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Dr Moxon & Partners (Burton Croft Surgery) Outstanding Also known as Burton Croft Surgery

Inspection Summary


Overall summary & rating

Outstanding

Updated 11 January 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Moxon and Partners (Burton Croft Surgery) on 17 November 2016. Overall the practice is rated as Outstanding.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There was a genuinely open culture in which all safety concerns raised by staff and people who use services were highly valued as integral to learning and improvement. We saw a formal meeting for the review and discussion of medicines, good practice guidelines and safety alerts. This ‘Learning Meeting’ ensured that information was disseminated to the right people in a timely manner.
  • Data from the most recent National GP Patient Survey showed that 95% of patients would recommend the surgery to someone new to the area and 99% of patients said the last appointment they got was convenient.
  • The practice gathered feedback from patients and it had a very engaged and proactive patient participation group (PPG), who liaised closely with staff and influenced practice development. Changes were made to the way it delivered services as a consequence of feedback from patients and the PPG.
  • Feedback from patients about their care was consistently and strongly positive. The PPG had carried out a survey of 500 patients in January 2016 with a response rate of 74%, 99% of patients said their overall experience of the surgery was positive and they were treated with care and respect.
  • Nursing staff carried out “spot checks” of each other competencies, for example, when conducting blood tests or administering vaccinations to ensure that their practice met national guidance and good practice.
  • We saw comprehensive safe systems and processes that promoted good quality, safe care for patients.
  • The practice had a clear pro-active 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 with them and the staff team.
  • The practice had strong and visible clinical and managerial leadership and governance arrangements.
  • We saw a culture of audit that was strongly embedded into the day to day management of the practice.
  • Patients with palliative care needs were well supported at the practice. A GP at the practice had undertaken additional qualifications in this area and supported a local hospice. He disseminated good practice to the team regularly at multidisciplinary meetings. Patients were also reviewed with specialist community staff.
  • The reception team had implemented a twice daily ‘huddle’ to review tasks, workloads and respond to urgent matters. This was a focussed, documented discussion that improved patient safety by ensuring the workload was continually reviewed, well managed and organised.
  • Patients who had complex needs were supported to receive coordinated care and we observed innovative and efficient ways of delivering joined up care for patients. For example, we saw a patient recall system whereby coded letters were sent to patients asking them to attend for reviews. This code was then used by the reception team to ensure that the correct length of appointment was allocated, reducing the need for the patient to explain their condition and allowing a review of multiple issues to take place at the same time.

We saw areas of outstanding practice including:

  • The practice had employed a Matron and a part time Care Homes Nurse to review and proactively support the care of approximately 170 older people living in care homes registered with the practice and also other patients living in their own homes. The matron conducted a daily review of unplanned admissions, accident and emergency (A&E) attendances and hospital discharges. These patients were then reviewed by the matron, lead health professional or the GP as appropriate. As a result, the practice could evidence they were 38% lower than the national average for A&E attendances and 28% lower than the national average for unplanned hospital admissions. An unplanned admissions audit was undertaken quarterly.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 11 January 2017

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events and these were regularly reviewed at the monthly Significant Events meeting.
  • Lessons were widely shared with the staff team to make sure action was taken to improve safety in the practice.
  • When things went wrong patients received reasonable support, truthful 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.
  • Risks to patients were assessed and well managed.
  • Safeguarding was identified as a priority for the practice and all requests for safeguarding reports were actioned on the day that they arrived at the surgery. Time out from surgery would be allocated for the GP to complete the necessary paperwork.
  • At the time of inspection we did not see evidence of a DBS check for one member of the nursing team. However, we were informed that a check had taken place and following the inspection we were sent evidence that an additional check was being undertaken.

Effective

Outstanding

Updated 11 January 2017

The practice is rated as outstanding for providing effective services.

  • Our findings at inspection showed that systems were in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines. These guidelines and other alerts such as medical device issues were discussed at the regular practice learning meeting.
  • We also saw evidence to confirm that the practice used these guidelines to positively influence and improve practice and outcomes for patients. Nursing staff carried out “spot checks” of each others’ competencies for example, when conducting blood tests or administering vaccinations to ensure that their practice met national guidance and good practice.
  • All staff at the practice were actively engaged in activities to monitor quality and outcomes and opportunities to participate in bench marking and peer review were actively pursued. For example, GPs at the practice also worked within the CCG and the local hospice and we saw that best practice was shared within the team.
  • There was a comprehensive audit schedule in place which was discussed and agreed upon at clinical meetings. A culture of audit was strongly embedded into the day to day management of the practice and we saw that actions were taken to improve care as a result of audits. For example, a Fraser/ Gillick competency template was produced to support young people under 16 who were attending for contraception. We saw that codes were used to alert clinicians to the ability of the patient to consent to treatment when their parents were not present.
  • Data showed that the practice was performing highly when compared to practices nationally. For example, the practice had achieved 100% of the QOF points available compared to the England average of 95%. (QOF is a system intended to improve the quality of general practice and reward good practice). Exception reporting was 10% which was the same as the England average and comparable to the CCG average of 9%. (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).
  • The practice used innovative and proactive methods to improve patient outcomes and worked with other local providers to share best practice.
  • Patients who had complex needs were supported to receive coordinated care and we observed innovative and efficient ways of delivering joined up care for patients. For example, we saw a patient recall system whereby coded letters were sent to patients asking them to attend for reviews. This code was then used by the reception team to ensure that the correct length of appointment was allocated, reducing the need for the patient to explain their condition and allowing a review of multiple issues to take place at the same time.
  • The practice participated in the Campaign to Reduce Opioid Prescribing (CROP) and in October 2016 were able to evidence a 9% reduction in the prescribing of these drugs at the practice. (Opioids are substances that act on opioid receptors to produce morphine-like effects. Opioids are most often used medically to relieve pain).

  • There was evidence of comprehensive appraisals and personal learning and development plans for all staff. The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high quality care. Staff were proactively supported to acquire new skills and share best practice.

Caring

Good

Updated 11 January 2017

The practice is rated as good for providing caring services.

  • Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this.
  • We found many positive examples to demonstrate how patient’s choices and preferences were valued and acted on. The practice displayed a “you said, we did” notice board in the reception area which informed patients about the walk-in service and that a new GP had been recruited.
  • We were told of numerous examples of staff “going the extra mile”. We were told of specific personal arrangements that had been were made to support a transgender patient.

  • Patients said they were treated with compassion, dignity and respect. Most patients said they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible. Patients were encouraged to make the practice aware of any additional communication needs.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 11 January 2017

The practice is rated as good for providing responsive services.

  • 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 practice had a lead role in establishing a local federation of GPs that had recently been awarded a four year contract to manage extended hours access across the locality. The practice offered appointments until 8pm Monday to Thursday and patients could also be seen by a GP from 8am to 4pm on a weekend. Nursing appointments were also available on two evenings per week and a Saturday.
  • Patients could access appointments and services in a way and at a time that suited them. In October 2015, following feedback from patients the practice had implemented a walk-in service each morning. Figures from August to October 2016 showed that an average of over 1,100 patients per month used this service. This was evaluated highly by patients and we were told all patients attending this service would be seen.
  • The nurse team manager reviewed the demand and capacity of nursing appointments each week and would add sessions as necessary to ease the workload and ensure patients were seen in a timely way if necessary.
  • A practice matron had been employed to proactively support those registered patients who lived in local care homes each week to review their needs.
  • There were innovative approaches to providing integrated patient-centred care. The practice had implemented the Accessible Information Standards, 2016. The aim of these standards is to make sure that people who have a disability, impairment or sensory loss get information that they can access and understand, and any communication support that they need. New patients were asked at registration if they required any additional support. Posters were displayed in reception and we were told of examples where patients had requested email consultations which met their needs.
  • There was a proactive approach to understanding the needs of different groups of people and care was delivered in a way that met their needs and promoted equality. This included people who were vulnerable or had complex needs. For example, the practice matron conducted a daily review of unplanned admissions, A& E attendances and hospital discharges. These patients were then reviewed by the matron, lead health professional or the GP as appropriate and we were given examples of when the matron was able to assist in timely and appropriate discharges. A reduction of 4% in unplanned admissions and 5% in A&E attendances had been evidenced from August 2015 to May 2016 across the Leeds West CCG and the practice were able to evidence a reduction in their own figures. A practice audit showed that 80% of patients were reviewed within three days of their discharge from hospital.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand, and the practice responded quickly when issues were raised. Learning from complaints was shared with staff and other stakeholders.
  • The practice offered over 1,500 appointments each week, which included face to face, telephone and walk in appointments.

Well-led

Outstanding

Updated 11 January 2017

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

  • The practice had a clear vision with quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.
  • High standards were promoted and owned by all practice staff and teams worked together across all roles. We saw that the partners at the practice had an inspiring shared purpose to deliver and motivate staff to succeed. The practice was committed to recruiting, retaining and training the right people for their roles. They had recently reviewed the holiday entitlement for their staff and decided to increase this for the administration teams.
  • Governance and performance management arrangements had been proactively reviewed and reflected best practice.
  • There was a high level of constructive engagement with staff and a high level of staff satisfaction. We were told that staff were proud to work for the organisation and spoke highly of the positive culture of the practice. Staff were actively encouraged to raise concerns and we were told that leaders in the practice were always approachable.
  • The practice gathered feedback from patients and it had a very engaged and proactive patient participation group (PPG), who liaised closely with the staff and influenced practice development. The group met regularly and had carried out a number of surveys to ascertain patients’ views including those patients in a care home setting. Issues such as car parking were highlighted and the practice had engaged a company to manage this and ensure that spaces were used appropriately. Challenges from the PPG were welcomed and issues acted upon.
  • There was a strong focus on continuous learning and improvement at all levels and a clear proactive approach to seeking out and embedding new ways of care and treatment. For example, the practice is a training practice which supports GP trainees (fully qualified doctors in training to become GP’s), medical students, dental students and student nurses. We saw evidence of an audit that a GP trainee was supported to undertake at the practice and that changes were made as a result.
  • A systematic approach was taken to working with other organisations to improve care outcomes, tackle inequalities and obtain best value for money. For example, the practice had a lead role in establishing a local federation of GPs that had recently been awarded a four year contract to manage extended hours access across the locality.

Checks on specific services

People with long term conditions

Outstanding

Updated 11 January 2017

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. The practice matron conducted a daily review of unplanned admissions, A&E attendances and hospital discharges. These patients were then reviewed by the matron, lead health professional or the GP as appropriate.
  • We observed a patient recall system whereby coded letters were sent to patients asking them to attend for long term condition (LTC) reviews. This code was then used by the reception team to ensure that the correct length of appointment was allocated, reducing the need for the patient to explain their condition and allowing a review of multiple issues to take place at the same time.
  • The percentage of patients newly diagnosed with diabetes, who had a record of being referred to a structured education programme within nine months after entry on to the diabetes register was 94%, compared to the CCG average of 89% and the England average of 92%.
  • Between February 2015 and February 2016, the practice had screened over 1,900 patients at risk of pre-diabetes and identified 564 patients who were eligible for annual review. Patients were referred to an intensive lifestyle and behaviour change programme as appropriate.
  • Longer appointments and home visits were available when needed or on request. Appointments for the review of LTC were up to 45 minutes in duration and were tailored to suit individual patient needs.
  • 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.
  • Two GPs and the matron had undertaken additional training to enable the initiation of New Oral Anticoagulants (NOAC) drugs for patients with atrial fibrillation (AF), a condition which causes an irregular heartbeat. The practice were currently auditing patient records to identify those at risk.

Families, children and young people

Outstanding

Updated 11 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. 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. For example, following an audit, a Fraser/ Gillick competency template had been produced to support young people under 16 who were attending for contraception. (The Gillick competency and Fraser guidelines help to balance children’s rights and wishes with the responsibility to keep children safe from harm).
  • The percentage of women aged 25 or over whose notes recorded that a cervical screening test has been performed in the preceding 5 years was 78% compared to the CCG average of 79% and the England average of 81%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies. We were told that children who were ill would be prioritised during the walk in service if necessary.
  • We saw positive examples of joint working with midwives, health visitors and school nurses.
  • The practice offers a weekly sports injuries clinic to review issues relating to sports or exercise. Patients could also be referred to physiotherapy services within the building.
  • A full range of contraceptive options were offered to patients and practice reception staff had undertaken additional training in sexual health to encourage the early detection of sexually transmitted infections.

Older people

Outstanding

Updated 11 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 participated in the Leeds West CCG Care Homes Scheme alongside other practices in the area. They had identified 1.4% of its population as residing in a care home compared to the CCG average of 0.3% A practice matron had been employed to proactively support those registered patients who lived in local care homes each week to review their needs. The homes were also supported by a dedicated care homes practice nurse, who monitored and managed long term conditions. GPs would visit when required.
  • The practice had higher than average numbers of patients who were 85 years and over. They were responsive to the needs of this age group. Home visits and urgent appointments were offered for those with enhanced needs including those with long term conditions.
  • The matron worked closely with the palliative care team to support end of life care planning in conjunction with care home staff, the patient and their families. This included planning for the preferred place of death, or care if a patient’s condition deteriorated. The practice held regular Gold Standard palliative care meetings. A GP at the practice had undertaken additional qualifications in this area and worked regular sessions at a local hospice.
  • We also viewed evidence of unplanned admissions and “do not attempt cardio pulmonary resuscitation” care plans completed for relevant patients. The matron would spend time with relatives and the patient to produce these.

Working age people (including those recently retired and students)

Outstanding

Updated 11 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.
  • Patients could be seen until 8pm Monday to Thursday and between 8am and 4pm on a Saturday and Sunday. Early morning appointments were also available.
  • The practice held a walk- in service every morning which allowed access to on the day appointments between 8am and 10.30am. This was evaluated highly by patients and we were told all patients attending this service would be seen.
  • During Freshers’ week the practice would attend a local halls of residence to encourage new students to register.
  • 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. Patients could also request telephone appointments or consult with the practice via email.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 11 January 2017

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

  • Overall performance for mental health related indicators was better than CCG and England averages. For example, the percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a comprehensive care plan documented in their notes in the preceding 12 months was 92%, which was better than the CCG average of 85% and the England average of 89%. Data also showed that 91% of the same patient group had their alcohol consumption recorded compared to the CCG average of 86% and the England average of 89%.
  • Data showed that 83% of patients diagnosed with dementia had received a review of their care in a face to face meeting in the last 12 months, which was comparable to the CCG average of 87% and the England average of 84%.
  • 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. Several nursing staff had completed dementia specific training and used a dementia screening tool and template to identify patients at risk. Ad hoc assessments would be conducted if a patients’ behaviour caused concern during the consultation.
  • We saw that care plans were in place for patients with dementia and mental health issues. Plans were also in place for patients at risk of an unplanned admission.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • Staff had a good understanding of how to support patients with mental health needs and dementia. Physical health checks were being undertaken for patients with serious mental illness.

People whose circumstances may make them vulnerable

Outstanding

Updated 11 January 2017

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

  • The practice held a register of patients living in vulnerable circumstances including homeless people, and those with a learning disability.
  • The practice offered longer appointments for patients with a learning disability and for patients who might request these.
  • The practice regularly worked with other health care professionals in the case management of vulnerable patients. We saw that care plans were in place for those who were at risk of an unplanned admission.
  • The practice informed vulnerable patients including carers, about how to access various support groups and voluntary organisations.
  • The practice matron conducted a daily review of accident and emergency attendances and hospital discharges. These patients were then reviewed by the matron, lead health professional or the GP as appropriate.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children and all staff had attended training relevant to their role. Staff were clear about their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.