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Cape Hill Medical Centre Outstanding


Review carried out on 9 September 2021

During a monthly review of our data

We carried out a review of the data available to us about Cape Hill Medical Centre on 9 September 2021. We have not found evidence that we need to carry out an inspection or reassess our rating at this stage.

This could change at any time if we receive new information. We will continue to monitor data about this service.

If you have concerns about Cape Hill Medical Centre, you can give feedback on this service.

Inspection carried out on 2 October 2019

During an inspection looking at part of the service

We carried out an announced focussed inspection at Cape Hill Medical Centre on 2 October 2019 as part of our inspection programme.

We carried out an inspection of this service following our annual review of the information available to us including information provided by the practice. Our review indicated that there may have been a significant change to the quality of care provided since the last inspection.

This inspection focused on the following key questions: Effective, Caring, Responsive and Well-led.

Because of the assurance received from our review of information we carried forward the rating for the following key questions: Safe.

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We have rated this practice as Outstanding overall and Outstanding for older people and people whose circumstances make them vulnerable. We rated working age people as requires improvement.

We rated the practice as outstanding for the population group older people because:

  • The clinical staff carried out weekly ward rounds at three local nursing homes and two care homes. Due to the demand for home visits and an increase in A&E attendances, the practice implemented the ward rounds at all of the homes to ensure patients were receiving regular reviews and appropriate care. To further support the nursing/care home staff working in the homes, the practice had implemented an education programme to support them in their role.
  • The advanced nurse practitioners offered housebound clinics. A total of six sessions were carried out each week to support patients who could not attend the practice.
  • The practice had achieved the Gold Standards Framework Royal College of General Practitioners (RCGP) Quality Hallmark award in end of life care. There were 139 patients on the practice’s Gold Standards Framework register and a single clinical lead was in place that examined all clinical notes and co-ordinated care for patients as a whole team approach with ongoing education and regular clinical meetings.

We rated the practice as outstanding for the population group vulnerable people because:

  • The practice had a wellbeing hub on-site and had employed a support team to provide high quality care and guidance to patients. The hub had a link worker to offer advice on local support groups and advice, a chaplain and counsellor and a work coach to support patients to return to work. Also vulnerable patients were able to access the ‘Thrive to Work’ programme which the practice had implemented in September 2018. Data provided by the practice showed 39 patients had attended the work programme.
  • The practice had identified some patients were attending the practice frequently. To ensure all of the patients’ needs were being met, the in-house social prescriber contacted each patient to offer support and advice of local services.

We rated the practice as outstanding for providing caring and well-led services because:

  • Services were tailored to meet the needs of individual patients. They were delivered in a flexible way that ensured choice and continuity of care. The practice had identified areas where there were gaps in provision locally and had taken steps to address them.
  • The practice were responsive to the needs of the local population and continually reviewed the services provided and implemented initiatives to ensure patients received appropriate care and support.
  • The culture of the practice and the way it was led and managed drove the delivery and improvement of high-quality, person-centred care.
  • There was a strong emphasis on learning and sharing outcomes with the whole team and external organisations to promote best practice.
  • All opportunities for learning from internal and external incidents were maximised. All learning was shared with staff regularly.
  • Leaders demonstrated they had the capacity and skills to deliver high quality, sustainable care.
  • There was effective leadership at all levels which supported innovation, implementation of processes and the continuous monitoring of patient care.
  • There was continuous commitment to patients and external stakeholders to share information, ideas and improvements. This included a well being hub, steering groups to improve service provision and an audit programme to drive quality improvement.

We rated the practice as good for providing effective and responsive services because:

  • The practice formed steering groups to review the effectiveness of their services and to discuss and implement new initiatives and improvements to ensure patients were receiving appropriate care.
  • There was effective leadership at all levels which supported innovation, implementation of processes and the continuous monitoring of patient care.
  • There was continuous commitment to patients and external stakeholders to share information, ideas and improvements. This included supporting local practices with the delivery of services to ensure continuity of care for patients in the locality.
  • The practice continually reviewed the effectiveness of their services and had a range of educational meetings and steering groups in place to monitor the effectiveness of the services provided.
  • Patient feedback demonstrated patients were satisfied with the services received and felt staff were helpful and supportive.

We rated the practice as requires improvement for working age people because:

  • Cancer screening rates were lower than the national targets.

The areas where the provider should make improvements are:

  • Monitor and review processes for exception reporting of patients with long term conditions.
  • Continue with efforts to improve uptake of childhood immunisations.
  • Continue to encourage patients to attend cervical screening appointments.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection carried out on 9 January 2017

During a routine inspection

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