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Chet Valley Medical Practice Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 19 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Barrie and Partners on 25 July 2016. Due to unforeseen circumstances a change of lead Care Quality Commission inspector took place and a further focused inspection was undertaken on 14 December 2016.

Overall the practice is rated as Outstanding.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. The systems in place included reporting to external agencies such as the National Reporting and Learning System (NRLS).
  • Risks to patients were assessed and well managed. The practice regularly reviewed their risk registers and took action appropriately. For example, learning from a serious case review for general practice led the practice to implement a policy to ensure a risk assessment was undertaken, and actions taken for patients who had not attended their appointments.
  • Practice staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Some GPs had specialist’s skills and worked within secondary care for example, a diabetes specialist centre, and A+E department. Other GPs had specialist skills such as managing patients with eating disorders, advance pre hospital/trauma care, sexual health, and managing pain by using acupuncture. These skills were maximised by the practice to enhance the care to their patients.
  • Patients said they were treated with compassion, dignity, and respect and they were involved in their care and decisions about their treatment. Data from national GP Survey showed that 91% of patients said that the last GP they saw or spoke to was good at involving them decisions about their care compared to the CCG average of 84% and the national average of 82%.
  • Information about services and how to complain was easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.

  • The patients had easy access to a variety of health leaflets and information and ensured that these were given to patients when appropriate.

  • The practice worked proactively to ensure that patients on their learning disability register received their annual health reviews. The CCG recognised their high achievements, and requested the systems and processes were shared with other local practices.

  • There was a clear strong leadership structure and staff felt engaged, supported and valued by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • New ideas were encouraged and several services had been integrated into the practice through the work of staff members, for example the dispensary staff had identified high amount of waste from stoma products. The management team approached the specialist stoma nurse who attended the practice and undertook face to face reviews with patients.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had a robust and comprehensive range of governance arrangements that were regularly reviewed to ensure their effectiveness.

Outstanding elements;

  • When designing their new premises the partners were forward thinking and demonstrated innovation. They ensured that opportunities to provide additional services were maximised, providing their patients with services closer to home. For example, they included the specialist power supply required to run the mobile breast screening units, and for patients that required input from the pulmonary rehab service, a room was designed, and fully equipped by the practice with various pieces of essential apparatus. The practice had specialist skills for managing diabetes within the practice team. The practice had invested in a Neurothesiometer, a diagnostic instrument that assessed vibration sensitivity thresholds; this enabled the GP to access the risk of foot ulceration which patients with diabetes are at higher risk of developing. At the time of the inspection 25 additional clinics were provided, the practice team had been instrumental in approaching the providers, setting up and managing the day to day running of these services. The practice had implemented some of these services successfully for their patients and now extended this to include patients from other practices. The practice met the costs of providing or part funded most these services.
  • In 2009 the practice invested in the specialist equipment required to provide microsuction to their patients to safely remove ear wax. The practice had been able to treat patients quicker and more effectively with this equipment with positive outcomes. Younger, older and patients with more complex needs had been treated in the practice rather than referred to the local hospitals. In 2014, the practice was contracted to offer this service to other practices. Three GP partners are trained to deliver this service and are supported by consultants from secondary care.
  • The practice used proactive methods to improve patient outcomes and these methods were shared with other practices. For example, the practice had worked extensively on producing effective admission avoidance processes. Data on admission avoidance for the period 2015/16 provided by the local CCG showed that the practice was amongst the best performing practices against emergency admissions, accident and emergency attendances and outpatient attendances in the area. The practice worked proactively to ensure that patients on their learning disability register received their annual health reviews. The practice had been asked to share its processes surrounding learning disability reviews with the CCG so that other practices can use them to improve their review rates.

There were areas where the provider should make improvements are:

  • Ensure that a clear audit trail for prescription stationery is embedded

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Outstanding

Updated 19 January 2017

The practice is rated as Outstanding for providing safe services.

  • The practice prioritised safety, an effective and robust system was in embedded for reporting and recording significant events, this included reporting to external agencies such as the National Reporting and Learning System (NRLS). The practice reviewed significant events that had happened in the practice and those that had happened in other settings and demonstrated shared learning.

  • When things went wrong patients were engaged and received reasonable support, relevant information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice had clearly defined and embedded systems, processes, and practices in place to keep patients safe and safeguarded from abuse. All staff including non-clinical staff were trained to safeguarding level 3 and some GPs were trained to level 4.

  • Risks to patients were fully assessed and well managed. Where risks were found or identified through internal or external learning the practice quickly implemented procedures to reduce the level of risk. The management team produced a development plan and risk register annually to ensure that progress was monitored.

  • The practice had clear protocols and guidelines to cover the dispensing of medicines; however prescription stationery was stored securely but not effectively tracked through the practice. The practice took immediate action and implemented systems to ensure safe management of prescription stationary.

Effective

Outstanding

Updated 19 January 2017

The practice is rated as outstanding 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 for the year 2014/2015 and we noted that the practice performance for 2015/2016 was similar in all domains and the exception reporting for 2015/2016 was in line with the CCG and national average.

  • Practice staff assessed needs and delivered care in line with current evidence based guidance. The practice GPs had several extended skills and experience for example three GPs undertook microsuction for removal of ear wax, enabling patients to have safer and quicker treatment.

  • A comprehensive programme of clinical audits demonstrated quality improvement.

  • The practice valued and encouraged education for all practice staff giving them the skills, knowledge, and experience to deliver effective care and treatment.

  • Practice staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs. We saw several examples of positive outcomes for patients, for example, we saw joint working of GPs, a mental health link worker and care home staff to ensure that a patient with complex needs was appropriately seen and their treatment managed.

  • The practice used proactive methods to improve patient outcomes. For example, the practice had worked extensively on producing effective admission avoidance processes. These had been shared with other practices.

  • The practice worked proactively to ensure that patients on their learning disability register received their annual health reviews. The practice had been asked to share its processes surrounding learning disability reviews with the CCG so that other practices can use them to improve their review rates.

Caring

Outstanding

Updated 19 January 2017

The practice is rated as outstanding for providing caring services.

  • Data from the national GP patient survey July 2016 showed patients rated the practice higher than others for several aspects of care. For example, 94% of patients said the last GP they saw was good at explaining tests and treatments compared to the CCG average of 87% and the national average of 86%.

  • Patients said they were treated with compassion, dignity, and respect and they were involved in decisions about their care and treatment.

  • The practice had been proactive and had initiated several services not usually available in primary to be offered from the practice.

  • When funding for NHS podiatry services was removed, the practice recognised because of their rural position, older and less mobile patients, who relied on social foot care (nail clipping), may not have access to a service. This could lead to more complex foot problems and have a negative on patient’s mobility. The practice offered a room for private podiatrist to use enabling those patients, who wanted, access to foot care without the need to travel and in surroundings they were familiar with.

  • Information for patients about the services available was easy to understand and accessible.

  • We saw many examples of how practice staff treated patients with kindness and respect, and maintained patient and information confidentiality.

  • The practice looked after patients in various care homes including those with complex needs. Regular visits were undertaken to ensure proactive as well as reactive care was provided.

  • The practice had identified 166 patients as carers (2% of the practice list).

  • The GPs ensured continuity of care for patients who were at the end of their lives or in complex situations, this included making their personal contact numbers available to the out of hours service.

The practice team were aware of carers and their time constraints. The practice told us that they ensured sufficient stocks of medicines and continence supplies were available in the dispensary to avoid carers making multi trips to the practice. Appointments were made at times convenient for them, either for their own needs or for those they cared for.

Responsive

Outstanding

Updated 19 January 2017

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, the practice referred patients to Clinks Care Farm, an initiative that patients diagnosed with mild to moderate mental health problems can attend. The practice worked closely with the farm to ensure that information was shared, and GPs maximised the opportunity of learning from this project and regularly attended with GP trainees and medical students.

  • Patients said they were able make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. The practice ensured that the out of hours providers held the GP home contact numbers and could contact them if needed for patients at the end of their lives or in a crisis.

  • Data from the National GP Patient Survey published in July 2016 showed that 93% of patients said they could get through easily to the practice by phone compared to the CCG average of 70% and the national average of 73%.

  • Patients were able to receive travel vaccinations available on the NHS as well as those only available privately. The practice was a registered Yellow Fever vaccination centre.

  • Additional services such as anticoagulation (INR) monitoring were undertaken at the practice, ensuring that patients received easy access for safe monitoring of their high risk medicine.

  • Health promotion was a priority for the practice, a health trainer regularly attended the practice to encourage and motivate patients to improve their lifestyle. The practice worked with the local community gym to encourage patients to increase their physical activities.

Well-led

Outstanding

Updated 19 January 2017

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

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Practice staff had been engaged in the development of and were clear about the vision and their responsibilities in relation to it. The practice staff had written a motto which reflected their aims and ethos; this was displayed on the staff notice boards.

  • There was a clear strong leadership structure and staff felt engaged, supported and valued by management.

  • When designing their premises the partners were forward thinking and demonstrated innovation for the provision of health in the future.

  • Services such as microsuction had been available in the practice for many years and now available to other practices.

  • Robust clinically and management led governance arrangements had been embedded, proactively reviewed and took account of current models of best practice.

  • The development of additional service provision was actively managed, enabling patients’ easy access to services not usually provided in primary care.

  • The GPs within the practice maximised the specialist skills and interest to the benefit of the patients.

  • The practice 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 and learning took place.

  • The practice proactively sought feedback from staff and patients, which it acted on. The practice actively engaged with the patient participation group (PPG) to promote healthcare for the practice and wider population. The practice responded to suggestions made by the PPG and implemented improvements accordingly.

  • There was a strong focus on continuous learning and improvement at all levels.

Checks on specific services

People with long term conditions

Outstanding

Updated 19 January 2017

The practice is rated as outstanding for people with long-term conditions.

  • GPs and nursing staff had lead roles in chronic disease management and worked together to ensure cohesive patient care.

  • A team consisting of a GP, nurse, and practice administration support was named for each lead area. This ensured patients received their reviews timely and all appropriate tests undertaken in the one review.

  • The practice used the information collected for the Quality and Outcomes Framework (QOF) to monitor outcomes for patients (QOF is a system intended to improve the quality of general practice and reward good practice). Data from 2014/2015 showed that performance for diabetes related indicators was 100%, which was above the CCG average of 98% and the national average of 95%. Exception reporting for diabetes related indicators was 15%, which was in line with the CCG average of 12% and the national average of 11% (exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects). Results for 2015/2016 showed the practice performance was 95% this was 4% above the CCG average and 5% the national average. The exception reporting was 6%; this was in line with the CCG and national average.

  • The practice team had specialist skills for managing diabetes and a specialist diabetic facilitator attended the practice to manage those patients with complex needs. The practice had invested in a Neurothesiometer, a diagnostic instrument that assessed vibration sensitivity thresholds; this enabled the GP to access the risk of foot ulceration which patients with diabetes were at higher risk of developing.
  • Longer appointments and home visits were available when needed.

  • Patients with complex needs had a named GP and a structured review to check their health and medicines needs were being met. Data from the national patient survey showed that 65% of patients said they usually got to see or speak with their preferred GP compared with the CCG average of 57% and the national average of 59%.

  • The practiced provided the space and equipment for the pulmonary rehab service to run courses at the practice. Patients attended a group session for eight weeks. This ensured patients who were frail and unable to travel had access to this service.

Families, children and young people

Outstanding

Updated 19 January 2017

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.

  • One GP regularly attended serious case review meetings for general practice, learning taken from one meeting resulted in the practice implementing a ‘did not attend policy’ to ensure that any risks identified were mitigated to keep children safe from harm. The policy was used for all patients.

  • All practice staff including reception staff had been trained to safeguarding level 3 and some GPs were trained to level 4. The practice told us that this enabled their staff to understand and recognise concerns more effectively.

  • Immunisation rates were 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.

  • The practice had two GPs with a special interest in managing young people with complex problems including eating disorders. The practice told us of examples where patients, who had not met the referral threshold to specialist services, were monitored and managed, preventing their condition deteriorating and reaching a crisis. The numbers of patients helped through this difficult time had increased; the practice told us that one of the reasons for this was the easy access to GPs who were able to identify the issue, even if it was not the presenting problem.

  • 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. Access to GPs was immediately available to these professionals should they have any concerns.

  • The practice offered a full range of contraceptive services including long acting reversible contraceptive services (LARC).The practice arranged appointments convenient to the patient.

  • The percentage of women aged 25-64 whose notes recorded that a cervical screening test had been performed in the preceding 5 years was 87%, which was above the CCG average of 84%

  • The practice provided the facilities for the mobile breast screening unit to visit the site annually. The percentage of females aged 50-70 who had been screened for breast cancer in the last 36 months was 87% compared to a CCG average of 80% and England average of 72%.

Older people

Outstanding

Updated 19 January 2017

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.

  • The practice was flexible with appointments and ensured that appointment times were allocated around carer availability where appropriate.

  • Nationally reported data showed that outcomes for patients for conditions commonly found in older people were in line or above local and national averages.

  • The practice looked after patients living in several local care homes. Named GPs were allocated to each care home and the GP visited patients on a regular day as well as when requested.

  • The practiced provided the space and equipment for the pulmonary rehabilitation service to run courses at the practice. Patients attended a group session for eight weeks. This ensured that patients who were frail and unable to travel had access to this service.

  • The practice worked with third sector and voluntary agencies to ensure support was available to older people. For example Age UK held weekly sessions in the practice.

  • The practice performed ultrasound tests (Doppler’s) for patients with complex leg wounds or who required medical support stockings ensuring that they were managed safely and if necessary referred to the specialist clinics such as the vascular clinic.

  • The practice provided space for the community leg ulcer clinic enabling patients to be seen closer to home.

  • Since 2009 the practice had offered microsuction for the removal of ear wax, this system enabled older people to access this service, we saw evidence that patient’s outcomes were improved when they received this treatment without delay.

  • Although not funded by the NHS, the practice enabled patients who required social foot care easy access to a private podiatrist.

  • The practice team were aware of carers and their time constraints. The practice told us they ensured sufficient stocks of medicines and continence supplies were available to avoid multi trips to the practice. Appointments were made at times convenient for them, either for their own needs or of those they cared for.

Working age people (including those recently retired and students)

Outstanding

Updated 19 January 2017

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.

  • Practice staff carried out NHS health checks for patients between the ages of 40 and 74 years. The practice had undertaken these checks since 2009. We saw evidence where an early diagnosis of diabetes and another of hypertension had been made for patients giving them the opportunity to improve their long term outcomes.

  • Extended hours pre-bookable appointments were available on a Thursday between 6:30pm to 8.30pm. In addition to this the practice offered flu clinic appointments on Saturdays and in the evening.

  • Telephone consultations were available for those that wished to gain advice this way.

  • The practice offered a full range of contraceptive services including long acting reversible contraceptive services (LARC).The practice arranged appointments convenient to the patient.

  • Appointments for annual reviews were offered at times convenient to the patients. The practice re-call team ensured that the appointments for patients who had more than one condition were co-ordinated to avoid repeat attendances.

Patients were able to receive travel vaccinations available on the NHS as well as those only available privately. The practice was a registered Yellow Fever vaccination centre.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 19 January 2017

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

  • A member of the practice staff was a ‘dementia champion’ and was proactive in increasing the awareness of information within the practice and ensuring they were dementia friendly.

  • Regular meetings were held with the CCG dementia lead, community pharmacist and care home managers. The practice employed further pharmacist hours to fully meet the practice needs in managing medicines for this group of patients.

  • 96% of patients experiencing poor mental health had a comprehensive care plan, which was above the CCG average of 90% and the national average of 88%.

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

  • A GP led and had completed external training in the Mental Capacity Act and undertook in-house training and education for all practice staff.

  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.

  • The practice had two GPs with a special interest in managing young people with complex problems including eating disorders. The practice told us of examples where patients who had not met the referral threshold to specialist services were monitored and managed effectively in a timely manner and preventing a crisis.

  • The practice referred patients with mild to moderate poor mental health to support organisations. For example, the practice was able to refer patients to Clinks Care Farm, a working farm that patients diagnosed with mild to moderate mental health problems can attend as part of a 12 week therapeutic programme. To ensure GP learning from this local project, the trainee GPs visited the farm with their trainer to learn the impact of this project on patient’s health and well-being. We saw evidence that patients had returned to their employment or found new employment following their time at the project.

People whose circumstances may make them vulnerable

Outstanding

Updated 19 January 2017

The practice is rated as outstanding for the care of people whose circumstances may make them vulnerable.

  • 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. Some of these agencies provided support from within the practice.
  • The practice proactively monitored those patients at risk of hospital admission and had developed a practice specific avoiding unplanned admissions programme. Patients at risk of hospital admission were identified as a priority. The practice provided alert notices for patients to display in their homes ensuring visiting professionals or emergency services were aware of the patient’s needs.
  • Patients who were carers were proactively identified and signposted to local carers’ groups. The practice engaged with groups such as Norfolk Carers, Admiral Nurses, Macmillan, and Age UK. The practice had identified 166 patients (2%) as carers.
  • The practice worked proactively to ensure that patients on their learning disability register received their annual health reviews. For example, the practice booked appointments for times which suited the specific needs of the patient, as well as conducting the reviews at the home of the patient if this was more appropriate. The practice had access to a variety of easy read health leaflets and ensured that these were given to patients when appropriate. The practice had been asked to share its processes surrounding learning disability reviews with the CCG so that other practices could use them to improve their review rates.
  • The practice ensured continuity of care for patients who were at the end of their lives. GP would ensure that the out of hour’s services held their personal telephone numbers and that they could be contacted if needed.
  • Only one patient in the past 12 months had not died in their recorded preferred place, the practice had reviewed this; the patient had died in hospital.
  • The practice team were aware of carers and their time constraints. The practice told us that they will ensure that sufficient stocks of medicines and continence supplies were available to avoid multi trips to the practice. Appointments were made at times convenient for them, either for their own needs or of those they cared for.