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St Georges Medical Practice Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 20 August 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St George’s Medical Practice on 10 February 2015. Overall the practice is rated as outstanding.

Specifically, we found the practice to be outstanding for providing responsive and well-led services and was good for providing safe, effective and caring services.

It was rated as outstanding for providing services to people with long-term conditions and working age people (including those recently retired and students). It was good for providing services to older people, families, children and young people, people whose circumstances may make them vulnerable and people experiencing poor mental health (including people with dementia).

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

  • The practice had a clear vision which had quality and safety as its top priority. High standards were promoted and owned by all practice staff with evidence of team working across all roles.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the practice hosted a weekly community clinic which provided a triage service for hip and knee conditions.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet people’s needs.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance.
  • Patients told us they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Patients told us they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day.
  • Information about safety was recorded, monitored, appropriately reviewed and addressed. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses.
  • Risks to patients were assessed and well managed.
  • Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about services and how to complain was available and easy to understand.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.

We saw several areas of outstanding practice including:

The practice was actively involved in developing and implementing innovative pilot projects with other stakeholders to improve patient outcomes across the wider community. For example:

  • the practice had hosted and co-authored a liver screening project along with other health professionals from the Nottingham University hospital and the Rushcliffe clinical commissioning group. This project had improved the diagnostic identification of significant liver disease in patients using a fibroscan and had won an NHS innovations award. This was published in the British Medical Journal after our inspection.

  • the practice had hosted a trauma and orthopaedic community clinic since April 2014 as a new model of care. This weekly clinic provided a triage service for a range of hip and knee conditions and was led by a consultant and specialist physiotherapist. An evaluation of the service showed positive outcomes were achieved for patients including timely diagnosis and referrals for further intervention, and efficient use of resources including financial savings in terms of inpatient costs. About 87% of patients who had used the service rated it excellent and 13% rated it good.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 20 August 2015

The practice is rated as good for providing safe services.

Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons were learned and communicated widely to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed. Risks to patients were assessed and well managed.

Robust systems were in place for the regular review of all medicines including for those patients living in care homes. Patients were encouraged to bring their medical equipment for portable appliances test at least once a year to ensure it was safe for use.

Patients were protected from the risk of harm through robust systems in place for safeguarding vulnerable adults and children as well as the recruitment of suitable staff. Appropriate arrangement were in place for dealing with emergencies and management of unforeseen circumstances.

Effective

Good

Updated 20 August 2015

The practice is rated as good for providing effective services.

Systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence guidelines and other locally agreed guidelines. We saw evidence to confirm that these guidelines were improving practice and outcomes for patients. The staff team were committed to working collaboratively with other providers to ensure that patients’ received coordinated care and services.

Quality Outcomes Framework (QOF) data for 2013/14 showed the practice was performing above local and national averages in respect of clinical results for long term conditions (6.1 percentage points above the CCG average and 7.7 percentage points above the national average) and in respect of public health indicators (5.4 percentage points above the CCG average and 3.5 percentage points above the national average).

They achieved 100% in all clinical indicators and had sustained this high performance since 2004. QOF is a voluntary incentive scheme which financially rewards practices for managing some of the most common long-term conditions and for the implementation of preventative measures.

The practice had an on-going clinical audit programme, which demonstrated continual improvement to patients care and treatment. The practice used proactive methods to improve patient outcomes and it linked with other local providers to share best practice.

Patient’s needs were assessed and care was planned and delivered in line with current legislation. Their knowledge of the Mental Capacity Act and deprivation of liberty safeguards was implemented in their practice.

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 all staff. Staff worked with multidisciplinary teams.

Caring

Good

Updated 20 August 2015

The practice is rated as good for providing caring service

Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. This was aligned with the most recent national patient survey results. The results showed most patients rated the practice very good for GP and nurse consultations including care planning and decision making arrangements. 92% described their overall experience of this surgery as good which was above the CCG average of 90% and the national average of 85%.

We saw that staff treated patients with kindness and respect, and maintained their confidentiality. Information to help patients understand the services available was easy to understand. Suitable arrangements were in place to support patients and carers to cope emotionally with their care and treatment.

Responsive

Outstanding

Updated 20 August 2015

The practice is rated as outstanding for providing responsive services.

The practice had initiated positive service improvements for its patients and wider community that were over and above its contractual obligations. This included hosting an orthopaedic triage service for hip and knee patients, and piloting an innovative diagnostic pathway to detect significant liver disease in the community in collaboration with other stakeholders.

The practice reviewed the needs of its local population and engaged with the NHS England rea Team and Clinical Commissioning Group (CCG) to secure service improvements within the practice and wider locality where these had been identified. Staff told us they were all committed to deliver the best care to patients, by staying abreast of all latest professional guidance and by embracing new initiatives of delivering care.

The practice acted on suggestions for improvements and changed the way it delivered services in response to feedback from the patient participation group (PPG). The PPG are a group of patients who work together with the practice staff to represent the interests and views of patients so as to improve the service provided to them.

Patients told us it was easy to get an appointment with a named GP or a GP of choice, there was continuity of care and urgent appointments were available on the same day. National data showed high satisfaction scores in respect of access to the service and appointments. These scores were above CCG and national average for all areas.

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 20 August 2015

The practice is rated as outstanding 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 external stakeholders and was regularly reviewed and discussed with staff. The practice carried out proactive succession planning including collaborative working with other local practices to create a federated network organisation offering local services of high quality to patients.

High standards were promoted and owned by all practice staff. This included promoting learning and innovation, as well as an open and fair culture for staff. The practice had participated in the productive general practice programme in 2014 and had maintained the positive outcomes achieved. This programme was developed by the NHS institute for innovation and improvement and is designed to help general practices continue to deliver high quality care whilst meeting increasing levels of demand and diverse expectations.

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. Governance and performance management arrangements had been proactively reviewed and took account of current models of best practice. Robust systems were in place to identify and manage risks, and to ensure the service was well managed.

The practice had a very active patient participation group (PPG) and proactively sought feedback from staff and patients, which it acted on. The PPG are a group of patients who work together with the practice staff to represent the interests and views of patients so as to improve the service provided to them.

Checks on specific services

People with long term conditions

Outstanding

Updated 20 August 2015

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

There was a holistic and pro-active approach to meeting patients’ needs, with a focus on the effective management and regular review of long-term conditions. Data showed the practice had consistently achieved high rates since 2006/07 that were above the local and national averages for all long term conditions assessed as part of the Quality Outcomes Framework (QOF).

In some cases their performance was significantly better, for example in respect of hypertension the practice performance was 13.4% above the CCG average and 11.6% above the national average. QOF is a voluntary incentive scheme which financially rewards practices for managing some of the most common long-term conditions and for the implementation of preventative measures.

The practice reviewed all repeat prescriptions each month (about 300) and 80% of the reviews were face to face consultations with the patient to ensure their medicines remained appropriate for their needs.

Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. Benchmarking data in respect of secondary care use showed the practice was in line with the CCG average. Longer appointments and home visits were available when needed.

All these patients had a named GP and a structured annual review to check that their health and medication needs were being met. Effective recall systems were in place to ensure patients attended. For those people 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 20 August 2015

The practice is rated as outstanding 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 those 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.

Appointments were available outside of school hours and the premises were suitable for children and babies. We saw good examples of joint working with midwives, health visitors and school nurses.

Older people

Outstanding

Updated 20 August 2015

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

Every patient over the age of 75 years had a named GP. Influenza and shingles vaccinations were offered in accordance with national guidance.

Nationally reported data showed good outcomes for conditions commonly found in older people (for example osteoporosis and stroke and transient ischaemic attack) and Quality Outcomes Framework (QOF) data showed the practice had achieved and sustained 100% performance since 2006/7 in respect of these conditions. QOF is a voluntary incentive scheme which financially rewards practices for managing some of the most common long-term conditions and for the implementation of preventative measures.

The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example, in dementia and end of life care. It was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs.

Working age people (including those recently retired and students)

Outstanding

Updated 20 August 2015

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.

The practice was involved in a range of innovative research projects to improve the outcomes for patients. For example, the practice was involved in a pilot related to nicotine pre-loading which looked at ways to help people to stop smoking and the practice was proactive in developing services that enabled diagnostic tests that reflected the needs of this age group to be carried out at the practice instead of the local hospitals.

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. Data showed uptake rates for health screening were above the local clinical commission group (CCG) averages.

For example, the practice’s performance for cervical screening uptake was 86.7%, which was better than the CCG average of 83.4% and the national average of 74.3%. Family planning services were provided by the practice for women of working age.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 20 August 2015

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

The clinical staff had comprehensive knowledge and understanding of the Mental Capacity Act and were able to give examples of when they had made referrals to the Independent Mental Capacity Advocate service for patients lacking capacity to make decisions and without friends and relatives to support them.

They had also made referrals to the local authority to request an assessment to determine whether a deprivation of liberty should be authorised for two patient's lacking capacity to consent to such a deprivation.

The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. National data for 2013/14 showed 92.3% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive care plan documented in the record, in the preceding 12 months.

The practice had a system in place to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health. Patients experiencing poor mental health were told how to access various support groups and voluntary organisations including MIND and SANE.

The practice carried out advance care planning for patients with dementia and 96 patients had received a dementia diagnosis in 2014/15. Staff had received training on how to care for people with dementia and mental health. The practice offered longer appointments as required and offered home visits for those patients unable to attend the surgery.

People whose circumstances may make them vulnerable

Outstanding

Updated 20 August 2015

The practice is rated as outstanding 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 identified 27 patients with a learning disability. All patients had been offered an annual physical health check and their care plan had been reviewed within the last 12 months.

Much longer appointments (40 minutes) were offered to patients with a learning disability. The practice had access to interpretation services if required.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. The staff had told vulnerable patients about how to access various support groups and voluntary organisations and relevant information as available.

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.