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Inspection Summary


Overall summary & rating

Good

Updated 4 July 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Appletree Medical Practice on 18 April 2016. Overall the practice is rated as good. Specifically, we found the practice to be good for providing safe, effective, caring and well-led services. It was outstanding for providing responsive services.

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

  • 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.

  • Risks to patients were assessed and well managed overall.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • The practice used clinical audit to drive quality improvement within the practice

  • Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. We found many positive examples to demonstrate how patient’s choices and preferences were valued and acted on.

  • The practice worked closely with four other GP practices (Belper five sublocality), Derbyshire Community health service NHS Foundation Trust (DCHS) and the local community in planning how services were provided to ensure they met patients’ needs.

  • 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).

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • The practice actively reviewed complaints and how they were 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.

  • Staff were committed to improving the services for patients and the wider community; and volunteered to pilot new ideas and innovations before they were rolled out across the local area

We saw areas of outstanding practice:

  • The practice worked in collaboration with four local practices on a project to drive improvement in care for older people and reduce emergency admissions from care homes. This had resulted in an 8% reduction in emergency admissions in the preceding 12 months.

  • The practice staff and PPG had engaged with patients aged 17 to 24 and with students (also referred to as community ambassadors) from the local school. The PPG had student representation at their meetings for the past three years.

  • The commitment by practice staff, allied health professionals and empowerment of the PPG to offer: a range of compassionate and additional services to support carers and people at risk of social isolation was outstanding. For example, The PPG facilitated a bi-monthly carers’ forum which enabled carers to seek peer support, form friendships and be empowered with information relating to their caring role and people they cared for. This forum has been running since November 2011 and attendance averaged 15 to 20 people. In addition, a tea party had been held for older people at risk of isolation and with multiple health needs in February 2016. The practice planned to continue offering this service to patients.

The areas where the provider should make improvement are:

  • Ensure a protocol is in place for following up children who do not attend hospital appointments.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 4 July 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for recording, investigating and monitoring significant events. Staff understood and fulfilled their responsibilities to raise concerns and to report incidents, and felt encouraged to do so.

  • Lessons were learned and communicated internally and externally to improve safety within the practice.

  • 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 overall.

  • There was enough staff to keep people safe.

Effective

Good

Updated 4 July 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed most patient outcomes were at or marginally above the local and national averages.

  • Staff assessed people’s needs and delivered care in line with current evidence based guidance. This included assessing capacity and promoting good health.

  • Systems were in place to ensure all clinicians were kept up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines.

  • Staff used these guidelines and clinical audits to deliver effective care and treatment that improved patient outcomes.

  • Staff had access to appropriate training to meet their learning needs and to cover the scope of their work. There was evidence of appraisals and personal development plans for staff.

  • Staff worked with other health and social care professionals to meet the range and complexity of patients’ care needs. This included district nurses, the care coordinator and community matron.

Caring

Good

Updated 4 July 2016

The practice is rated as good for providing caring services.

An outstanding feature of the practice was the commitment by practice staff, allied health professionals and the patient participation group (PPG) to offer a range of compassionate services to address social isolation amongst the practice population and to meet the needs of carers. For example:

  • The PPG facilitated a bi-monthly carers’ forum which enabled carers to seek peer support, form friendships and be empowered with information relating to their caring role and people they cared for.

  • A tea party had been held for older people at risk of isolation and / or with multiple health needs.

  • The practice was one of five GP practices within the local area that facilitated a carer’s clinic run by Derbyshire carers association. Appointments for confidential advice and information were available and people did not have to be a patient in order to benefit from this service.

  • Feedback from patients about their care and treatment was consistently positive; and 85% would recommend this surgery to someone new to the area compared to a local area average of 80% and national average of 78%.

  • Patients felt they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • We observed a strong patient-centred culture and found many positive examples to demonstrate how patient’s choices and preferences were valued and acted on.

  • Views of external stakeholders including three care home providers, district nurses and the care coordinator were very positive and aligned with our findings.

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

Responsive

Outstanding

Updated 4 July 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 they meet patients’ needs. For example, the practice worked closely with four other GP practices and the local NHS Trust to provide integrated and patient-centred care for older people at risk of hospital admission and / or frail.

  • The practice worked in collaboration with four local practices on a project to drive improvement in care for older people and reduce emergency admissions from care homes. This had resulted in an 8% reduction in emergency admissions in the preceding 12 months.

  • Patients discharged from hospital were reviewed and followed up to ensure they had appropriate care in place to promote their independence and to reduce further hospital admissions. They were also signposted to relevant support services.

  • The practice hosted a range of services which enabled patients to access care closer to home. For example, patients had access to clinics for orthopaedic and general surgery, audiology and physiotherapy.

  • 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 could 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

Good

Updated 4 July 2016

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

  • 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.

  • Governance and performance management arrangements were proactively reviewed by the GP partners and management team to ensure the delivery of good quality care. This included arrangements to assess and monitor identified risks and service provision.

  • There was a clear leadership structure and staff felt supported by management.

  • The practice proactively sought feedback from staff and there was a high level of staff satisfaction.

  • High standards were promoted and owned by all practice staff, and teams worked together across all roles.

  • The practice had a very engaged patient participation group which influenced practice development.

  • There was a strong focus on continuous learning and improvement at all levels.

  • Staff told us they felt involved and engaged to improve how the practice was run.

Checks on specific services

People with long term conditions

Good

Updated 4 July 2016

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

  • Each GP had a lead role for the overall monitoring of specific long term conditions and were supported by the nurses in chronic disease management. For example, the nurses facilitated a range of clinics for conditions such as asthma, diabetes and chronic obstructive pulmonary disease (COPD); and patients were encouraged to understand and self-manage their conditions in line with agreed care plans.

  • An anti-coagulation service was offered for patients prescribed warfarin (a drug used in the prevention of blood clot formation which requires regular blood tests).

  • Patients at risk of hospital admission were identified as a priority and systems were in place to follow-up their care post hospital discharge.

  • 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.

  • The practice used telehealth monitoring devices to aid in the diagnosis of hypertension for patients with high blood pressure.

  • Longer appointments and home visits were available when needed.

Families, children and young people

Good

Updated 4 July 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 at risk of abuse. This included practice staff engaging with midwives, health visitors and school nurses in regular safeguarding meetings. There was no protocol in place to ensure staff followed up children who did not attend hospital appointments.

  • 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.

  • Families were allocated the same named GP for continuity of care.

  • Immunisation rates for all standard childhood immunisations were comparable to the local average and school age vaccination clinics were held after school or on a Saturday morning.

  • Appointments were available outside of school hours and children presenting with urgent medical needs were seen on the same day.

  • The premises were suitable for children and babies.

  • The practice had engaged students from the local sixth form secondary school and a number of students had attended the patient participation group meetings for the past three years.

Older people

Good

Updated 4 July 2016

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

  • The practice staff prioritised the care needs of older people including residents living in six care homes they supported. The practice had taken a lead role in piloting the locally commissioned care home enhanced service which included providing regular and planned “ward rounds” for the residents and having a nominated GP with lead responsibility for each of the care homes to ensure continuity of care.

  • The practice was part of the Belper five (group of five local GP practices) integrated community care pilot project which included working in partnership with Derbyshire community health service NHS foundation Trust to address the challenges relating to the care provision of older people. For example, the practice’s advance nurse practitioner and CCG employed advanced care practitioner specifically focused on the management of frail and elderly patients. As a result of this project hospital admissions and accident and emergency presentations had reduced.

  • Regular multi-disciplinary meetings were held to discuss the care needs of older people and the practice was responsive to their needs. This included use of care plans to ensure co-ordinated care and signposting

  • Home visits and urgent appointments were offered for those with enhanced needs.

  • A tea party had been facilitated in February 2016 for older people at risk of isolation and with multiple health needs and eight patients had attended.

  • All patients, including those aged 75 and over had a named GP but were free to consult with any of the GPs.

  • The practice had a high success rate in administering flu vaccines to this age group with an 80% uptake, including 157 done during home visits.

Working age people (including those recently retired and students)

Good

Updated 4 July 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 reflected the needs for this age group. For example, the practice’s uptake for the cervical screening programme was 89%, which was marginally above the local average of 84% and the national average of 82%.

  • A range of appointment types were offered to these patients and this included telephone consultations and extended opening hours on a Saturday morning between 8am and 11am. This enabled more flexibility for patients wishing to access appointments outside of standard working hours.

  • The practice used social media such as twitter and facebook to communicate with this population group as well as a text messaging service.

People experiencing poor mental health (including people with dementia)

Good

Updated 4 July 2016

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

  • Staff had a good understanding of how to support patients with mental health needs and dementia. This included working with multi-disciplinary teams in the case management of these patients and carrying out advance care planning for patients with dementia.

  • Published data showed:

  • 93% of patients with a mental health condition had a documented care plan in the last 12 months which was in line with the CCG average of 92% and the national average of 88%.

  • 86% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months which was in line with the CCG average of 85% and the national average of 84%.

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

  • Patients with symptoms of anxiety or depression were referred or directed to counselling clinics hosted at the practice.

  • 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.

People whose circumstances may make them vulnerable

Good

Updated 4 July 2016

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

  • The practice and supporting its carers. For example, “Friends of Carers” (volunteers from the PPG) facilitated a bi-monthly carers' forum at the Duffield surgery. The forum empowered carers to share their experiences, form new friendships and learn more about facilities available to them.

  • The practice was one of five GP practices within the local area that hosted a carers' clinic run by Derbyshire Carers Association. The clinics were held on the first Thursday of every month and carers did not have to be a patient with the practice to benefit from the service.

  • The practice provided care to a residential care home for young adults with challenging behaviour including severe autism and learning disabilities.

  • A comprehensive yearly health check was offered to these residents and other patients with a learning disability. A total of 93% of eligible patients with a learning disability had received an annual health check. Easy read information using pictures and simple language was used in invitation letters and explanations about their care.

  • The practice was a member of the Derbyshire safe place scheme, providing a safe haven for patients with learning disabilities who felt unwell, confused or threatened whilst out in the local community.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients and longer appointments were offered.

  • 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.

  • The premises were user friendly for patients with a range of disabilities including patients using wheel chairs and hard of hearing.