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Dr N Chandra and Partners Outstanding Also known as North Road Suite

Inspection Summary


Overall summary & rating

Outstanding

Updated 4 August 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr N Chandra and Partners on 21 April 2016. Overall the practice is rated as outstanding.

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

  • All staff were open, transparent and fully committed to reporting incidents and near misses. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning and personal reflection from internal and external incidents were maximised.
  • The whole team was engaged in reviewing and improving safety and safeguarding systems. They used the Care Quality Commission fundamental standards to measure standards of care and signed up to the NHS England Sign up to Safety campaign.
  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, they developed practice specific protocols to safeguard patients, identify patients at risk of exploitation and assess patient need.
  • Feedback from patients about their care was consistently and strongly positive.
  • The practice carried out regular patient engagement and surveys, including surveys for children for whom they introduced specific survey forms.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs and reduced inequalities. For example, they worked with the local community support workers to create new practice specific literature in Urdu and European languages.
  • Comprehensive information about the practice and services was made available to patients including a patients’ charter and quarterly practice and patient group newsletter..
  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from external stakeholders, patients and from the patient participation group. For example, the practice reserved child only appointments after school and increased the availability of urgent appointments as a result of PPG discussions.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was active review of complaints and how they were managed and responded to, and improvements are made as a result. People who use services were involved in the review. The practice had a mission statement and 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. Staff, patients and external stakeholders were encouraged to contribute to the practice strategy to deliver this vision.
  • The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw several areas of outstanding practice:

  • The practice was very responsive to the needs of minorities. They engaged with the local community to co-produce practice specific information in their own language, for example, Urdu, Hungarian and Polish and introduced specific survey forms for children. Hungarian patients had a 21% fail to attend (FTA) rate for new patient appointments. They worked with local community support workers to create new practice specific literature in these languages. After the introduction of these resources the FTA rate decreased significantly.
  • The practice recognised problems locally with human trafficking. They consulted local authorities and national guidance. The information was discussed with staff to raise awareness and identify indicators of modern slavery. Bespoke protocols were developed to assess these patients upon registration and at subsequent appointments or if they failed to attend for appointments.
  • Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. For example, they invited dementia patients and family members to suggest how services could be improved, which they acted upon.
  • The practice made significant efforts to identify and support carers. There was a named carers champion who worked with local organisations to support carers and attended local carers champion meetings and events. We saw a dedicated carers corner in the waiting area with up to date information and saw examples of the support offered to patients, carers and their families. Carers were given a direct practice telephone number to ring for support. A local carer support organisation had acknowledged the practice’s proactive approach to carers. The practice was featured in the Carers Count newsletter shortly after the inspection. The practice had significantly increased the proportion of carers on their register as a result of this activity.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Outstanding

Updated 4 August 2016

The practice is rated as outstanding for providing safe services.

  • The practice had signed up to the NHS England national Sign up to Safety campaign. As a result they undertook additional training and produced practice specific protocols on the clinical system to improve incident reporting, identify, safeguard and support patients at risk.

  • All staff were open, transparent and fully committed to reporting incidents and near misses. Staff were encouraged to raise concerns and report incidents and near misses through a no blame culture. The process prompted staff to personally reflect on incidents.
  • The practice could evidence where patients affected by incidents were invited to work with the practice to improve services for patients. For example, a family member of a dementia patient was invited to contribute to the development of a practice dementia patient pathway.
  • They had a dedicated practice safeguarding team. GPs and the carer’s champion attended local safeguarding meetings and liaised with the local safeguarding leads to ensure patients at risk were supported.
  • The practice noticed an increase in young, Eastern European patients registering with the practice. The practice were aware of examples of human trafficking locally and developed protocols to assess these patients.
  • The practice appeared to use every opportunity to learn from internal and external incidents, to support improvement. Learning was based on a thorough analysis and investigation.
  • Practice development plans were themed on the year of safety. Information about safety was highly valued and was used to promote learning and improvement. The whole team was engaged in reviewing and improving safety and safeguarding systems. Staff members had signed pledges to put safety first and contributed to discussions to improve safety. As a result the practice carried out assessments of the locality and bespoke practice protocols were developed which linked to local and national guidance. For example, in response to evidence of local human trafficking and exploitation.
  • Risk management was comprehensive, well embedded and recognised as the responsibility of all staff.
  • There was a clinical lead for infection control who undertook regular audits and provided hand hygiene training for other staff members.The nursing team carried out regular audits of the vaccine fridges. Action was taken to identify medication approaching expiry dates to be used before new stock.
  • There were comprehensive business continuity plans. The practice discussed the plans with other occupiers of the building and included emergency contact numbers for staff, building managers and other services.

Effective

Good

Updated 4 August 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average.
  • The nurses had lead roles in the management of patients with long term conditions.
  • Eighty eight per cent of patients with diabetes, on the register, had a record of a foot examination and risk classification (CCG average 89%, national average 88%).
  • The practice identified a high prevelance of Chronic Obstructive Pulmonary Disease (COPD). Two nurses received additional training in spirometry to deliver local care to this group of patients. Spirometry is a test used to diagnose COPD. Data from 2014/15 showed that 88% of patients with COPD (diagnosed on or after 1 April 2011) had their diagnosis confirmed by post bronchodilator spirometry. The practice showed us data from March 2016 which showed this increased to 93%.
  • Staff assessed needs and delivered care in line with current evidence based guidance. Clinical protocols were reviewed in response to new guidelines. For example, the practice carried out a review of patients with atrial fibrillation in response to new Oral Anticoagulant Therapy (NOAC) guidance for primary care. Patients were invited to attend the surgery to assess and discuss the initiation of new medication.
  • The practice demonstrated quality improvement which included clinical audits.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of comprehensive appraisals and personal development plans for all staff which included discussion and staff contribution to the practice vision and strategy.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs. For example, health visitors, school nurses, local palliative care nurses and midwives.
  • Patients at risk of hospital admission but not under the care of the community matron were referred to the CCG care co-ordinators. The practice worked with the care co-ordinator who liased with NHS and social care services to ensure patients were supported.
  • Clinical staff carried out alcohol brief intervention advice. They used AUDIT-C which is a recognised screening tool that can help identify persons who are hazardous drinkers or have active alcohol use disorders.
  • The service hosted a shared care specialist drug and addiction service. The GPs and specialist nurse from the community service worked closely with other local support services and safeguarding teams to support patients’ recovery and help them to regain their independence.

Caring

Outstanding

Updated 4 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 many aspects of care. For example, 99% of patients said they had confidence and trust in the last GP they saw compared to the CCG average of 96% and the national average of 95%.

  • Feedback from patients about their care and treatment was consistently and strongly positive. We spoke with eight patients, received 56 comment cards and saw letters and cards of thanks which were all positive about the service.

  • Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. For example, they invited dementia patients and family members to suggest improvements and improve services. As a result staff had received additional dementia friendly training and dementia friendly signage and information was displayed.
  • There was a named carers champion who worked with local organisations to support carers. There was a dedicated carers corner in the waiting area with up to date information. Vulnerable patients and carers were given a direct practice telephone number to ring for support. We saw examples of how the carers champion liaised with the local safeguarding team, carers’ support organisations, social care and housing assosiations to identify support for patients and carers. We saw examples of how they worked on a one to one basis with patients and their carers.
  • The practice invited a local carer support organisation into the practice in February 2016 to deliver carer awareness training and review the information and support available. We saw a letter from the organisation confirming that the practice had signed up to the Carers Count GP partnership working scheme and the practice was featured in the Carers Count newsletter shortly after the inspection to highlight good practice.
  • The introduction of a carers champion and proactive efforts to identify carers led to an increase of carers recorded by the practice. The practice had 91 patients recorded as carers up to May 2015. The number of carers recorded increased by 162 to a total of 253 by April 2016 (3% of the patient list).

  • Information for patients about the services available was easy to understand and accessible in different languages that met the needs of the local population. There was a quarterly practice and patient group newsletter. The practice produced information leaflets for patients including a welcome pack for new patients and a top tips guide to accessing services.
  • We saw staff knew patients well and treated them with kindness and respect, and maintained patient and information confidentiality. Data showed 92% of patients found the receptionists at this surgery helpful (CCG average 85%, national average 87%).
  • The practice developed a bereavement protocol to ensure support was provided to the families and other services and support groups involved in their care were made aware.

Responsive

Outstanding

Updated 4 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 to secure improvements to services where these were identified. For example, they participated in the pilot of the CCG Clarity Project which aims to reduce the overall prescribing of benzodiazepines.
  • The practice signed up to initiatives to improve services. For example, Sign up to Safety and the Dementia Action Alliance to drive improvements.
  • The practice hosted services which supported the local CCG care closer to home policy. For example, extended minor operations, 24 hour blood pressure monitoring, ECGs, spirometry and phlebotomy.
  • Services were tailored to meet the needs of individual people and were delivered in a way to ensure flexibility, choice and continuity of care.The staff monitored the practice population.They identified that Romanian and Hungarian patients had a 21% fail to attend (FTA) rate for new patient appointments. They worked with local community support workers to create new practice specific literature in these languages. After the introduction of these resources the FTA rate decreased to 10%.
  • Patients said they found it easy to make an appointment with a named GP and 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.
  • The practice had reviewed the availability of appointments and recruited an advanced nurse practitioner to improve access.
  • The practice had a dedicated 24 hour appointment cancellation line. Patients left a message to cancel their appointment. Staff checked the messages daily and contacted patients to rearrange their appointment. They used text messages to remind patients of appointments.
  • There was active review of complaints and how they are managed and responded to, and improvements were made as a result. People who use services were involved in the review process. Information about how to complain was available in different languages and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.
  • Staff raised concerns that patients often attended for travel vaccinations in the days immediately before they travelled. The practice developed specific vaccination information in English and Urdu. Staff linked with the local library and community centre to publicise the importance of accessing vaccinations in a timely way before travel.
  • The practice responded to the high prevelance of Chronic Obstructive Pulmonary Disease (COPD). Two nurses received additional training in spirometry to deliver local care to this group of patients. Spirometry is a test used to diagnose COPD. Data from 2014/15 showed that 88% of patients with COPD (diagnosed on or after 1 April 2011) had their diagnosis confirmed by post bronchodilator spirometry. The practice showed us data from March 2016 which showed this increased to 93%.

Well-led

Outstanding

Updated 4 August 2016

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

  • The practice had a mission statement and clear vision with quality and safety as its top priority. The strategy to deliver this vision had been produced with staff and stakeholders. The mission statement and individual declarations of what the statement and work meant to all staff members were displayed prominently in the practice.
  • Staff were encouraged to contribute to the vision, values and practice plan which were regularly reviewed and discussed with staff.
  • A systematic approach was taken to working with other organisations to improve care outcomes and tackle health inequalities. For example, the practice engaged with local organisations to improve care for Eastern European patients, carers and patients with dementia.
  • There were named clinical and non-clinical support leads for safeguarding, mental health carers and dementia.
  • The practice developed a patient charter, practice specific and health information in languages that reflected the needs of the local population.
  • High standards were promoted and owned by all practice staff and teams worked together across all roles.
  • The practice had comprehensive business continuity plans . The practice manager implemented learning from pandemic flu to ensure continuity of services.
  • Staff appraisals were comprehensive and encouraged staff members to identify opportunities to develop their roles and improve patient services.
  • Governance and performance management arrangements had been proactively reviewed and took account of current models of best practice.
  • Leaders strived to deliver and motivate staff to succeed. Many staff members told us how they had been encouraged to undertake further education, suggest ideas for and lead on areas of improvement.
  • There were high levels of staff satisfaction. Staff were proud of the organisation as a place to work and spoke highly of the culture. There were consistently high levels of constructive staff engagement.
  • The practice had an engaged patient participation group which influenced practice development. The PPG met regularly and members told us the senior GP and practice manager always attended the meetings.The group actively encouraged new and diverse membership to reflect the local population and had recently recruited two new members.
  • 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.
  • There was a strong focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions

Outstanding

Updated 4 August 2016

The practice is rated as outstanding 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.
  • Eighty eight per cent of patients with diabetes, on the register, had a record of a foot examination and risk classification (CCG average 89%, national average 88%).
  • Longer appointments and home visits were available when needed.
  • The practice identified a high prevelance of Chronic Obstructive Pulmonary Disease (COPD). Two nurses received additional training in spirometry to deliver local care to this group of patients which increased the number of patients who had their diagnosis confirmed.
  • Patients at risk of hospital admission but not under the care of the community matron were referred to the CCG care co-ordinators. The practice worked with and referred patients to a care co-ordinator who liased with NHS and social care services to ensure patients were supported.
  • 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.
  • Many Eastern European patients presented with poorly managed long term conditions. The practice used interpreters and produced patient information in other languages to encourage patients to manage their condition and attend for screening and review appointments.

Families, children and young people

Outstanding

Updated 4 August 2016

The practice is rated as outstanding 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 81%, which was comparable to the CCG and national average of 82%.
  • Appointments were available outside of school hours and a number of child only appointments were reserved after school hours.
  • The premises were suitable for children and babies.
  • We saw positive examples of joint working with midwives, health visitors and school nurses.
  • The practice introduced specific patient survey forms for children.
  • There was a practice safeguarding team and the practice developed systems to proactively identify children at risk. The team attended safeguarding meetings and met regularly with local safeguarding leads.

Older people

Outstanding

Updated 4 August 2016

The practice is rated as outstanding 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.
  • Flu vaccination rates for the over 65s were 79% compared to the national average of 73%.
  • The percentage of older people attending for screening programmes was comparable to national averages. For example, 50% of patients aged 60-69, were screened for bowel cancer within 6 months of invitation compared to the national average of 52%.
  • The practice reviewed patients aged over 75 with more than 10 medications on repeat prescriptions and reviews for patients over 75 without any long term conditions.
  • Care home staff were issued with a dedicated telephone number for instant access when the surgery is open.
  • The practice referred vulnerable older people to the Kirklees Carephone home safety service which provides assistive technology to help older people to live independently in their own home.
  • Older people were signposted to use The Silver Line which is a free confidential helpline providing information, friendship and advice to older people, 24 hours a day.
  • Data showed that 31% of older patients were affected by income deprivation. The carers champion helped them to identify sources of financial help and assisted them with completing application forms. Older people at risk of hospital admission but not under the care of the community matron were referred to the CCG care co-ordinators. The practice worked with and referred patients to a care co-ordinator who liased with NHS and social care services to ensure patients were supported.

Working age people (including those recently retired and students)

Outstanding

Updated 4 August 2016

The practice is rated as outstanding 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 as well as a full range of health promotion and screening that reflects the needs for this age group.
  • The practice offered late appointments on Tuesday and Wednesday evenings for working people.
  • The practice had a dedicated 24 hour appointment cancellation line and used text messages to remind patients of appointments.
  • Drop in phlebotomy and ECG services were provided five days a week.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 4 August 2016

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

  • 90% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is better than the national average of 84%.
  • 95% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive care plan documented in the record, in the preceding 12 months (CCG average 89%, national average 88%).
  • 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.
  • They invited dementia patients and family members to suggest improvements and improve services. As a result staff had received additional dementia friendly training and dementia friendly signage and information was introduced.
  • 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.
  • There were clinical and non clinical leads identified for dementia and mental health. Staff had a good understanding of how to support patients with mental health needs and dementia.
  • The practice encouraged carers and family members to the West Yorkshire Police Herbert Protocol scheme which encourages carers to compile useful information which could be used in the event of a vulnerable person going missing.

People whose circumstances may make them vulnerable

Outstanding

Updated 4 August 2016

The practice is rated as outstanding 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.
  • Staff regularly worked with other health care professionals in the case management of vulnerable patients.
  • There was a named carers champion who worked with local support organisations to support carers. There was a dedicated carers corner in the waiting area with up to date information and carers were given a direct telephone number to ring for support.
  • The introduction of a carers champion and proactive efforts to identify carers lead to an increase of carers recorded by the practice. The practice had 91 patients recorded as carers up to May 2015. The number of carers recorded increased by 162 to a total of 253 by April 2016 (3% of the patient list).
  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations. Staff liased with local support groups and ensured that information given to patients was up to date.
  • The practice had a dedicated safeguarding team who met with the local safeguarding teams regularly. 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 service hosted a shared care specialist drug and addiction service. The GPs and specialist nurse from the community service worked closely with other local support services and safeguarding teams to support patients’ recovery and help them to regain their independence.
  • The practice was registered with the Kirklees Safe Places scheme. The scheme helps vulnerable people who become confused, frightened or need help when they left their homes.