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Inspection carried out on 25 January 2018

During a routine inspection

Letter from the Chief Inspector of General Practice

This practice is rated as Outstanding overall. (Previous inspection May 2015 - Outstanding

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Outstanding

Are services responsive? – Outstanding

Are services well-led? – Outstanding

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Outstanding

People with long-term conditions – Outstanding

Families, children and young people – Outstanding

Working age people (including those recently retired and students – Outstanding

People whose circumstances may make them vulnerable – Outstanding

People experiencing poor mental health (including people with dementia) – Outstanding

At this inspection we found:

  • The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice was open and transparent, and had systems in place to adhere to the Duty of Candour. When things went wrong, we saw that the practice offered patients an apology and an explanation. Quality improvement was embedded into practice. There was a comprehensive programme of clinical and non-clinical audit that all staff were involved with that was routinely monitored and changes made to practice resulted in measurable improvements to patient care.
  • The practice was proactive in identifying new ways of working to streamline services and improve patient experience.
  • The practice was strongly committed to multidisciplinary working and could evidence how this had a positive impact on patient care.
  • Discussions with staff and feedback from patients demonstrated staff were highly motivated and were inspired to offer care that was kind, caring and supportive and met the needs of the population.
  • The practice organised and delivered services to meet patients’ needs. The practice had initiated positive service improvements for their patients. There was a proactive approach to understanding the needs of different groups of patients and to deliver care in a way that met their needs and where possible, their preferences.
  • Patients were able to access a wide range of services at the practice, which enabled patients to be treated closer to home.
  • The practice improved services where possible in response to unmet needs. They made reasonable adjustments when patients found it hard to access services even if it was only for a small number of patients.
  • The practice was passionate about ensuring they always provided their patients with the best care possible. They demonstrated a determined attitude to overcome barriers faced by the practice and the population they served. They focussed on the challenges faced by a rural community and planned their services around this.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw a wide range of outstanding practice. Examples included:

The practice proactively 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. Nationally reported data showed the number of patients of Reeth Medical Centre dying in their preferred place was significantly above the national data.

The number of patients on the practice’s palliative care register was three times the national average.

The practice funded a local community transport scheme to provide free at the point of use transport for housebound patients so they could attend appointments at the practice. This included using the bus service or someone walking the patient to their appointment. The practice worked closely with the district nursing team hosting their services allowing them to see patients centrally at the practice which after one year, there were 42% fewer district nurse home visits and a high level of satisfaction from the patients using the scheme.

The practice had provided unfunded voluntary support to the Yorkshire Ambulance Service since 2007. This worked by allowing the ambulance service to directly mobilise and inform the practice of incidents in which it was beneficial for the GP to attend (usually the GP could be on scene before the ambulance arrived). On average the practice attended approximately four serious or life threatening incidents a year.

The areas where the provider should make improvements are:

Review the practice’s home delivery service in relation to maintaining an appropriate audit trail.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection carried out on 1 May 2015

During a routine inspection

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Reeth Medical Centre on 1 May 2015. Overall the practice is rated as outstanding.

Specifically, we found the practice to be outstanding for effective, caring, responsive and well led. It was also outstanding for providing services for all the population groups. It was good for providing safe services. The performance that led to the ratings of outstanding in effective, caring, responsive, and well-led services applies to everyone using the practice. The achievement of these ratings meant the practice also provided outstanding services to all population groups including older people, families, children and young people, working age people, people whose circumstances may make them vulnerable and people experiencing poor mental health.

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

  • The practice used innovative and proactive methods to improve patient outcomes.
  • The practice demonstrated they were accutely aware of their population groups and responded to context. They focussed on the challenges faced by a rural community and planned their services around this.
  • The practice responded and was engaged with notable local groups and stakeholders.
  • Staff demonstrated they supported patients' emotional and social needs and recognised they were as important as patients physical needs. Care needs were assessed and care was planned and delivered following best practice guidance.
  • The continuing development of staff skills, competence and knowledge was recognised as integral to ensuring high quality care. Staff had received training appropriate to their roles and additional training to enhance the service offered to patients.
  • Feedback from patients who used the service and stakeholders was continually positive about the way staff treated patients. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Discussions with staff and feedback from patients demonstrated staff were highly motivated and were inspired to offer care that was kind, caring and supportive and that met the needs of the population. Patients visited the practice on the day of the inspection specifically to share their positive experiences with us. A large proportion of the patients told us that staff went the extra mile and the care they received exceeded their expectations.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
  • 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.
  • Leadership at the practice was reflective, strong and decisive. Although already achieving high outcomes in a number of areas, the practice team wished to improve their services and the experience of patients. They actively explored ways to do this.

We saw a wide range of outstanding practice, examples of which included:

  • The practice supported patients to live healthier lives through a targeted and proactive approach to health promotion and prevention of ill health. The practice was actively involved in the local community; they had reached out to them to promote better health. For example, they wrote a regular column in the local newspaper and had attended pre-schools to administer flu vaccines.
  • The practice offered an e-mail consultation service. Patients using the electronic consultation usually received a response within one working day.
  • The practice had taken numerous locally available opportunities to implement service improvements and manage delivery challenges to its population. Two specific examples included the ‘Find Your 1% campaign and the Population intervention for fall and injury prevention in the over 75 year olds. In January 2011 the practice published an article in the local newspaper about making advanced decisions in response to the find your 1% campaign. The Dying Matters Coalition campaign was part of the government’s Quality, Innovation, Productivity and Prevention (QIPP) agenda. Around 1% of the population dies each year and the ‘Find Your 1%’ campaign aimed to get GPs talking to patients likely to die within the year ‘as early as possible’ about wishes for palliative care. It sought to persuade GPs to discuss end-of-life care with patients who were likely to die in the next 6-12 months, in order to increase the number of people dying in their usual place of residence. Both GPs had either completed or were in the process of completing a palliative care diploma to improve their confidence at both identifying those nearing the end of life and initiating discussion about people's wishes. As a result, 1.5% of the practice list currently had an advanced directive or community do not resuscitate order in place. The second example was the practice was the only one to secure funding from the CCG following submission of a comprehensive bid to run a population intervention for fall and injury prevention in the over 75 year olds. The practice recognised that patients living in the community were at risk and calculated based on International studies that a large proportion of their patients were at risk of fall related injuries. The practice had put in place a comprehensive plan to address this matter as a community rather than using an individual approach.
  • The practice had become a member of the Upper Dales Area Partnership as they felt it likely there would be issues of common interest and concern between all different community groups. The meetings allowed an exchange of information, compliments, comments and concerns between members of the public, community groups and locally elected representatives.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice