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Bradford on Avon & Melksham Health Partnership Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 29 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bradford on Avon and Melksham Health Partnership on 18 August 2016. Overall the practice is rated as outstanding.

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

  • The leadership and culture of the practice was used to drive improvements and deliver high quality person centred care. The practice undertook a systematic approach to work effectively as a whole practice team, involve the patients and the community and other organisations to deliver the best outcomes and deliver the care within the community wherever possible.

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example the practice had introduced a wide range of initiatives over the past two years to support people; The ‘Leg Club’, a Memory Café, a balance and falls class, and set up a social hub in the local community.

  • The practice used opportunities to improve outcomes where possible for example, during the flu clinic they checked patients over 65 for an irregular pulse and identified 24 new patients with atrial fibrillation (an irregular heart beat which led to identification of patients who may be have an increased risk of stroke and needed advice and/or medication).

  • Feedback from patients about their care was consistently positive.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group (PPG). For example the PPG had contributed to producing a directory of self-care support groups, raised awareness of key public health messages, conducting surveys and submitting proposals for improvements. The PPG had recently been involved in discussions on recruitment for new staff, including GPs.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice actively reviewed complaints and how they are managed and responded to, and made improvements as a result.
  • The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.
  • The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw several areas of outstanding practice including:

The practice provided a ‘Leg Club’, an innovative primary care led service to deliver research based wound management in a friendly social environment, provide staff development and learning, provide continuity of care and coordinated care, promote health and wellbeing and achieve outcomes and peer support. This service had improved outcomes for patients including reduced healing times, reduced recurrence rates (from 75% to 25%), improved social isolation, reduced house-bound contacts by 26% and reduced referrals to secondary care.

The practice employed an integrated team to drive forward the Transforming Care for Older People Team (TCOP) work programme who worked together to integrate the information technology systems to improve information sharing, break down barriers to effective communication and improve discharge planning and reduce admissions . The team undertook urgent home visits to enable a rapid service to those who may be at risk of an admission, the care coordinator visited patients in hospital prior to their discharge to facilitate their discharge and ensure the correct care was in place.

The practice offered seven day nurse support for local Nursing and Care homes, education support for staff in local Nursing and Care homes and access to wound care at the weekends in the local community.

The practice had responded to some concerns relating to delays accessing some mental health services for children and recognised that some needs were not fully met. The practice implemented regular meetings with the Health Visitors, introduced a mental health resource file for each consultation room with self-help material an assessment and support pack, and and created a mental health representative post to provide a contact for mental health patients (or their families) that need assistance.

The practice had an active patient participation group (PPG), they were very engaged in how the practice was run and had delivered health promotion sessions, contributed to producing a directory of self-care support groups and run volunteer support services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 29 September 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events which included identifying any areas where they could improve practice. The practice valued opportunities to discuss incidents in an open, blame-free culture, including what went well, positive points and to commend and acknowledge good practice.

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

  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.

  • Risks to patients were assessed and well managed.

Effective

Outstanding

Updated 29 September 2016

The practice is rated as outstanding for providing effective services.

The practice had a holistic approach to assessing, planning and delivering care and treatment for their patients. They used innovative approaches to care and actively sought opportunities to deliver the care within the local community, involve the community and empower the patients to improve their outcomes. For example the practice during the last flu clinic checked patients over 65 for an irregular pulse and identified 24 new patients with atrial fibrillation (an irregular heart beat which led to identification of patients who may be have an increased risk of stroke and needed advice and/or medication).

The practice had focussed on the services in place after a diagnosis of dementia and provided a comprehensive one-stop-clinic for people living with memory problems. This led to improved diagnosis targets.

The practice developed a “lunch and learn” for staff training on dementia, which the practice shared across the whole region (which had been downloaded by over 100 practices).

  • Our findings at inspection 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) guidelines and other locally agreed guidelines.

  • We also saw evidence to confirm that the practice used these guidelines to positively influence and improve practice and outcomes for patients.

  • Housebound patients who are on insulin are visited by the community nursing team. They met regularly with the diabetic lead GP to adjust the patient’s medicine, optimise control and reduce complications.

  • Data showed that the practice was performing highly when compared to practices nationally. For example diabetes indicators showed that the practice was performing higher than local and national averages.

  • The practice used innovative and proactive methods to improve patient outcomes and working with other local providers to share best practice.

Caring

Outstanding

Updated 29 September 2016

The practice is rated as outstanding for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. Many commented that staff went the extra mile and the care they receive exceeds expectations.

  • People who used the services were active partners in their care. Staff empowered the patients to have a voice and contribute to their care.

  • Information for patients about the services available was easy to understand and accessible.

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

Responsive

Outstanding

Updated 29 September 2016

The practice is rated as outstanding for providing responsive services.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. For example the practice had introduced a wide range of initiatives over the past two years including the’ Leg Club’, Memory Café and a balance and falls class.

  • There were innovative approaches to providing integrated patient-centred care. For example: the practice integrated care team worked in collaboration with Wiltshire Council on the ‘Single View’ project which aims to bring the information systems together to provide a single view of patients who are known to Adult Social Care which aims to avoid duplication and find out the patients story only once.

  • The practice implemented a patient liaison officer role to specifically assist patients with home visit requests, community nurse visits and death notifications.

  • The GPs observed that some patients were repeatedly booking multiple appointments, visiting the surgery on multiple occasions in a single day and impacting on the capacity for other patients. The practice undertook an audit to review the appointment reasons; from this a number of conditions were identified where patients needed extra support and early intervention. The practice recognised that many of these patients would benefit from a structured treatment plan to develop patient self confidence and self-esteem. This audit was shared with the clinical team. The practice introduced self-help care plans for a number of these patients and noted an improvement in 13 patients. The importance of an individualised patient centred approach was noted as key to engaged improved care.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group.
  • Patients can access appointments and services in a way and at a time that suits them.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand, and the practice responded quickly when issues were raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Outstanding

Updated 29 September 2016

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

The leadership and culture of the practice was used to drive improvements and deliver high quality person centred care.

The practice undertook a systematic approach to work effectively as a whole practice team, involve the patients and the community and other organisations to deliver the best outcomes and deliver the care within the community wherever possible

Governance and performance management arrangements are proactively reviewed and reflect best practice.

  • The leadership of the practice valued continuous improvement and the whole practice was involved in delivering change and seeking out new ways of providing care.

  • The practice had a robust strategy and supporting business plans which reflected the vision and values and were regularly monitored.

  • The practice had a clear vision with quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. Staff were all encouraged to identify any areas where they could improve practice. Opportunities were taken to discuss incidents in an open environment and within a blame-free culture, including what went well, positive points and to commend and acknowledge good practice.

  • High standards were promoted and owned by all practice staff and teams worked together across all roles. Staff were developed to maximise their potential, for example staff were encouraged to mentor new staff, encouraged to take ownership of projects and develop new ideas to the practice.

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

  • There was a high level of constructive engagement with staff and a high level of staff satisfaction, many staff told us they were encouraged to develop and they valued the learning culture of the practice and felt it was an environment where they were supported to grow.

  • The practice gathered feedback from patients and it had a very engaged patient participation group (PPG) which influenced practice development. For example the PPG had produced a directory of self-care support groups, been involved in engaging the community in health and social care delivery of services including volunteer support at the ‘Leg Club’ the social ‘Hub’ in the community and recently become involved in discussions on recruitment.

Checks on specific services

People with long term conditions

Outstanding

Updated 29 September 2016

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

The practice worked with the older person’s forum and the health and wellbeing board to develop social prescribing initiatives for people with long term conditions.

The practice liaised with the Consultant Diabetologist and Diabetes Specialist Nurse for complex patients with diabetes for care and treatment reviews. Patients who are housebound with diabetes are reviewed yearly in their home.

The practice was actively involved in monitoring and improving outcomes for patients with long term conditions and had undertaken research studies including multiple diabetes studies, coronary heart disease and heart failure, asthma and COPD, vaccine studies and many other therapeutic areas.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

  • Performance for diabetes related indicators were similar or above the local and national averages:

  • The percentage of patients with diabetes, on the register, in whom the last blood test showed their blood sugar levels were in the target range (in the preceding 12 months 2014/15), was 85% which was higher than the CCG average of 82% and the national average of 78%.

  • The percentage of patients on the diabetes register, with a record of a foot examination and risk classification within the preceding 12 months (2014/15) was 97% which was higher than the CCG average of 91% and the national average of 88%.

  • Longer appointments and home visits were available when needed.

  • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Outstanding

Updated 29 September 2016

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

  • The practice had developed a young persons assessment and support pack for young patients and had made links with the local school and the youth club to offer assistance and advice and to promote the surgery and services available to them.

  • The practice developed a range of booklets following an audit of the information available to patients relating to long term contraception advice; these had been shared with other practices. The practice offers a range of contraceptive and emergency contraceptive services.

  • The practice offers a comprehensive ‘No Worries’ service which is confidential and includes a ‘condom service’, this is available for patients up to 24 years of age whether they are registered at the practice or not.

  • A Health Visitor works at the surgery on a Monday and has a liaison meeting with the lead family GP to discuss concerns, safeguarding and complex patients.

  • Parents with addictive behaviours are also identified on the child record with a specific patient identifier.

  • The Friends and Family Test was extended to gain the views of children.

  • Appointments were available with the emergency GP or a Nurse Practitioner at the end of the school day to support parents and children who need an appointment – double appointments were available if requested.

  • The practice asked at patient registration if a young person was a carer to sign post to support and activities that may help them. There was information on a carers information board aimed at young carers, a tailored leaflet for young carers and access to support and other services.

  • A maternity pack was available for collection for the newly-pregnant mums. 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.

  • We saw positive examples of joint working with midwives, health visitors and school nurses including weekly sessions in a dedicated medical centre at two local boarding schools, working alongside the school nurses.

Older people

Outstanding

Updated 29 September 2016

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

The practice had introduced a wide range of initiatives over the past two years to support people at risk of social isolation and worked with the older person’s forum and Age UK to offer a range of additional services to encourage people to learn new skills or attend social events.

The practice employed an integrated team to drive forward the Transforming Care for Older People Team work programme. The practices’ integrated team had worked together to integrate the information technology systems to improve information sharing, break down barriers to effective communication and improve discharge planning and reduce admissions.

• All patients over the age of 75 have a named GP and care plans where required.

• Patients who are in hospital including any who have attend A+E are reviewed and specific patients (for example following orthopaedic surgery or a fall) are visited by the care coordinator (including visiting during the hospital stay) and then followed up by a telephone call or a visit.

• The practice has regular end of life meetings with local community teams and the local hospice, care plans are documented along with preferred place of death

• The practice held a weekly ward round with 12 local Care Homes and regular nurse visits. The nursing team provided education sessions and support for the staff. The practice has delivered this service for the past three years and seen a 30% reduction on patients being admitted as an emergency from Care Homes.

The practice worked with Age UK to roll out the ‘Improving Access to Psychological Therapies’ for older people.

Working age people (including those recently retired and students)

Outstanding

Updated 29 September 2016

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

The practice offered a range of on line services and a range of telephone consultations for people unable to visit the surgery for work reasons.

The practice took part in a pilot to increase the uptake of health checks which was entered into the Public Health Awards for innovation, the practice put on extra sessions in the evenings for a three month period and increased attendance by follow up phone calls.

The practice had a range of health promotion and advice leaflets also on the website with links to external support, including referrals to weight management, exercise on prescription and other self-help options. The practice held a ‘Topic of the Month’ health promotion initiative in the practice and on the website.

• The practice offered early morning clinics.

• The practice offered minor operations delivered in-house.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 29 September 2016

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

The practice had focussed on the services in place after a diagnosis of dementia and provided a comprehensive one-stop-clinic for people living with memory problems.

The practice had responded to some concerns relating to delays accessing some mental health services for children and recognised that some patient’s needs were not being fully met. The practice implemented regular meetings with the Health Visitors to discuss individual children and families, ensured Health Visitor clinics at the practice on a Monday morning, introduced a mental health resource file for each consultation room with self-help material and created a mental health representative post to provide a contact for mental health patients (or their families) that need assistance.

Talking Therapies counselling support were available in the practice.

The practice had three dementia champions who delivered dementia friends training to the staff. The practice worked with the secondary care memory services and jointly reviewed complex patients. Patients were discussed with the multidisciplinary team, given a care plan involving their carers and offered support.

The practice had been accredited as dementia friendly, they were a partner of the Bradford on Avon Dementia Alliance Action Group which met quarterly and is collaborating on the ‘Safe-Place’ initiative and becoming a dementia friendly town.

  • Performance for mental health related indicators were in line or higher than the local and national averages:

  • The percentage of patients diagnosed with dementia whose care has been reviewed in a face-to-face review in the preceding 12 months (2014/15) was 93% which was higher than the CCG average of 88% and the national average of 84%.

  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

  • The practice carried out advance care planning for patients with dementia.

  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.

  • Staff had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Outstanding

Updated 29 September 2016

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

  • The practice had a register of people deemed vulnerable to hospital admission; there were over 400 on the list who were sent a letter offering them a range of enhanced services within the surgery.

  • The practice offered a rapid home visit service and emergency slots for vulnerable people with enhanced needs such as dementia and health anxiety.

  • The practice had a list of people registered with a learning disability (LD) and all were offered an annual health assessment with joint health care planning. We saw 94% had had their health review in 2014/15. The practice attended the LD home regularly and supported carers with ad hoc visits and requests.

  • The practice held quarterly and ad hoc vulnerable adult multidisciplinary meetings and safeguarding meetings. The practice had a safeguarding lead for children who had regular meetings with the health visiting team.

  • The practice had a process in place to register people with no fixed abode and access treatment from a doctor or nurse.

  • The practice had set up links to the social ‘Hub’ and provided a signatory for foodbank vouchers.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.

  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.