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Inspection Summary


Overall summary & rating

Good

Updated 27 March 2019

We carried out an announced comprehensive inspection of Watling Medical Practice on 8 November 2018 as part of our inspection programme. The overall rating for the practice was good, however we rated the practice as requires improvement for safe. The full comprehensive report on the November 2018 inspection can be found by selecting the ‘all reports’ link for Watling Medical Practice on our website at www.cqc.org.uk.

This inspection was a desk-based review carried out on 6 February 2019 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 8 November 2018. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

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Overall the practice is now rated as Good.

Our key findings were as follows:

  • The system for recruiting staff had been reviewed to ensure only fit and proper persons were employed.
  • The provider had taken action to address the areas where we advised them that improvements should be made. Improvements had been made to the procedures for the management of prescriptions. The risk assessment for taking medication on home visits had been updated. Staff had received guidance on the updated safeguarding policies and procedures. A revised procedure had been developed to encourage the uptake of cervical screening which referred to screening being encouraged through monitoring of uptake, sending reminder letters and telephoning patients.
  • At our previous inspection on 8 November 2018, we advised the provider that infection control should be improved by the provision of an elbow mixer tap in the minor surgery room and that curtains should be provided in two treatment rooms to promote privacy and dignity during examinations. At this inspection, this has not been fully addressed, however the provider told us the action being taken to address these issues.

The areas where the provider should make improvements are:

  • Provide an elbow mixer tap to the sink in the minor surgery room to improve infection control.
  • Provide curtains in two treatment rooms to promote privacy and dignity during examinations.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Requires improvement

Updated 17 December 2018

We rated the practice as requires improvement for providing safe services.

This was because there were shortfalls in the required information that needs to be obtained prior to recruiting staff. The practice advised us after the inspection of the steps that had been taken to remedy the shortfalls identified.

Safety systems and processes

Overall the practice had systems to keep people safe and safeguarded from abuse.

  • Overall, the practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff had received safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Learning from safeguarding incidents was available to staff. Staff had access to written policies and procedures for safeguarding vulnerable adults and children, however they had not been updated with information on identifying and reporting female genital mutilation (FGM) and modern slavery. The provider submitted evidence that this information had been added to the safeguarding procedures following the inspection. There was a policy and procedure for Prevent (support to people at risk of joining extremist groups and carrying out terrorist activities) however a member of staff spoken with was unclear about what this referred to. The practice manager reported that an update on the safeguarding procedures would be provided to all staff at the next staff meeting. The practice had redesigned a template for sharing safeguarding concerns. Concerns were recorded and shared with the health visiting service every 4-6 weeks.
  • Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.) However, we found two DBS checks had been used from a previous employer. This was addressed following the inspection.
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, discrimination and breaches of their dignity and respect.
  • There was a system in place to carry out ongoing checks of the registration of clinicians with their professional bodies. We looked at two recruitment records for staff employed since the last inspection. A reference was not available for one member of staff. This was provided following the inspection. A risk assessment was not always recorded when the practice had made a decision not to carry out a DBS check on non-clinical staff. This was addressed following the inspection. Evidence of physical and mental suitability of staff for their role was not recorded. This shortfall had been identified at the last inspection. The practice manager reported that this information was gathered during pre-employment interview. A template to ensure this information is recorded for future employees was provided following the inspection.
  • Infection control audits and monthly premises checks were carried out. Staff had received training in infection control.
  • Overall, the practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

Overall the practice had reliable systems for appropriate and safe handling of medicines.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks. Two types of medication that could be used in an emergency where not held on site and a recorded risk assessment was not in place to demonstrate why. Following the inspection the provider confirmed that this medication had been obtained for use in an emergency.
  • We found uncollected prescriptions (one from April and two from August 2018). The protocol for the management of uncollected prescriptions indicated these would be checked monthly and a GP informed. Following the inspection the practice manager reported that they had ensured all staff were aware of this protocol.
  • GPs did not take medication on home visits. Following the inspection, a risk assessment was provided to demonstrate the reasoning for this. However, this did not include factors that would impact on patient safety such as ambulance response times.
  • Patients did not sign when they collected prescriptions for controlled drugs. Following the inspection, the provider confirmed that a record book had been introduced to enable this.
  • Staff prescribed and administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines. The provider had identified that improvements were needed to ensure an annual review of medication was carried out for all patients and they had a plan in place to address this.

Track record on safety

  • The practice monitored and reviewed safety using information from a range of sources.
  • The practice monitored and reviewed activity such as significant events, referral and prescribing practices. This helped it to understand risks and gave a basis on which to make safety improvements.
  • There was a system for receiving and acting on safety alerts.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the evidence tables for further information.

Effective

Good

Updated 17 December 2018

We rated the practice and all of the population groups as good for providing effective services

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Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • The practice was working with the medicines management team from the Clinical Commissioning Group (CCG) to review older patients prescribed multiple medications to ensure that they were appropriately prescribed.
  • The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail and at risk of falls had a clinical review including a review of medication.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

  • Patients with long-term conditions were offered an annual review to check their needs were being met. The provider had identified that improvements were needed to ensure an annual review of medication was carried out for all patients and they had a plan in place to address this.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension).
  • The most recent data from Public Health England showed that the practice was above local and national averages for treating hypertension patients between the ages of 30 – 74 with a cardiovascular risk assessment with statins (practice 100%, CCG average 75%, national average 72%).
  • The practice’s performance on quality indicators for long term conditions was in line with local and national averages.

Families, children and young people:

  • Childhood immunisation uptake rates were overall in line with the target percentage of 90% or above. The practice was taking action to ensure that the 90% target was reached for all immunisations by offering opportunistic screening, flexible appointment times and contacting the health visiting service when appointments were missed to encourage attendance. Following the inspection, the provider informed us that they had appointed an immunisation champion who would be following up patients who did not attend for this service.
  • The practice had designed a template for sharing safeguarding concerns. Concerns were recorded and shared with the health visiting service every 4-6 weeks.

Working age people (including those recently retired and students):

  • The practice’s uptake for cervical screening was 75%, which was in line with the CCG and national average but below the 80% coverage target for the national screening programme. To increase coverage the practice offered early morning and evening appointments, opportunistic screening and publicised the importance of this screening at the practice. A reminder letter was not sent to women. Following the inspection, the provider informed us that they had appointed a cytology champion who would be following up patients who did not attend for this service.
  • The practice’s uptake for breast and bowel cancer screening was above the national average
  • Patients had access to appropriate health assessments and checks. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

  • The practice held meetings and communicated with health and social care professionals to ensure that end of life care was delivered in a coordinated way which considered the needs of those 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 had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

People experiencing poor mental health (including people with dementia):

  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • The practice offered annual health checks to patients with a learning disability.
  • The practices performance on quality indicators for mental health was in line with local and national averages.
  • The most recently published data from Public Health England showed that the practice performed above local and national averages for reviews of newly diagnosed patients with depression within 10-56 days after diagnosis (practice 77%, CCG average 64% and national average 65%.) The practice was also above local and national averages for reporting patients with dementia (practice 1.5%, CCG average 0.6% and national average 0.5%). The practice placed alerts on the records of patients prescribed anti-depressant medication to prompt the clinicians to review the patient’s medication and well-being.

Monitoring care and treatment

The practice reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • The practice used information about care and treatment to make improvements.
  • The practice had completed clinical audits to evaluate the operation of the service and the care and treatment given.
  • Where appropriate, clinicians took part in local and national improvement initiatives. For example, the practice had attended a presentation on research carried out by Action on Cancer and had approached the organisation for support in further improving their cancer detection rates.
  • The practice used the Quality and Outcomes Framework (QOF) and other performance indicators to measure their performance.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.

Coordinating care and treatment

Staff worked with other health and social care professionals to deliver effective care and treatment.

  • The clinicians told us how the practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children.
  • Clinicians told us how patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital.
  • The practice held regular meetings with the local community nursing teams to discuss and manage the needs of patients with complex medical issues.

Helping patients to live healthier lives

Staff helped patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians told us how they supported patients to make decisions. Where appropriate, they told us they assessed and recorded a patient’s mental capacity to make a decision.

Please refer to the evidence tables for further information.

Caring

Good

Updated 17 December 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The practices GP patient survey results were in line with local and national averages for questions relating to kindness, respect and compassion.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials could be made available.
  • Staff helped patients and their carers find further information and access community and advocacy services.
  • The practice identified carers and supported them.
  • The practices GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues or appeared distressed reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of treating patients with dignity and respect.
  • The doors to treatment rooms where lockable. Two treatment rooms did not have a curtain to promote privacy and dignity during examinations.

Please refer to the evidence tables for further information.

Responsive

Good

Updated 17 December 2018

We rated the practice, and all of the population groups, as good for providing responsive services

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Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • A room was provided free of charge to the Improving Access to Psychological Therapies (IAPT) team and domestic violence support services to ensure patients could easily access this support.
  • Referrals were made to external services to support patients with their social and physical and mental health needs.
  • The practice had encouraged secondary care providers to operate a consultation service at the premises. For example, for ophthalmology, general surgery and orthopaedics. This reduced patient waiting and travelling time.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits, urgent and double appointments for those with enhanced needs.
  • Electronic examination couches which could be adjusted were provided to meet the needs of frail patients.

People with long-term conditions:

  • Patients with a long-term condition were offered an annual review to check their health needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • We were informed that the practice had systems 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 accident and emergency (A&E) attendances.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

Working age people (including those recently retired and students):

  • To meet the needs of this population group appointments and prescriptions could be managed on-line, telephone appointments and double appointments were offered. Early appointments with a GP could be booked from 8am and early and late appointments (from 8.30am – 6pm) were available with the practice nurses.
  • The practice publicised self-care and directed patients with minor ailments to a pharmacy.

People whose circumstances make them vulnerable:

  • People in vulnerable circumstances were able to register with the practice. For example, the practice provided a service to a women’s refuge.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.

People experiencing poor mental health (including people with dementia):

  • The practice maintained a register of patients who experienced poor mental health. The register supported clinical staff to offer patients experiencing poor mental health, including dementia, an annual health check and a medication review.
  • Reception staff were aware of patients that needed additional support due to poor mental health and offered longer or urgent appointments as needed.
  • The practice told us how they worked with external mental health professionals in the case management of people experiencing poor mental health, including those with dementia. There were clear pathways to refer patients who may need urgent support.
  • Referrals were made to support services to assist patients experiencing poor mental health.

Timely access to care and treatment

Patients were able to access care and treatment from the practice within an acceptable timescale for their needs.

  • Patients had timely access to appointments.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • The practices GP patient survey results were in line with national averages and above some local averages for questions relating to access to care and treatment. Feedback regarding access to a preferred GP was above local and national averages.
  • The percentage of respondents to the GP patient survey who usually get to see or speak to their preferred GP when they would like to was 67% (CCG average 47%, national average 50%).

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were overall in line with recognised guidance. Details of the role and contact information for the Parliamentary Health Service Ombudsman and NHS England were not included to provide guidance to patients. This was addressed following this inspection.
  • The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 17 December 2018

We rated the practice as good for providing a well-led service.

Leadership capacity and capability

Leaders had the capacity and skills to deliver good quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

The practice had a clear vision to deliver good quality care and promote good outcomes for patients.

Staff were aware of and understood the vision, values and strategy and their role in achieving them.

The practice told us how they worked with the CCG to ensure their strategy was in line with health and social priorities across the region. The practice planned its services to meet the needs of the practice population.

Culture

The practice had a culture of good quality sustainable care.

  • Staff stated they felt respected, supported and valued.
  • The practice focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • The safety and well-being of staff was promoted.
  • There were positive relationships between staff and teams.

Governance arrangements

There were systems of accountability to support good governance and management.

  • There were clear systems to enable staff to report any issues and concerns.
  • Staff were clear on their roles and accountabilities including safeguarding and infection prevention and control.
  • The practice leaders told us and a sample of records reviewed confirmed that they had policies and procedures to ensure safety and assured themselves that they were operating as intended.
  • Practice leaders had established policies, procedures and activities to ensure safety.
  • There were shortfalls in the required information that needs to be obtained/documented prior to recruiting staff. The practice advised us after the inspection of the steps that had been taken to remedy the shortfalls identified.

Managing risks, issues and performance

There were processes for managing risks, issues and performance.

  • There was a system to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was evidence of action to change practice to improve quality.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to monitor performance. The practice monitored how it performed in relation to local and national practice performance. There were plans to address any identified weaknesses.
  • Quality and sustainability were discussed in relevant meetings.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The provider informed us that they submitted data or notifications to external organisations as required.
  • The practice manager told us that there were arrangements in place for data security standards to be maintained that promoted the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved patients, the public, staff and external partners to support a good standard of service.

  • The views and concerns of patients’, staff and external partners were encouraged and acted on to shape services and culture. For example, the practice gathered feedback from staff through staff meetings and informal discussion. The practice had a system for the management of complaints.
  • The practice had a patient participation group (PPG) which was consulted with via email regarding specific issues and to ascertain their views about how the practice was operating. The practice manager said that this group had been established due to difficulty in getting patients to participate in face to face meetings. The practice manager told us that they had 30 members which were from a cross section of the patient population. Following feedback from the PPG about how the practice could make information about in-house and local services more accessible to patients’ reception staff had received sign posting training.
  • Staff told us how the service worked with stakeholders to improve performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good