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Inspection Summary


Overall summary & rating

Good

Updated 6 December 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Walm Lane Surgery on 30 November 2016. The overall rating for the practice was good, with a rating of requires improvement in the safe domain. The full comprehensive report on the November 2016 inspection can be found by selecting the ‘all reports’ link for Walm Lane Surgery on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 29 September 2017 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 30 November 2016. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Overall, the practice is rated as Good.

Our key findings were as follows:

  • The practice had a fire alarm installed on the premises.

  • There were systems in place to ensure disposable equipment was now in date.

  • Suitable sharps bins were now in place in all consultation rooms.

  • All vaccination fridges had back up thermometers in place.

  • There were processes in place to monitor the use of prescription pads and sheets.

  • All emergency medicines were now available.

  • Carers registered with the practice had remained at less than 1% of the patient list.

The areas where the provider should make improvements are:

  • Consider reviewing processes in place to identify carers in order to ensure that these patients are appropriately identified and offered support.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 6 December 2017

The practice is rated as good for providing safe services.

  • The practice had installed a fire alarm on the premises.

  • There were processes in place to monitor the use of prescription pads and sheets.

  • Suitable sharps bins were now available in all consultation rooms.

  • All vaccination fridges had back up thermometers in place.

  • All emergency medicines were now available.

  • There were systems in place to ensure disposable equipment was now in date.

Effective

Good

Updated 6 December 2017

Caring

Good

Updated 6 December 2017

Responsive

Good

Updated 6 December 2017

Well-led

Good

Updated 6 December 2017

Checks on specific services

People with long term conditions

Good

Updated 31 March 2017

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.
  • The practice provided ECGs, 24 hour blood pressure monitoring, and spirometry in-house.
  • Performance for diabetes related indicators were mixed. Overall the practice achieved 78% of the total QOF points available for diabetes indicators, compared with an average of 87% locally and 90% nationally; however, their overall exception reporting rate for diabetes was lower than average at 8% compared the CCG average of 10% and national average of 12%. 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 31 March 2017

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 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.
  • The practice’s uptake for the cervical screening programme was 68%, which was below the CCG average of 77% and the national average of 81%; however, their exception reporting rate was 4% compared to a CCG average of 9% and national average of 7%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • We saw positive examples of joint working with midwives and health visitors.

Older people

Good

Updated 31 March 2017

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’s performance in relation to conditions commonly found in older people was comparable to local and national averages. For example, the percentage of patients with hypertension who had well controlled blood pressure was 75%, compared to a CCG and national average of 83%.

Working age people (including those recently retired and students)

Good

Updated 31 March 2017

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 offered extended hours appointments and telephone consultations for patient who were unable to attend the practice during usual working hours.
  • 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.

People experiencing poor mental health (including people with dementia)

Good

Updated 31 March 2017

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

  • The practice had 18 patients diagnosed with dementia and 75% of these patients had had their care reviewed in a face to face meeting in the last 12 months, which was below the CCG average of 86% and national average of 84%. The practice’s exception reporting rate for this indicator was 11% compared to the CCG and national average of 7%.
  • The practice had 92 patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses and 92% of these patients had had their care reviewed in a face to face meeting in the last 12 months, which is comparable to the CCG average of 91% and national average of 89%. The practice’s exception reporting rate for this indicator was 4% compared to the CCG average of 7% and national average of 13%.
  • 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 31 March 2017

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.
  • 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; however, staff had not received training in safeguarding vulnerable adults.