritised for patients at risk of hospital admission. All these patients had a named GP and were offered a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.
  • The practice worked closely with the CCG pharmacist to ensure appropriate prescribing practice.
  • There was rapid direct access to specialist nurse and consultant diabetes services for patients with complex care needs.
  • The practice were in line with local and national averages for achievement in QOF indicators relating to diabetes. For example; 95% of patients with diabetes had received an influenza vaccination which was the same as both CCG and national averages.

  • Longer appointments and home visits were available when needed. The practice had a high home visiting rate of between 10 and 20 visits per day, and provided early visits to ensure that those patients who were potentially the sickest were seen early for timely treatment or admission. The aim was to improve the patients’ journey and improve outcomes for patients by treating early to avoid unnecessary hospital admission. This had resulted in an overall A/E admission rate that was lower than the CCG average.

Families, children and young people

Good

Updated 6 October 2016

The practice is rated as good for the care of families, children and young people.

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances.
  • Immunisation rates were higher than average 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.
  • There were GPs who had specialist training and knowledge in family planning services, coil and contraceptive implant fitting. The practice also had access to a community based gynaecology service for advice when required. This meant that patients could attend an appointment with a consultant gynaecologist in their community within three weeks of referral and the relevant tests were arranged beforehand so that results were available on the initial appointment with the consultant.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • There was a midwife aligned to the practice and we saw positive examples of joint working with midwives, health visitors and school nurses.
  • The practice had Fraser and Gillick competence assessments embedded into the computer system to ensure that young people were actively encouraged to be involved in their care. A survey conducted by the practice identified that teenage patients felt that they were being provided with a service that met their needs.

Older people

Good

Updated 6 October 2016

The practice is rated as good for the care of older people.

The practice serves a population that is much higher than average for older people and looks after 260 patients living in local care homes. The practice has 13.2% of patients who are aged 75 or over, which is ranked as the highest in the CCG. They also have 4.7% of their practice list who are aged over 85 years, which is also ranked as the highest in the CCG.

  • The practice offered proactive, personalised care to meet the needs of the older people in its population. All patients over 75 had a named GP
  • Each of the eight residential and care homes aligned to the practice had a named GP who visited each home for one morning or afternoon session each month to plan care, conduct medication reviews, meet with patients, relatives and staff. The GP also made shorter weekly visits and urgent visits on the day when required. The practice scheduled dedicated time each day for residential and care home staff to speak to a GP for telephone advice. This had resulted in a 9.1% reduction in visits to the A/E department and a reduction of 22% in unplanned admissions to hospital in the preceding 12 months. The practice were proud of their relationships with the patients, relatives and care teams. Feedback from two care homes we spoke with was extremely positive about the care and service provided to residents and regarding the communication with relatives and staff.
  • The practice had coordinated educational events for residential and care home staff to enable staff to develop their understanding of end of life care and to enhance relationships between the practice and care home staff.
  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs, including those patients in nursing and residential care.
  • There were 2.3% of their older population who had care plans with the aim of enabling appropriate out-of-hours care, and ensuring that patients’ expressed needs were met
  • There was a proactive process for providing Influenza vaccinations and this included providing flu clinics on Saturday mornings and in peoples own homes if they were housebound. There was a dedicated administrator who contacted all eligible people by telephone to arrange appointments and chase people who had not attended a planned clinic.
  • The practice utilised a care coordinator to work with the named GP and community support team to facilitate care and respond to patients needs following discharge from hospital. Monthly multi-disciplinary team meetings were held to discuss and plan ongoing care.
  • Services such as phlebotomy, hearing aid services and citizens advice were available on site for older patients

Working age people (including those recently retired and students)

Outstanding

Updated 6 October 2016

The practice is rated as outstanding for the care of working-age people (including those recently retired and students).

  • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. This included access to telephone consultations and on-line appointment booking services.
  • The practice offered GP appointments throughout the day, including lunchtime, and extended hours clinics were available for two evenings and on Saturday mornings each week for working patients who could not attend during the day. Patients were also able to ask advice via email.

  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group. The practice had provided a cervical screening test for 91% of eligible women in the preceding five years, which was around 10% better than the CCG and national averages.

  • The practice used electronic prescribing and patients could request repeat prescriptions online.
  • The practice utilised a community based provider that enabled patients to be seen by a consultant for gynaecology, musculoskeletal problems and diabetes in the community instead of at hospital, within three weeks of referral.

People experiencing poor mental health (including people with dementia)

Good

Updated 6 October 2016

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

  • The practice had established excellent collaborative working relationships with a local specialist unit for patients with dementia and other homes with a high proportion of patients with dementia. They had arranged for joint educational sessions for their aligned nursing homes with a psychiatry consultant guest speaker. Care home managers we spoke with confirmed that the events were useful and informative, and also provided an opportunity to build relationships with other care home staff and the practice staff.
  • 78% of patients diagnosed with dementia who had their care reviewed in a face to face meeting in the last 12 months, which was comparable to the CCG and national averages
  • All indicators relating to mental health were comparable to CCG and national averages.
  • They held a register of patients who had a mental health problem and offered them an annual health review. They had provided a health review for 76% of patients on their register in the preceding 12 months.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia and carried out advance care planning for patients with dementia.
  • The practice worked closely with adult and older adult psychiatry services and were able to refer patients with mental health problems to psychological therapy services
  • They had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health, and utilised a care coordinator to assist with timely planning of care and to discuss any unmet needs.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 6 October 2016

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 those with a learning disability. They had 49 patients on their register.

  • The practice offered longer appointments for patients with a learning disability and an annual health review with a GP who had a special interest in learning disability. A GP had recently left the practice who had a lead role in managing patients with a learning disability. The practice had provided additional training for the new GP lead and also the administration lead and the health care assistant who would both be involved in treating or speaking with patients with a learning disability.
  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.
  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
  • Staff received appropriate safeguarding training and knew how to recognise signs of abuse in vulnerable adults and children. They 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.
  • The practice recognised the needs of carers and provided them with a named GP and a health care assistant (HCA) who was a designated carers champion to assist in signposting them to the local resources for support.