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Mersea Island Medical Practice Good

Inspection Summary


Overall summary & rating

Good

Updated 20 June 2018

This practice is rated as Good overall. The previous inspection carried out 17 May 2016 was rated as Good overall

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

We carried out an announced comprehensive inspection at Mersea Island Medical Practice on 24 April 2018. This inspection was carried out under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider was meeting the legal requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service and to provide a rating for the service under the Care Act 2014.

At this inspection we found:

  • The practice had clear systems to manage risk to reduce the risk of safety incidents from occurring. When incidents did happen, the practice learned from them and improved their processes.
  • The practice consistently reviewed the effectiveness and appropriateness of the care they provided.
  • Care and treatment was delivered according to evidence- based guidelines.
  • We saw evidence that staff involved and treated patients with compassion, kindness, dignity and respect.
  • Patients reported appointments could be accessed when they needed one.
  • There was a strong focus on continuous learning across the whole practice and improvement was seen at every level.

There was one area where the practice should make improvement;

  • Continue to find ways to improve patient satisfaction in relation to the opening hours and contact for patients with the practice by phone.

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Inspection areas

Safe

Good

Updated 20 June 2018

We rated the practice as good for providing safe services.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse.

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff had received up-to-date safeguarding and safety training to the appropriate level for their role. Staff knew how to identify and report concerns. Reports and learning from safeguarding incidents were available to staff.
  • Staff who acted as chaperones were trained for their role and had received a 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.)
  • Staff worked with other agencies, to protect patients from abuse, neglect, harassment, discrimination and infringements of their dignity or respect.
  • The practice carried out
  • There was an effective system to manage infection prevention and control. Evidence of audits regularly undertaken showed effective control and management within the practice.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order including the arrangements for managing waste and clinical specimens.

Risks to patients

There were adequate 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. The practice employed a member of staff to cover planned administrative holidays, also sickness, busy periods and epidemics.
  • There was an effective induction system for temporary staff tailored to their role.
  • 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 patient records we saw showed that information clinicians needed to deliver safe care and treatment was available for use. There was a documented procedure for managing test results appropriately at the practice.
  • 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

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.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had audited its antibiotic prescribing to support good antimicrobial management in line with local and national guidance.
  • Patients’ health was monitored in relation to their disease or condition and followed up in a timely and appropriate way. Patients were involved in regular reviews of their medicines.
  • The practice computer software was used to set up reviews for long term conditions and for patients taking high-risk medicines.

Track record on safety

The practice had a good record of accomplishment for safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture of safety that led to safety improvements.

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. For example, a clinician triaged home visits after receiving an alert two years ago warning practices that home visit requests should be prioritised for safety.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 20 June 2018

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

(Please note: Any Quality Outcomes (QOF) data relates to 2016/17. QOF is a system intended to improve the quality of general practice and reward good practice.)

Effective needs assessment, care and treatment

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

  • Patients’ immediate and on-going needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We observed no evidence of discrimination when making care and treatment decisions.
  • We found adjustments had been made to remove barriers for patients to use or access services, for example: The consultation and treatment room signs were in braille, and colour contrast strips on the flooring to the treatment and consultation rooms for those with reduced vision.
  • Staff used appropriate tools to assess the level of pain in patients.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice had employed a nurse practitioner to provide preventative care and treatment for patients identified as aged 65 and over who were living with moderate or severe frailty. Those identified as being frail were provided a clinical review, which included a review of medication.
  • Patients aged over 75 were offered a health check, and those that wanted to be checked received one. If necessary, they were referred to other services such as voluntary services and supported by an appropriate care plan.
  • The nurse practitioner followed up on older patients discharged from hospital. This ensured that their care plans and prescriptions were updated to reflect any extra or changed treatment or medicine needs.
  • 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 had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for long-term conditions patient’s reviews had received specific training.
  • Clinicians followed up patients who had received treatment in hospital or if treated by the ‘Out of Hours services’ for an acute exacerbation of their condition.
  • The practice had arrangements for adults with newly diagnosed cardiovascular disease including the offer of high‑intensity statins for secondary prevention. People suspected of hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated appropriately.
  • The practice could demonstrate how they identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension) when providing regular and new patient checks.

Families, children and young people:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates for the vaccines given were above the target percentage of 90%.
  • The practice had a procedure to identify and review the treatment of newly pregnant women on long-term medicines. These patients were provided with advice and post-natal support in accordance with best practice guidance.
  • The practice had procedure to follow up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.

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

  • The practice’s uptake for cervical screening was 76%, which was comparable with coverage target for the national screening programme. This was also in line with the CCG average of 72% and national average of 72%.
  • The practices’ uptake for breast and bowel cancer screening was above the local and national average.
  • The practice had systems to offer eligible patients the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. 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:

  • End of life care was delivered in a coordinated way, which took into account the needs of those whose circumstances may make them vulnerable.
  • A standing agenda item at the weekly clinical meeting discussed vulnerable people.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • The practice had a mandate that they never turned patients away that were seeking to register.
  • The practice had a system to prompt patients with an underlying medical condition to come for vaccination according to the recommended schedule.

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

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, or a personality disorder by offering access to health checks. Interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services were also offered. There was a process for following up patients who failed to attend to receive their long-term medication.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • 80% of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the previous 12 months. This is above the local and national average.
  • 97% of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the previous 12 months. This is above the local and national average.

  • The practice specifically considered the physical health needs of patients with poor mental health and those living with dementia. For example, 100% of patients experiencing poor mental health had received discussion and advice about alcohol consumption. This is above the national average.
  • 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.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. The practice took part in local and national improvement initiatives. For example, an audit had been undertaken to determine the practice compliance with the National Institute for Health and Care Excellence (NICE) guidelines relating to a high-risk medicine. The practice found areas of their existing procedure that could be strengthened to ensure all monitoring and reviews where compliant with the guidelines. Further audit showed the recommendations developed after the original audit, had improved patient monitoring.

  • The QOF results were in line with and above the local and national averages. The overall clinical exception reporting for 2016/2017 was significantly below the local and national averages.
  • The practice used quality information about care and treatment to make informed decisions about their service delivery.
  • Where appropriate, the practice was involved with local and national improvement initiatives.

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. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with on-going support. This included an induction process, one-to-one meetings, appraisals, and mentoring, clinical supervision and support for revalidation. The healthcare assistant had trained and received the Care Certificate. The practice ensured the competence of staff employed in advanced roles by audit of their clinical decision-making, including non-medical prescribing.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together in the practice team and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when deciding care delivery for people with long-term conditions and when coordinating healthcare for care home residents. The shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • 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 worked with patients to develop personal care plans that were shared with relevant agencies. The nurse practitioner provided visits to three local care homes, and supported staff to reduce hospital admissions.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent, proactive, and able to provide stability to help 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 self blood pressure monitoring available in the waiting room.
  • Staff discussed changes to care or treatment with patients and their carers as necessary and provided them printed information when needed.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity, screening for bowel and breast cancer and mental health support available locally.

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 supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the Evidence Tables for further information.

Caring

Good

Updated 20 June 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 practice manager consulted the patient participation group on a monthly basis and kept them updated with all developments or changes occurring at the practice during meetings.

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 those 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 were available. The practice had a hearing loop for patients with reduced hearing. There were braille room signs and colour contrast strips on the flooring to the treatment and consultation rooms for those with reduced vision.
  • Staff helped patients and their carers find further information and access to community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them.
  • The patient computer records system alerted staff if a patient was also a carer. The practice had identified 149 patients as carers, this equates to 2% of the practice list. There was information for carers in the practice waiting room, and on the practice website.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • Reception staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs. A sign at the reception desk explained this service.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the Evidence Tables for further information.

Responsive

Good

Updated 20 June 2018

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

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. Although they recognised that, more space would be an advantage.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • 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 and urgent appointments for those with enhanced needs.
  • The nurse practitioner provided home visits for those who had difficulties getting to the practice due to limited local public transport availability.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at a single 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 found there were 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. The safeguarding lead at the practice updated colleagues at the weekly meeting.
  • 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):

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, extended opening hours and Saturday appointments. For example, GP telephone consultations, and online appointment booking.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.
  • The practice declaration was that no patient would be turned away.

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

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia. Staff knew the patients that may forget their appointment and rang them as a reminder to ensure they received continuity of care.
  • The practice had recently performed an audit related to dementia compliance and reviewed their procedures.

Timely access to care and treatment

Patients were able to access care and treatment from the practice within an acceptable timescale for their needs. The national GP patient survey published in July 2017 showed two results were lower compared with local and national practices in relation to the opening hours at the practice and getting through on the phone. The practice told us they were aware of this data and had been in discussions with their patient participation group to identify ways in which they could improve. Patients had timely access to initial assessment, test results, diagnosis and treatment.

  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Patients reported that the appointment system was easy to use.

Listening and learning from concerns and complaints

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

  • Information about how to make a complaint or raise concerns was available in the practice and on the website. Staff treated patients who made complaints respectfully.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns, complaints, and from annual reviews to identify any trends which were acted on.

Please refer to the Evidence Tables for further information.

Well-led

Good

Updated 20 June 2018

We rated the practice and all of the population groups as good for providing a well-led service.

Leadership capacity and capability

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

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the practice and population challenges.
  • 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. To this end, an operational manager had recently been employed at the practice to support the practice manager.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care. The concept promoted on signs at the practice was “Beyond Better”.

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities. The practice developed its vision, values and strategy jointly with patients, staff and external partners.
  • Staff were aware of and understood the vision, values, strategy, and their role in how to support the practice to achieve them.
  • The 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.
  • The practice monitored progress against delivery of the strategy.

Culture

The practice had a culture of high-quality sustainable care.

  • Staff stated they felt respected, supported and valued by the GPs and management at the practice. They were proud to work in the practice and valued the close team working atmosphere.
  • 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 an annual appraisal and career development conversations. All staff had received an appraisal in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Clinical staff were considered valued members of the practice team. They were given protected time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training and told us they were all treated equally.
  • There were positive relationships between staff and teams. This included the community teams in the health clinic shared with the practice.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Practice leaders had written policies and procedures that were formally agreed by the partners before sharing with staff. These were available on the shared drive of the practice computer system as an online resource for staff. These documents were reviewed and updated to assure the leaders practice governance was current.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process 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. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Practice leaders had oversight of national and local safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice implemented service developments with input from clinicians to understand their impact on the quality of care.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information to monitor and manage staff if they needed to be held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust arrangements in line with data security standards for 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 high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The service was transparent, collaborative and open with stakeholders about 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.

The practice leadership was focussed on ensuring they could provide the best care possible for their patients. They told us this had included a number of innovations and pieces of improvement work:

  • Since the appointment of the advanced nurse practitioner, housebound and elderly patient care had significantly improved. This included improved long term condition management, and learning disability health checks.
  • The early home visit triage had ensured those people needing urgent medical care had received it in a timely manner.
  • Working within community building and with the community teams had improved communication and a greater holistic approach to patient care for; physiotherapy, district nursing, social services, occupational therapy, co-ordination of end of life, and follow-up care.

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

Older 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