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Inspection Summary


Overall summary & rating

Good

Updated 14 November 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection on 29 September 2016 at The Bacon Lane Surgery. At that inspection the practice was rated good overall. However, we rated the practice as requires improvement for providing a safe service. This was because the practice could not demonstrate it assessed and managed risks safely.

The full comprehensive report of the 29 September 2016 inspection can be found by selecting the ‘all reports’ link for The Bacon Lane Surgery on our website at www.cqc.org.uk.

This inspection was a focused inspection undertaken on 5 October 2017 to check that the practice had addressed the requirements identified in our previous inspection. This report covers our findings in relation to those requirements.

Overall the practice remains rated as good. Following this inspection, we have revised our rating for whether the practice is providing a safe service. The practice is now rated as good for providing a safe service.

Our key findings were as follows:

  • The practice had effective systems in place to assess and manage risks to patients and staff. The practice had developed a tailored health and safety policy. Fire safety and legionella risk assessments had been carried out by suitably qualified persons with clear recommendations for further action and monitoring.
  • The practice had implemented the recommendations arising from relevant risk assessments. The practice was document the health and safety related monitoring checks it routinely carried out.

At our previous inspection, we also noted that:

  • Consent was not always documented in patient notes for example when carrying out procedures such as joint injections. At this inspection, the practice showed us the patient consent form and information leaflet provided to patients undergoing joint injections. We reviewed a number of records and found that consent had been recorded in the patient notes.
  • GPs were not always familiar with the Deprivation of Liberty Safeguards (DoLS). At this inspection, we reviewed staff training records. Staff had received update training on the Mental Capacity Act and Deprivation of Liberty Safeguards within the last 12 months. Staff we spoke with understood their roles and responsibilities under this legislation.

However, there were areas where the practice should make improvements:

  • The practice should ensure that all staff can access practice policy and procedures relating to the storage and management of liquid nitrogen (a hazardous substance).
  • The practice should ensure that treatment rooms are kept uncluttered to avoid impeding fire exits; to reduce the risk of accidents and as part of effective infection prevention and control.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 14 November 2017

The practice is rated as good for providing safe services. The practice was able to demonstrate that risks were effectively assessed and managed.

Effective

Good

Updated 15 November 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the local and the national average.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 15 November 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice similar to others for most aspects of care.
  • 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.

Responsive

Good

Updated 15 November 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified. For example the practice engaged with the CCG to deliver multidisciplinary care management of complex patients and avoid re-admissions to hospital through ‘Virtual Wards’. (Virtual Wards work just like a hospital ward with the same staffing, systems and daily routines, except the patients stay in their own homes throughout with an aim to prevent unnecessary hospital admissions).
  • The practice had a triage-led appointment system and some patients did not find it easy to get an appointment particulary with their preferred GP.
  • The practice had adequate facilities and was equipped to treat patients and meet their needs however the practice was in need of an upgrade. The provider had applied for funding from the CCG to improve the premises and they were awaiting the decision .
  • 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.

Well-led

Good

Updated 15 November 2016

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

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk. Although a number of risks relating to health and safety had not been addressed.
  • 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.
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.
  • There was a focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions

Good

Updated 15 November 2016

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.
  • Performance for diabetes related indicators was 96% which was 9% above the CCG average and 7% above the national average. QOF exception reporting for diabetes indicators was low at 5% compared to the CCG average of 9% and the national average of 11%.
  • 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

Good

Updated 15 November 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 comparable to others 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.
  • The practice’s uptake for the cervical screening programme was 75%, which was comparable to the CCG average of 77% and the national average of 82%. 
  • Appointments were available outside of school hours and the premises were suitable for children and babies.

Older people

Good

Updated 15 November 2016

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 carried out care planning for older patients on the avoiding unplanned admissions to hospital register.

Working age people (including those recently retired and students)

Good

Updated 15 November 2016

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.
  • 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. 

People experiencing poor mental health (including people with dementia)

Good

Updated 15 November 2016

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

  • 94% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which was comparable to the CCG average of 86% and the national average of 84%.
  • 93% of patients with schizophrenia, bipolar affective disorder and other psychoses had had a comprehensive, agreed care plan documented in the record, in the preceding 12 months which was comparable to the CCG average 91% and the national average of 88%.
  • 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

Good

Updated 15 November 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 homeless people, travellers and those with a learning disability.
  • The practice offered longer appointments for 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 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.