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Bilbrook Medical Centre Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 6 June 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Bilbrook Medical Centre on 14 March 2016. Overall the practice is rated as Outstanding.

Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the Care Quality Commission (CQC) at that time.

Our key findings were as follows:

  • There was a no-blame; open culture for reporting incidents and near misses. Safety and learning drove continuous improvement at the practice.
  • Risks to patients and staff were thoroughly assessed and well managed. The practice used simulated drills when testing emergency procedures.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • Patients were treated with dignity and respect and the premises had been developed to improve patient experience with particular emphasis on vulnerable groups.
  • Information about services and how to complain was available and easy to understand.
  • Patients told us they could get an appointment when they needed one. Urgent appointments were available the same day.
  • The practice had excellent facilities and was well equipped to treat patients and meet their needs. This supported the practice mission statement to provide treatment in a primary care setting.
  • There was a clear leadership structure and staff felt very well supported by management. The practice proactively sought feedback from staff, patients and third party organisations, which it acted on.

We saw some areas of outstanding practice:

  • Thorough risk assessment processes delivered proactive safety and care in the practice, for example, simulation was used when emergency drills were carried out, children who presented with a rash were isolated to minimise the risk of contamination.
  • The practice was proactive in sharing learning from significant events with external stakeholders. For example, an event reported by the practice had resulted in a national safety alert.
  • Effective tracker systems were used to monitor newly registered patients, staff rota including absence and referrals made to secondary care. For example, the patient journey was monitored and followed up when required until discharged from hospital.
  • A strong culture of education and learning was seen. Education sessions were held twice weekly and protected time was provided monthly for all staff.
  • Innovation was used to bring care closer to home. The practice purchased ultrasound equipment and employed a sonographer to provide diagnostic and pelvic ultrasound services.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Outstanding

Updated 6 June 2016

The practice is rated as outstanding for providing safe services.

  • There was a robust system in place for reporting and recording significant events. A GP partner was nominated as the lead for significant events. The practice had recorded and reviewed 50 events in the past 12 months. The level and quality of incident reporting ensured a robust picture of safety.
  • The practice was proactive in sharing learning from significant events with external stakeholders. For example, an event reported by the practice had resulted in a national safety alert.
  • When there were unintended or unexpected safety incidents, the practice recorded, reviewed and held a meeting for all staff where learning could be shared.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep people safe and safeguarded patients from the risk of abuse. They were able to describe cases where they had implemented their safeguarding processes and knowledge to keep vulnerable patients safe.
  • The practice had well maintained facilities and equipment.
  • Regular infection prevention control audits were carried out.
  • A review of personnel files evidenced that comprehensive checks on staff were completed.
  • There was a comprehensive training programme for staff. For example, chaperone training given to staff was a full day.
  • Risks to patients and staff were assessed, regularly reviewed and well managed with a proactive approach.

The practice included patients in testing out their emergency procedures. For example, simulated fire drills and emergency procedures that required basic life support. A debrief and analysis was performed after the simulated incidents and shared with staff.

Effective

Good

Updated 6 June 2016

The practice is rated as good for providing effective services.

  • Data from the Quality Outcomes Framework (QOF) showed that the practice performed above both local and national averages. The practice achieved 98.2% of the total number of points available in 2014/15
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Regular clinical audits were completed and repeated cycles demonstrated quality improvement.
  • 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 had regular meetings with other healthcare professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 6 June 2016

The practice is rated as good for providing caring services.

  • Data showed that patients rated the practice above local and national averages in 14 out of the 16 indicators in aspects of care.
  • Patients said they were treated with compassion, dignity and respect and were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw that staff treated patients with kindness and respect, and maintained confidentiality.
  • Home visits were given to patents when housebound or unable to attend the practice.
  • The practice offered a safe haven to vulnerable patients and staff would offer refreshments, a quiet area to sit and support to patients who attended the surgery with or without an appointment.

Responsive

Good

Updated 6 June 2016

The practice is rated as good for providing responsive services.

  • Patients said they could get an urgent appointment on the same day.
  • Same day appointments were available for children and those with serious medical conditions.
  • The practice had excellent 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 that the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.
  • The practice showed an awareness of health problems specific to the local population. Approximately half of the phlebotomy service was performed in the patient’s home.
  • Ultrasound and dermoscopic assessment was provided at the practice and a sonographer employed (a sonographer is a specialised health worker who performs diagnostics using high-frequency sound waves, also known as ultrasound).
  • The practice had performed an audit for nutritional requirement for patients in care and nursing homes.

Well-led

Outstanding

Updated 6 June 2016

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

  • There was a clear vision and strategy to deliver high quality care and promote good outcomes for patients and their families. Staff were clear about the vision and their responsibilities in relation to this.
  • The practice had a written business plan that included succession planning.
  • There was a mission statement that all staff had contributed to. This statement was evident and central to decision making and staff we spoke with demonstrated a clear understanding of the practice objectives.
  • There was a clear leadership structure and staff felt supported by the management.
  • The practice had policies and procedures to govern activity.
  • Clinical staff supported one another in daily group sessions that followed morning clinics.
  • Regular governance meetings held included all practice staff.
  • 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 provider was aware of and complied with the requirements of the Duty of Candour. There was a strong culture of openness and honesty and staff felt comfortable when raising issues.
  • The practice had systems in place for knowing about notifiable safety incidents. These included a system developed for the notification of concerns in secondary care, developed at the practice, and implemented by other local practices.
  • The GP partners and the management team were aware of the practice performance and the specific requirements of their patients. Many examples were seen of how services and facilities had been adjusted to meet these requirements.
  • The practice used effective tracking systems to monitor patient referrals, staff absence and newly registered patients. These systems provided visibility and information that allowed for a proactive management approach.
  • There were many examples of the practice using innovation that improved the patient experience. For example, healthcare services were delivered closer to the patient’s home and reduced the requirement of onward referral to secondary care.

Checks on specific services

People with long term conditions

Good

Updated 6 June 2016

The practice is rated as good for the care of people with long-term conditions. Patients were reviewed in nurse led chronic disease management clinics. We found that the nursing staff had the knowledge, skills and competency to respond to the needs of patients with long term conditions such as diabetes and asthma. Longer appointments and home visits were available when needed. Written management plans had been developed for patients with long term conditions and those at risk of hospital admissions. For those people with the most complex needs, the GPs worked with relevant health and social care professionals to deliver a multidisciplinary package of care. The practice used the gold standards framework (GSF) to provide end of life care.

Families, children and young people

Good

Updated 6 June 2016

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 who were at risk, for example, children and young people who had protection plans in place. Appointments were available outside of school hours and the premises were suitable for children and babies. Same day emergency appointments were available for children. There were screening and vaccination programmes in place and the practice indicators were comparable with the local Clinical Commissioning Group averages. The practice worked with the health visiting team to encourage attendance. New mothers were offered post-natal checks and development checks for their babies. The practice website and posters in the waiting room promoted breastfeeding. The waiting areas included sections that had been converted to play areas for young children. The practice had a protocol to isolate from the main waiting area children identified to have rashes to minimise the risk of contamination to other patients.

Older people

Good

Updated 6 June 2016

The practice is rated as good for the care of older people. Every patient over the age of 75 years had a named GP and all hospital admissions were reviewed. This included patients that resided in nursing and care homes. Each care home had a named, designated GP who performed regular visits. The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example, risk profiling and case management. All over 75 year olds had a completed care plan. The practice was responsive to the needs of older people and offered home visits and offered longer appointments as required. The practice had identified and supported patients who were also carers.

Working age people (including those recently retired and students)

Good

Updated 6 June 2016

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. A range of on-line services were available, including medication requests, booking appointments and access to health medical records. The practice offered all patients aged 40 to 75 years old a health check with the nursing team. The practice offered extended opening hours and a full range of health promotion and screening that reflected the needs for this age group. The practice had developed it’s presence on social media as a way to communicate health messages within the community. The practice had extended the telephone consultation service and made around 30 telephone consultation calls per day. Patients could access the travel clinic by telephone to be assessed for vaccination requirement.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 6 June 2016

The practice is rated as outstanding for the care of people experiencing poor mental health (including people with dementia). Patients who presented with an acute mental health crisis were offered same day appointments. People experiencing poor mental health were offered an annual physical health check. The practice had regular meetings with other health professionals in the case management of patients with mental health needs. A voluntary counsellor attended the practice on a weekly basis to support patients with mental health needs. The practice was a high achiever in depression assessments performed (84% compared with a national average of 75%).

Dementia screening was offered to patients identified in the at risk groups. Advance care planning was carried out for patients with dementia. A dementia training and awareness day had been arranged for all practice staff. The practice had a higher than average prevalence for dementia patients (1.2% compared to CCG and national average of 0.7%). This had doubled since 2014 and was attributed to the continued dementia related education. The QOF achievement for dementia reviews completed on patients within six months of diagnosis was 95%, CCG average 71%, national average 82%). All staff had received Dementia Friends training and the practice had undertaken a self-assessment process to become a dementia friendly practice.

The practice worked closely with the health visiting team to support mothers experiencing post-natal depression. It had told patients about how to access various support groups and voluntary organisations and signposted patients to support groups where appropriate. The practice website included links to emotional wellbeing resources.

People whose circumstances may make them vulnerable

Good

Updated 6 June 2016

The practice is rated as good for the care of people whose circumstances may make them vulnerable. We found that the practice enabled all patients to access their GP services and assisted those with hearing and sight difficulties. A translation service available for non-English speaking patients was clearly displayed at the reception. One of the GPs could sign Makaton. Makaton is a language programme using signs and symbols to help people communicate. The building had an automated entrance door, a sliding door for the disabled toilet and disable parking bays in the car park. Raised seating in the waiting area was provided for patients with reduced mobility. All treatment and consultation rooms were on the ground floor but a lift had been installed to assist and required access to the second floor of the building. Staff told us that isolated patients were supported by the GP delivering the prescription to the pharmacy and a home delivery requested.

The practice held a register of patients with a learning disability and had developed individual care plans for each patient. Out of 21 patients on the learning disabilities register, 13 had received annual health checks for the year ending 21 March 2016 and three had declined. Longer appointments were offered for patients with a learning disability and carers were encouraged by GPs to be involved with care planning. There was a policy to provide patients with learning disabilities with appointments on a day and at a time to suit the individual.

The practice had a register of vulnerable patients and displayed information about how to access various support groups and voluntary organisations. For example there were posters for a local substance misuse support service. Staff knew how to recognise signs of abuse in vulnerable adults and children and demonstrated a proactive care programme. For example, concerns were shared with the community matron and patients invited for an appointment. 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. Practice staff told us that vulnerable patients could use their services as a safe haven. This included offering a quiet room, refreshments and an informal chat if a vulnerable patient presented showing signs of distress.