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Inspection Summary


Overall summary & rating

Outstanding

Updated 16 August 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Combe Down Surgery on 15 June 2016. Overall the practice is rated as outstanding.

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

  • The practice leadership and culture were used to drive and improve the delivery of high quality person centred care. The practice sought opportunities to deliver tailored care in the local community and improve health outcomes for patients.
  • The practice’s key ethos valued working with partners across health and social care community and contributing to improvements in care and health for the wider population and positive health outcomes for patients.
  • The practice was using innovative and forward thinking measure to address the changing face of primary care needs in the population.
  • 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 been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • The practice demonstrated a positive learning culture; opportunities for sharing learning were valued.
  • The practice invested in the development of staff.
  • Feedback from patients about their care was consistently 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. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with a range of urgent appointments available the same day.
  • The practice had developed weekly exercise classes for older patients delivered locally at the branch surgery to improve wellbeing and social support for older patients. Patients reported this service as excellent.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw several areas of outstanding practice:

One of the GPs had led a project and audit with the local hospital and a clinical commissioning group (CCG) prescribing adviser to review the medication advice being given to patients with Parkinson’s disease, as they recognised the impact and implications on patient condition if medicines were not given at the correct hours during the day. The audit gained data from all the practices across the CCG and asked all practices to amend the repeat prescriptions for the relevant medicines to give clear timings for patients, which was shown to significantly impact on quality of life. We saw a communication from the local hospital which supported a positive impact on symptoms for patients.

The practice GPs undertook a weekly ward round and regularly reviewed all the care plans of patients for patients who were registered with the practice and resided in the local nursing home (46 out of 48). Staff at the local nursing home confirmed care plans are individualised, regularly reviewed and medicines were also regularly reviewed with a pharmacist, the GP, the Nursing Home team and the patient. This had demonstrated a significant decrease (70%) in unnecessary hospital admissions.

The practice had tailored their yearly health check for patients with a learning disability (LD); they provided a 30 minute appointment with a specialist LD nurse followed immediately by a 20 minute joint consultation with the patients named GP. The patient’s carer (if relevant) and the LD nurse meet with the patient and GP and review the care, to identify any needs and formulate a written updated care plan

Areas where the provider should improve:

The practice should ensure it continues to take steps identify carers for their care and support.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 16 August 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events, opportunities were taken to share any learning and improve care wherever possible.

  • Lessons were shared to make sure action was taken to improve safety in the practice.

  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • 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.

Effective

Outstanding

Updated 16 August 2016

The practice is rated as outstanding for providing effective services.

  • Our findings at inspection showed that systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines.

  • The practice used innovative and proactive methods to improve patient outcomes and working with other local providers to share best practice.

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

  • Clinical audits demonstrated quality improvement. The practice undertook continuing ‘rolling audits’ in a range of conditions to ensure the optimum care was in place. Rolling audit examples we saw included inhaler use in asthma and antibiotic prescribing.

  • The practice monitored changes in national and local guidelines and updated and developed templates to support patients’ needs assessments. Examples we saw included a diabetes template and a safeguarding template which were being shared across the clinical commissioning group.

  • 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

Outstanding

Updated 16 August 2016

The practice is rated as outstanding for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care. Feedback from patients about their care and treatment was consistently positive.
  • We observed a strong patient-centred culture:
  • 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.
  • Views of external stakeholders were very positive and aligned with our findings
  • 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

Outstanding

Updated 16 August 2016

The practice is rated as outstanding 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 (CCG) to secure improvements to services where these were identified. For example one of the GPs had led a project and audit with the local hospital and a CCG prescribing adviser to review the medication advice being given to patients with Parkinson’s, as they recognised the impact and implications on patient condition if medicines were not given at the correct time of day. The audit gained data from all the practices across the CCG and asked all practices to amend the repeat prescriptions for the relevant medicines to give clear timings for patients, which was shown to significantly impact on quality of life.

  • The practice provided access for a range of services at the branch surgery so patients could access services locally, including physiotherapy, counselling and drug and alcohol support.

  • The practice ran two exercise classes a week for older patients to improve health and wellbeing which also provided social support.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with a wide range of urgent and on the day appointments available.

  • 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 evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Outstanding

Updated 16 August 2016

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

  • The practice leadership and culture were used to drive and improve the delivery of high quality person centred care, promote health and wellbeing, and involve families, carers and the community. The practice sought opportunities to deliver tailored care in the local community and improve health outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.

  • The practice’s key ethos valued working with partners across health and social care community and contributing to improvements in care and health for the wider population and positive health outcomes for patients.

  • 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.

  • The practice was using innovative and forward thinking measure to address the changing face of primary care needs in the population. The practice was working with the local community, to provide a whole person holistic model of health care and wellbeing. The programme was being developed to target health educational, health promotion care and support needs.

  • A programme of continuous clinical and internal audit was used to monitor quality and to make improvements. Opportunities for learning and development were valued.

  • The practice regularly reviewed how to meet the current and changing needs of the community and was diversifying the workforce, for example the practice had just employed an advance nurse practitioner, was utilising a practice pharmacist and supporting apprentices, as well as increasing the range of online services including looking into how to provide governance for future online consultations.

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

Checks on specific services

People with long term conditions

Outstanding

Updated 16 August 2016

The practice is rated as outstanding for the care of patients with long-term conditions. The provider was rated as outstanding for being effective, caring,responsive and well led these ratings apply to everyone using the practice, including this population group.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

  • The practice had developed and adapted templates to ensure best practice care and treatments were in place.

  • The percentage of patients with diabetes, on the register, in whom the blood test to monitor diabetes (in the preceding 12 months 2014/15) was in the target range was 84% which was higher than the clinical commissioning group (CCG) average of 81% and the national average of 78%.

  • The percentage of patients with diabetes, on the register, in whom the last blood

    pressure reading (measured in the preceding 12 months) was in the target range was 85% which was higher than the CCG average of 81% and the national average of 78%.

  • The percentage of patients on the diabetes register, with a record of a foot examination

    and risk classification within the preceding 12 months (2014/15) was 95% which was higher than the CCG average of 92% and the national average of 88%.

  • 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

Outstanding

Updated 16 August 2016

The practice is rated as outstanding for the care of families, children and young patients. The provider was rated as outstanding for being effective, caring, responsive and well led these ratings apply to everyone using the practice, including this population group.

  • 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 patients who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.

  • The practice had adjusted the childhood immunisation clinics to improve access times across the two practice locations.

  • The practice held open access clinics for young patients from local schools whether registered at the practice or not. All young patients could get seen without an appointment for sexual health advice.

  • The practice held a weekly drop in clinic at a local boarding school.

  • Patients told us that children and young patients 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 82%, which was comparable to the CCG average of 83% and the national average of 82%.

  • 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, health visitors and school nurses.

Older people

Outstanding

Updated 16 August 2016

The practice is rated as outstanding for the care of older patients. The provider was rated as outstanding for being effective, caring, responsive and well led these ratings apply to everyone using the practice, including this population group.

The practice GPs undertook a weekly ward round and regularly reviewed all the care plans of patients for patients who were registered with the practice and resided in the local nursing home (46 out of 48). Staff at the local nursing home confirmed care plans are individualised, regularly reviewed and medicines were also regularly reviewed with a pharmacist, the GP, the Nursing Home team and the patient. This had demonstrated a significant decrease (70%) in unnecessary hospital admissions.

  • The practice offered proactive, personalised care to meet the needs of the older patients in its population.

  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.

  • The practice had developed weekly exercise classes for older patients delivered locally at the branch surgery to improve wellbeing and social support for older patients. Patients reported this service as excellent.

  • The practice, with the Friends of Combe Down Surgery ran a transport service for patients with mobility problems to access appointments and clinics. They supported an average of four patients each day.

Working age people (including those recently retired and students)

Outstanding

Updated 16 August 2016

The practice is rated as outstanding for the care of working-age patients (including those recently retired and students). The provider was rated as outstanding for being effective, caring, responsive and well led these ratings apply to everyone using the practice, including this population group.

  • 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.

  • The practice held a walk-in flu-vaccination service to improve flexibility of access to routine vaccinations.

  • The practice offered a range of appointments including a daily walk in clinic, on day and next day appointments and a range of telephone appointments to increase access.

  • The practice had a 24/7 automated telephone appointment booking service.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 16 August 2016

The practice is rated as outstanding for the care of patients experiencing poor mental health (including patients living with dementia). The provider was rated as outstanding for being effective, caring, responsive and well led these ratings apply to everyone using the practice, including this population group.

  • The percentage of patients with a serious mental health problem who had a comprehensive, agreed care plan documented in the record, in the preceding 12 months (2014/15) was 92% which was the same as the clinical commissioning group (CCG) average and higher than the national average of 88%.

  • The percentage of patients with a serious mental health problem whose alcohol consumption has been recorded in the preceding 12 months (2014/15) was 94% which was higher than the CCG average of 91% and the national average of 90%.

  • The percentage of patients diagnosed with dementia whose care has been reviewed in a face-to-face review in the preceding 12 months (2014/15) was 85% which was in line with the CCG average of 86% and the national average of 84%.

  • 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

Outstanding

Updated 16 August 2016

The practice is rated as outstanding for the care of patients whose circumstances may make them vulnerable. The provider was rated as outstanding for being effective, caring, responsive and well led these ratings apply to everyone using the practice, including this population group.

  • 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 had tailored their yearly health check for patients with a learning disability (LD); they provided a 30 minute appointment with a specialist LD nurse followed immediately by a 20 minute joint consultation with the patients named GP. The patient’s carer (if relevant) and the LD nurse meet with the patient and GP and review the care, to identify any needs and formulate a written updated care plan.

  • 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.