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Cape Hill Medical Centre Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 5 May 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cape Hill Medical Centre on 9 January 2017. Overall the practice is rated as outstanding.

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

  • The practice had a clear 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 and discussed with staff. There was visible clinical and managerial leadership and effective governance arrangements.
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. The practice was proactive in the management of safeguarding children and vulnerable adults.

  • The practice used innovative and proactive methods to improve patient outcomes. Clinical audits had been triggered by new guidance and from learning from significant events.

  • Results from the national GP patient survey showed patients felt they were treated with compassion, dignity and respect. For example: 97% of respondents had confidence and trust in the last GP they saw or spoke to.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example, a new telephone system with the initial greeting in five languages and the ability to book an appointment with the GP of choice.

We saw several areas of outstanding practice including:

  • The practice was one of only 17 practices nationally to receive the Gold Standards Framework award for end of life care. The End of Life Care programme considered all care parameters using NICE guidance as the basis and demonstrated improvements in every aspect care. This included documentation of advanced planning, patient preferences, bereavement support, holistic assessment of care, plus seven other elements. One key factor was having a single clinical lead who examined all clinical notes, they co-ordinated the practice to meet the targets it had set in the aspiration for End of Life Care. Learning points showed a clear appreciation of the advantage of having a single person take the lead, with whole team buy in and continuous review and ongoing education and reflection in the regular clinical meetings.

  • The practice had developed detailed holistic care plans that included reviews of physical and social care, plus patient education. They provide a holistic approach to reduce co-morbidities and reduce unplanned admissions. For example, the inclusion of social aspects of care, falls prevention and self-management education for the patients. We saw detailed evidence that demonstrated multiagency working to support isolated and patients who were housebound. The nurses attend weekly meetings with the community nursing team to enable concerns about patients to be acted upon immediately to improve unplanned admissions

  • The clinical leads at Cape Hill Medical Centre believed that the ‘standard’ model of a short consultation with a single health professional was not well-adapted to serve the needs of their patient population. To meet the population needs and following a review of the patient experience the practice developed a wellbeing hub, this involved a work coach, link worker, chaplain and a mental health team practitioner working side by side. The aim of these roles was to provide high quality care, support and guidance to patients.

However there were areas of practice where the provider should make improvements:

  • The practice should consider how to further promote national screening for bowel cancer in order to address the lower than average uptake.
  • The practice should continue to monitor the measures taken to improve patient satisfaction rates in relation to access and appointments.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 5 May 2017

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. The practice used every opportunity to learn from internal and external incidents, to support improvement. Learning was based on a thorough analysis and investigation.
  • Information about safety was highly valued and was used to promote learning and improvement.
  • Risk management was comprehensive, well embedded and recognised as the responsibility of all staff. For example, the infection control lead nurse completed additional monthly audits, for sharps management, hand washing, equipment and environment cleaning and legionella testing. Feedback was provided to all staff concerned with a clear audit trail.
  • The practice had a proactive approach to safeguarding vulnerable adult and children. A practice initiative had identified and specified a ‘trio’ of risk factors for children at risk, these were mental health issues, substance abuse including alcohol and domestic violence in the family home. The audits had assisted the practice in identifying patients who may be at risk

Effective

Good

Updated 5 May 2017

  • 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.
  • Each GP with an interest in a specific area managed all referrals for their speciality to ensure appropriate referrals were made.
  • We saw ten clinical audits which had been undertaken. Clinical audits were triggered by new clinical guidance, significant events, personal interest, changes in prescribing practice and monitoring of effectiveness.

  • The most recent published QOF results from 2015/16 showed the practice had achieved 98% of the total number of points available compared with the clinical commissioning group (CCG) average of 95% and national average of 95%.

  • The practice had developed detailed holistic care plans that included reviews of physical and social care, plus patient education. They holistic approach assisted the reduction of co-morbidities and unplanned admissions. We saw evidence that demonstrated multiagency working to support isolated patients who were housebound.

  • The practice had taken account of the practice population which had influenced additional training for GPs and nurses, for example in supporting patients who were asylum seekers and refugees. The nurses had received extended training in the management of long term conditions.
  • The practice had reduced paediatric accident and emergency attendances by 16% following the introduction of a minor ailments clinic which ran each day after school. To improve outpatient attendance the practice provided a three monthly consultant led paediatric clinic
  • The practice had reviewed the service available to patients with COPD. The practice had a low prevalence of patients with a COPD diagnosis and a high admission rate for asthma. They appointed a Respiratory Advanced Nurse Practitioner and had introduced a monthly one stop clinic with the ANP, GP and healthcare assistant. The practice had seen a reduction in admissions for asthma, COPD and paediatric respiratory admissions

Caring

Outstanding

Updated 5 May 2017

  • The practice had completed the Gold Standard Framework. The Gold Standard Framework (GSF) is a training programme for clinicians that provide care for all patients approaching the end of life. The practice was only one of 17 practices nationally to receive the GSF award. All the key outcome ratios for end of Life Care had improved, for example, patients are offered care planning discussions increased from 21 to 110.

  • The practice had a team of staff that provided physical, mental, spiritual and social support for patients. The chaplain, employed by the practice, provided spiritual support to patients and staff of all faiths. Patients going through a life crisis in need of listening and guidance and patients in the last year of life in the nursing homes were referred by staff.

  • The practice had identified 105 patients as carers (1% of the practice list). A nurse practitioner was the carers’ lead to help ensure that the various services supporting carers were coordinated and effective with a carer’s clinic held monthly. Carers were invited to attend carer’s day which was supported by the Sandwell carers’ team.

  • Carers were contacted by a nurse and offered a 30 minute appointment to gather a full account of support and guidance required. Referrals to other healthcare professions were actioned as required. The Carers lead had plans in place to visit schools in order to raise awareness of the needs of young carers.

Responsive

Good

Updated 5 May 2017

  • The practice recognised that some patients who had been long term unemployed did not benefit from the experience of the mental and physical benefit of working or being employed. The practice had developed a wellbeing hub and employed a link worker and chaplain. The Hub also provided a work coach and mental health workers working side by side. The team enabled the practice to consider physical, mental, spiritual and social needs.

  • The link worker, employed by the practice, offered social support and sign posting to other agencies. Over a 12 month period 733 patient appointments had been offered and 142 individual patients had received support. We saw evidence that showed positive outcomes for this patient group.

  • The practice had seen an increase in the number of patients residing in nursing homes. As a result they had applied and were successful in achieving the Gold Standards Framework quality hallmark award and had initiated an End of Life Care programme. The practice demonstrated improvements in advanced planning, patient preferences, bereavement support, holistic assessment of care.

  • We saw evidence that the practice had developed a training plan for the care home staff, this included training on sepsis, urinary tract infections, guidelines on admission avoidance and care planning, management of COPD and asthma and Mental Capacity training.
  • The practice adapted it's services to meet the needs of the local population. For example developing guidelines, polices and service for those who may be vulnerable. Consideration had been given to ensuring this patient group were aware of how to access healthcare.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. The introduction of a new telephone system with the initial greeting in five languages and the facility to book the GP of choice.

  • Practice data showed that a high percentage of non-attendance for paediatric outpatient appointment, with high follow up rates, as a result a paediatric consultant led clinic had been instigated. The practice had also introduced a nurse practitioner led paediatric minor ailments clinic each day to help reduce A&E attendance. The clinic ran outside of school hours and was supported and supervised by a GP. The practice demonstrated that this had reduced A&E attendance by 16%.

Well-led

Outstanding

Updated 5 May 2017

  • 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. Throughout our inspection we noticed a strong theme of positive feedback from staff. Staff spoke highly of the culture of the practice and were proud to be part of the practice team.
  • Governance and performance management arrangements had been proactively reviewed and took account of current models of best practice.
  • The practice was able to articulate its current challenges with regards to their population groups and opportunities within its local context and emerging national programmes. They had a clear understanding at a high level of their overall clinical and managerial performance.
  • The leadership at the practice had focused on providing holistic care to their patients. For example, the delivery of comprehensive care to patients with multiple co-morbidities that were housebound and the introduction of the wellbeing hub which included the link worker and chaplain
  • There was a strong focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions

Outstanding

Updated 5 May 2017

  • The practice ensured that patients with complex needs, including those with life-limiting progressive conditions were supported to receive coordinated care in innovative and efficient ways. The practice provided a holistic approach to reduce co-morbidities and reduce unplanned admissions. For example, they focus on social aspects of care, falls prevention and self-management education for the patients.

  • The advanced nurse practitioners had lead roles in long-term disease management and patients at risk of hospital admission were identified as a priority. For example, diabetes, COPD and hypertension and they all provided home visits where necessary. The healthcare assistant provided phlebotomy, ECG, foot assessments, spirometry, blood pressure and weight checks for patients who were housebound.

  • All these patients had a named GP and there was a system to recall patients for 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 care professionals to deliver a multidisciplinary package of care.

  • The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.

  • The practice had a low prevalence of patients with a COPD diagnosis and a high admission rate for asthma. They appointed a Respiratory Advanced Nurse Practitioner and had introduced a monthly one stop clinic with the ANP, GP and healthcare assistant. The practice could demonstrate a reduction in admissions for asthma, COPD and paediatric respiratory conditions.

Families, children and young people

Outstanding

Updated 5 May 2017

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk. They were proactive in their approach to safeguarding children. A practice initiative had identified and specified a ‘trio’ of risk factors for children at risk, these were mental health issues, substance abuse including alcohol and domestic violence in the family home. The audits had assisted the practice in identifying patients who may be at risk.

  • The clinical coder reviewed the records of all new children registered at the practice, if any concerns were identified a named GP was allocated to oversee their care in conjunction with the safeguarding team.
  • Childhood immunisations were comparable to CCG and national averages. For example, rates for the vaccines given to under two year olds were 94% and five year olds were 91%.
  • The practice’s uptake for the cervical screening programme was 78%, which was comparable with the CCG average of 79% and the national average of 81%.

  • The practice introduced a paediatric minor injuries clinics three times a week, to help reduce A&E attendance. The practice demonstrated that this had reduced by 16%. Practice data also showed poor outpatient attendance rates for paediatrics with high follow up rates, as a result a paediatric consultant led clinic had been instigated.

Older people

Outstanding

Updated 5 May 2017

  • The practice had seen an increase in the number of patients in nursing homes. The practice had implemented regular visits to he homes and had seen the number rise from 45 to approximately 80 registered patients. The practice attributed this to the routine visits mage by a nominated GP to proactively manage patients care. This included the review of care plans, liaising with relatives where appropriate and needs assessments for end of life care.

  • The practice had initiated an End of Life Care programme. They developed a policy with consideration of all care parameters using NICE guidance as the basis. The practice demonstrated improvements in advanced care planning, patient preferences, bereavement support and holistic assessment of care. The practice demonstrated continuous reviews and ongoing education and reflection during regular clinical meetings.

  • The practice was responsive to the needs of older people. The Advanced Nurse Practitioner (ANP) and nurse practitioners regularly provided home visits. The practice had developed detailed holistic care plans that included reviews of physical and social care, plus patient education. They holistic approach assisted the reduction of co-morbidities and unplanned admissions. We saw evidence that demonstrated multiagency working to support isolated patients who were housebound.

  • The practice provided care and treatment to patients living in two local care homes where some of the practice’s patients lived. Each care home had a nominated GP who visited patients when necessary and attended each care home weekly. We received positive feedback from staff at both homes. We saw that the practice had developed a training plan for the care home staff, this included training on, sepsis, urinary tract infections, guidelines on admission avoidance and care planning, management of COPD and asthma and Mental Capacity training.

  • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

  • The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs.

Working age people (including those recently retired and students)

Outstanding

Updated 5 May 2017

  • The needs of these populations 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.

  • 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. Appointments could be booked over the phone, face to face and online.

  • The practice had identified within their practice population patients who required additional support, they had developed a wellbeing hub, this involved a work coach to support patients.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 5 May 2017

  • Performance for mental health related indicators was 94% compared to the CCG average of 92% and a national average of 91%. For example, 95% of patients with severe mental health had a recent comprehensive care plan in place compared with the CCG average of 88% and national average of 89%.

  • Performance for dementia related indicators was 100% compared to the CCG average of 96% and a national average of 71%, with an exception rate of 9% compared to the CCG and national average of 12%.

  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. The link worker, chaplain and a mental health team practitioner worked side by side to provide support to patients.
  • The practice had told patients experiencing poor mental health how they could access support groups and voluntary organisations.
  • The practice had a system in place to follow up patients who had attended A&E where they may have been experiencing poor mental health.
  • Staff spoken with had a good understanding of how to support patients with mental health needs and dementia. One of the GPs had a diploma in primary mental health with special interest in neuropsychiatry

People whose circumstances may make them vulnerable

Outstanding

Updated 5 May 2017

  • The practice had taken account of the practice population which had influenced additional training for GPs and nurses, for example in supporting patients who were asylum seekers and refugees.
  • The practice had developed guidelines, polies and services to ensure equitable services were afforded to marginalised groups. They gave examples of trafficked women and high infant mortality rates. Guidelines for care of pregnant migrant patients had been developed and utilised.
  • With many patients from war torn countries the practice had developed in-house expertise in the management of patients who may have suffered violence, torture of bereavement. Best practice guidelines for staff had been produced. Staff had received training from the Medical Foundation for Victims of Torture.
  • The practice had developed an extended health check and had trained staff to identify new migrant patients who may be vulnerable. The health check provided screening for mental and physical health as well as highlighting social needs. The practice told us that this allowed for effective support and education in a timely way.
  • Staff we spoke with knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.

  • The practice had identified within their practice population patients who required additional support, they had developed a wellbeing hub, this involved a work coach, link worker, chaplain and a mental health team practitioner working side by side. The link worker, employed by the practice, offered social support and sign posting to other agencies. Over a 12 month period 733 patient appointments had been offered and 142 individual patients had received support. We saw evidence that showed positive outcomes for this patient group.

  • The practice’s computer system alerted GPs if a patient was also a carer. A nurse practitioner was the carers’ lead to help ensure that the various services to support carers were coordinated and effective, a carer’s clinic was held monthly. Once an individual has been registered as a carer, they were contacted by a nurse and offered a 30 minute appointment to gather a full account of support and guidance required.