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Inspection Summary


Overall summary & rating

Good

Updated 11 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Pump House Surgery. Overall the practice is rated as good.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Incidents were investigated and learning had been identified but there was a lack of evidence to demonstrate that this learning had been cascaded to relevant staff.

  • There were no practice specific standard operating procedures in place for the dispensary service offered by the practice; however medicine errors and near misses were being reported, analysed and lessons learnt embedded into practice.

  • We saw that national patient safety and medicine alerts were received, reviewed and actioned appropriately. However some staff were not aware of a recent alert and the documentation of initialling the alert once read; several alerts had one signature.

  • There was a bespoke standard operating procedure in place for the dispensary.

  • Infection control audits were undertaken and actions identified dealt with in a timely way.

  • Families who suffered bereavement received personalised follow up care from the GP that had most contact with the family in the last weeks of care.

  • 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.

  • There was some evidence of quality improvement activity including clinical audit. However the conclusions of the audits did not identify where improvements could be made.

  • Patients were supported, treated with dignity and respect. Patients were encouraged and supported to be involved as partners in their care.

  • 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; however the lessons identified and actions to be taken were not sufficiently documented to ensure the improvements had ben actioned.
  • Patients said they were able to access the right care at the right time; appointments were managed to take account of patient’s needs, including those with urgent needs.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice had identified a low number of patients who were carers.
  • There was a system in place for infection control but issues identified as areas for improvement had not been actioned. There had been no infection control audit as required by guidance.
  • 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 provider was aware of and complied with the requirements of the duty of candour.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.

The areas where the provider should make improvement are:

  • Ensure that the learning from the investigation of safety incidents and complaints is shared with relevant staff and documented.

  • Identify a lead staff member to oversee infection control.

  • Improve the identification of patients who are carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 11 April 2017

The practice is rated as good for providing safe services and improvements must be made.

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Reviews and investigations were thorough but there was a lack of evidence to demonstrate that the learning had been shared with relevant staff.

  • We saw that national safety alerts were received, reviewed and actioned appropriately.

  • There was practice specific standard operating procedures in place for the dispensary service offered by the practice. The practice was signed up to the Dispensary Services Quality Scheme; medicine errors and near misses were reported, analysed and lessons learnt were being shared with relevant staff.

  • Infection control audits had been completed and actions identified; however the practice had not identified a lead staff member for this speciality.

  • We reviewed a range of personnel files and found that all of the appropriate recruitment checks had been undertaken for all staff prior to employment. For example, proof of identification, references, qualifications, registration with the appropriate professional body and the appropriate checks through the Disclosure and Barring Service.

  • The practice had a business continuity plan in place for major incidents such as power failure or building damage. The plan included emergency contact numbers for staff.

  • The practice had adequate arrangements in place for dealing with emergencies.

Effective

Good

Updated 11 April 2017

The practice is rated as good for providing effective services.

  • Patients care and treatment was planned and delivered in line with current evidence based guidance, standards, best practice and legislation. This included during assessment, diagnosis, when patients needed to be referred to other services and when managing people’s chronic or long-term conditions, including patients identified to be in the last 12 months of their life.

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

  • There was some evidence of quality improvement activity including clinical audit but it required strengthening.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • There was evidence of appraisals and personal development plans for staff.

  • Staff were proactive in supporting patients to live healthier lives. For example smoking cessation advice was available from the nursing staff.

Caring

Good

Updated 11 April 2017

The practice is rated as good for providing caring services.

  • Patients were supported, treated with dignity and respect. Patients were encouraged and supported to be involved as partners in their care.

  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.

  • 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.

  • Written information was available in the waiting area to direct carers to the various avenues of support available to them. The practice had only identified 0.7% of its patients as carers. there were patient that identified themselves as a carer on registration. Carers identified were offered health checks and flu immunisation.

  • Families who suffered bereavement received bespoke personalised follow up care from the GP that had most contact with the family in the last weeks of care.

Responsive

Good

Updated 11 April 2017

The practice is rated as good 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 to secure improvements to services where these were identified.

  • Patients said they were able to access the right care at the right time; appointments were managed to take account of patient’s needs, including those with urgent needs.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • Information about how to complain was available. Complaints were recorded and investigated but action taken as a result of analysis was not recorded and there was no evidence that learning from complaints had been shared with staff.

Well-led

Good

Updated 11 April 2017

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

  • The practice had a clear vision and strategy to deliver high quality care and promote good 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.

  • When something went wrong, patients received a sincere and timely apology and were told about any actions taken to improve processes to prevent the same happening again.

  • 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 encouraged and valued feedback from patients, the public and staff.

Checks on specific services

People with long term conditions

Good

Updated 11 April 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. Annual reviews of these patients were carried out by the practice nurses.
  • Phlebotomy services were provided within the practice five days a week.
  • Dispensing services were provided for patients living more than one mile away from the practice.
  • The practice had processes in place for monitoring prescriptions that were not collected from the dispensary.
  • Longer appointments and home visits were available when needed.
  • Patents received 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 11 April 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.

  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals.

  • Child immunisation performance data was comparable to the CCG.

  • 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. Weekly clinics were held at Halsted hospital for the health visitors and midwives.

  • The practice offered postnatal checks and eight- week baby checks. We saw a copy of the letter sent to new mothers that included a new birth registration form and an invitation to visit the practice for the child health clinic.

  • Same day appointments were available for children and those with serious medical conditions.

  • The practices uptake for the cervical screening programme was 90%, which was above the national average of 82%.

Older people

Good

Updated 11 April 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 patient list included residents living in eight care homes locally.

  • Phlebotomy services were provided within the practice five days a week.
  • Dispensing services were provided for patients living more than one mile away from the practice.

  • The practice had processes in place for monitoring prescriptions that were not collected from the dispensary.
  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. Flu vaccinations were offered on home visits.

  • The practice participated in the Avoiding Unplanned Admissions Enhanced Service. The practice contacted patients shortly after discharge and after attendance at an emergency department. We reviewed the care plan of a patient in this category and found it was well written.

  • All eligible patients were offered the shingles vaccination.

  • Regular meetings were held with the palliative care nurses, district nurses and community matron.

Working age people (including those recently retired and students)

Good

Updated 11 April 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 was proactive in offering online services including appointments, prescriptions and summary care records.

  • Telephone consultations were available each day for those patients who had difficulty attending the practice due, for example, to work commitments.

  • The practice offered a full range of health promotion and screening that reflects the needs for this age group.

  • Patients were able to receive travel vaccinations available on the NHS.
  • The practice registered students as temporary patients.

  • 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.

People experiencing poor mental health (including people with dementia)

Good

Updated 11 April 2017

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

  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. Information leaflets were available in the waiting area.

  • Staff had a good understanding of how to support patients with mental health needs and dementia.

  • 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.

People whose circumstances may make them vulnerable

Good

Updated 11 April 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 homeless people, travellers and 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.

  • The practice had processes in place for monitoring prescriptions that were not collected from the dispensary.

  • The practice gained written consent for relatives to share their medical information and treatment planning for patients diagnosed with memory loss or dementia.

  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities and how to contact relevant agencies in normal working hours and out of hours.