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Inspection carried out on 6 March 2019

During a routine inspection

We carried out an announced comprehensive at Leatside Surgery on Wednesday 6 March 2019 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected

  • information from our ongoing monitoring of data about services and

  • information from the provider, patients, the public and other organisations.

We have rated this practice as Outstanding overall -Good in the Safe, Effective and Caring key questions and Outstanding in the Responsive and Well led key questions. (Previous rating October 2015 – Outstanding overall )

At this inspection we found:

  • Feedback from patients about the staff, care and treatment was positive. National patient survey results regarding staff, care, treatment and the service were consistently higher than local and national averages.

  • Patients appreciated the appointment system and ‘same day’ service and said it was easy to use. Patients reported that they were able to access care when they needed it.

  • There was a stable leadership team. Leaders communicated well with each other and with the team. They were knowledgeable about issues and priorities relating to the quality and future of services and participated in external groups to ensure they understood the local changes and challenges. The partners and general manager were instrumental in setting the practice strategy, so it was in line with health and social care priorities nationally and across the local area.

  • The practice worked effectively with other practices in the locality and involved in the future of General Practice nationally and within South Devon. The new practice manager had conducted a review and updated the governance process to meet the latest guidance.

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice recognised where systems and processes had worked well and improved their processes where appropriate.

  • The practice had established and embedded systems in place to assess, monitor and manage risks to patient safety.

  • There was a strong commitment for staff to develop their skills, competence and knowledge through weekly mentoring, supervision, support and additional learning programmes.

  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines which contributed to improvements for patient outcomes.

  • The practice had identified higher than average exception reporting rates for mental health indicators and lower than average childhood immunisation rates and had taken action regarding these. Rates were starting to improve.

  • Staff involved and treated patients with compassion, kindness, dignity and respect.

  • There was a strong focus on continuous learning and improvement at all levels of the organisation. Staff said the practice was a good place to work and added that the leadership team were supportive and encouraged career development and learning which impacted positively on the quality of care offered to patients.

  • There was evidence of systems and processes for learning, continuous improvement and innovation. The practice had been pivotal in several local pilots and schemes which tested new processes and systems designed to improve the patient experience. For example, the practice had worked with the rotary club to host a ‘Know Your Blood Pressure Day’ and had supported the charity ‘Supporting Cardiac Risk in the Young’ by providing free premises for their checks over a weekend.

  • Practice staff provided dedicated medical support for the local Health and Wellbeing Team (HWBT) comprised of community health and social care teams which were based at Totnes Hospital. This collaborative group enabled patients to remain at home with enhanced care needs, offering an alternative to being in hospital and so support a reduction in hospital based care through admission avoidance and supported hospital discharge.

  • The practice had responded to feedback of patients with regard to access to appointments by the introduction of an Advanced Nurse Practitioner and implementation of health navigators to direct patients to the most appropriate source of support. This had resulted in quicker appointment access, increased patient satisfaction, reduction of staff stress and the delivery of a safe ‘on the same day’ appointment system.

  • Providing practice staff for pulmonary rehabilitation classes for patients in the community.

We found areas of outstanding practice:

The practice took a leadership role in the local health and social care community to identify and proactively address challenges and meet the needs of the practice population. For example,

  • in response to a local incident the practice worked closely with a local school to equip pupils and parents with basic life support and first aid skills’

  • The practice work closely and effectively with the support of the ‘Caring Town Rough Sleepers’ group and had secured a community drug and alcohol practitioner to run an outreach clinic in Totnes. This removed the need for these patients to travel to Newton Abbot for this service and meant they could access support and treatment. Patients were encouraged to use the practice address for correspondence.

  • providing a dedicated integrated GP for Totnes Community Hospital to provide ongoing support enabling patients in the community to be cared for closer to home and being a contributing factor for shorter in patient stay during the busy winter period.

Instigating and now supporting the Totnes Caring charity to meet unmet need in the community in relation to home help, transport, befriending and social activities.

The practice had a dedicated early visiting GP with the aim of avoiding admissions or reducing the wait for elderly patients in the emergency department. An audit of the project set up in Autumn 2018 showed that the practice had received 50 requests for visits. Of these 37 visits had been completed, resulting in 11 early admissions and 5 avoided admissions. The practice estimated that this had saved the Clinical Commissioning group £12,500 in admission costs.

There were consistently high levels of constructive engagement with staff, stakeholders and people who used the services. Rigorous and constructive challenge was welcomed and seen as a vital way of holding services to account and improving services. For example, when implementing the Advanced Nurse Practitioner role and changing the premises.

There was a deeply embedded system of leadership development and succession planning, which aimed to ensure that the service was not disrupted, and staff received the support required. Often this involved overlapping roles at considerable expense to the practice.

The areas where the provider should make improvements are:

  • Continue to review, monitor and address Quality Outcome Framework (QOF) exception reporting rates, immunisation rates and cervical screening rates and continue to review and action alternative approaches to reach the non-engaged population.

  • Should continue to monitor and take actions to reduce the rate of antibiotic prescribing in line with national guidance.

  • Continue to review, monitor and take actions to reduce the rate of prescribed hypnotic medicines.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection carried out on 28 October 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Leatside Surgery on Wednesday 28 October 2015. Overall the practice is rated as outstanding.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • 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.
  • Feedback from patients about their care was consistently and strongly positive.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • 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.
  • 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 an effective approach to succession planning.

We saw areas of outstanding practice. The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. which impacted on the population groups served by the practice. For example:

Older people

GPs at the practice provide daily medical support to inpatients at Totnes Community Hospital and one specialist GP had recently expanded the role. This included liaising with staff, patients, carers, social services and the voluntary sector to ensure patients once well enough to be discharged, do so in a timely, safe manner. The impact of this service also reduced admissions to the local district general hospital.

The practice worked in partnership with a third sector organisation, Totnes Caring. This team originated through the practice and have a GP on their Board. The 200 volunteers provide befriending, transport, and support to patients who need services that are not provided by the statutory sector. They organise a daily lunch club and arrange transport for patients to attend. The GPs refer patients and carers to the Totnes caring bi-monthly memory café for patients suffering with dementia. Appropriately vetted Totnes Caring staff were invited to the practice multi-disciplinary meetings to facilitate the support patients may need.

Families, children and young people

The practice had responded well to the low uptake of childhood immunisations in the town. The practice carried out an awareness campaign which included the local press as well as the Totnes Directory. The GPs also gained TV coverage on both the ITV and BBC on working collaboratively with the local schools, nurseries and Devon County Council to improve the uptake. The staff ran clinics outside of school times and offered ‘drop-in’ sessions, the result of the campaign increased immunisation uptake by 1.5%.

The practice had responded to the needs of the town by offering two family planning clinics per week, for all patients in Totnes including patients from neighbouring practices.

Working age people (including those recently retired and students)

The practice had been nominated for an award as General Practice Team of the Year in the HEART UK NHS Health Check Awards 2015. This was for outstanding teamwork in the delivery of a project/ innovation in the commissioning or delivery of the NHS Health Check Programme. The impact of this team delivered programme has been an increased prevalence and treatment of patients with pre-diabetes, diabetes and hypertension. The practice increased their Health Care Assistant capacity by 16 hours per week to improve access for patients.

People whose circumstances may make them vulnerable

The practice worked with the Caring Town Totnes group to recently raise the issue of homelessness and people begging on the streets of Totnes. Practice staff link with the local pastors and the ‘drop-in’ centre supporting homeless people in keeping these patients safe.

The GPs had also offered an outreach service to two traveller communities in Totnes to ensure they were aware of the services available, particularly for young family members.

The practice had also supported a programme in Totnes in offering sanctuary to refugees and asylum seekers if they wish to live in Totnes. Leatside Surgery stated they supported this to ensure people had access to healthcare.

The areas where the provider should make improvement are:

Introduce a system to ensure all equipment carried in GPs bags were included on the programme of calibration and safety checks.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 4 December 2013

During a routine inspection

Patients were very positive about the care they received and told us they thought the practice was "really good" and "satisfactory for my needs" and "super". Another patient said “I have no complaints at all."

We were told that staff treated patients with respect, dignity and said staff were "lovely", "very kind" and "professional." Patients all said they had been involved in the decisions made about their care. One patient said "I am not bullied into anything. It is a two way discussion."

Patients told us they could see the doctor they preferred and liked this, although it sometimes meant they had to wait a little longer for an appointment. Patients said it was easy to make a same day ‘emergency appointment’ and added, "if you phone early" or "if you tell them you need to be seen on the day they squeeze you in somewhere.”

All staff knew the correct local safeguarding procedures to follow if abuse was suspected and all had attended safeguarding training.

Patients told us that they always felt safe in the care of the staff. There were appropriate arrangements in place which ensured that staff kept their knowledge and skills up to date. Staff spoke about the supportive environment.

The practice was organised and well led. There were effective systems in place to monitor the quality of the service provided and patients felt able to give feedback about the service they received.