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Inspection Summary


Overall summary & rating

Good

Updated 8 July 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Richmond Lock Surgery on 19 April 2016. Overall the practice is rated as good.

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. All opportunities for learning from internal and external incidents were maximised.
  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed and well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

  • 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, following a complaint from a patient about having to attend the practice on different occasions for different blood tests, they had taken steps to reconcile the scheduling of blood tests so that patients could attend one appointment for all of the tests they required.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.
  • The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw some areas of outstanding practice:

  • The practice had analysed their performance for the management for patients with diabetes and had re-designed its process for monitoring these patients to ensure that it had the capacity to review the care of all these patients. This involved introducing nurse-led care but also making changes to the appointment system to ensure that patients identified by the nurse as needing to be seen by a doctor or dietician could be seen the same day.

The areas where the provider should make improvement are as follows. They should:

  • Ensure that they have processes in place to monitor that staff are up to date with mandatory training.
  • Ensure that they have processes in place to ensure that locum staff are up to date with training and professional registrations.
  • Ensure that they are taking all reasonable action to identify carers.
  • Advertise their translation service to patients at the surgery.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 8 July 2016

The practice is rated as good for providing safe services.

  • 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.
  • There was an effective system in place for reporting and recording significant events.
  • Lessons were shared 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.

Effective

Good

Updated 8 July 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above the national average.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 8 July 2016

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. For example, there had been an incident where a patient had said that they felt particularly unwell whilst in the waiting room and had been taken to lie down in a clinical room which was not being used whilst they waited for the doctor to attend to them. This was raised as a significant event due to the risks associated with a patient being unsupervised in a clinical area. In analysing the significant event, the practice identified that some patients would find it helpful if a quiet room was available for them to lie down whilst awaiting their appointment. They therefore converted their baby changing room to be used for this purpose, installing a couch and comfortable chair and an alarm button.
  • Data from the national GP patient survey showed patients rated the practice higher than others for several aspects of care.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Good

Updated 8 July 2016

The practice is rated as good 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, they made use of the local GP seven-day opening hub, which enabled practices in Richmond to book appointments for their patients outside of normal GP opening hours.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
  • 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 evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff.
  • 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, following a complaint from a patient about having to attend the practice on different occasions for different blood tests, they had taken steps to reconcile the scheduling of blood tests so that patients could attend one appointment for all of the tests they required.

Well-led

Good

Updated 8 July 2016

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

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to it.
  • High standards were promoted and owned by all practice staff and teams worked together across all roles.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The provider 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 was taken
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.
  • There was a strong focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions

Good

Updated 8 July 2016

The practice is rated as good 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.
  • Performance for diabetes related indicators was above average. Overall the practice achieved 93% of the total QOF points available, compared with an average of 90% locally and 89% nationally. The proportion of diabetic patients who had a record of well controlled blood pressure in the preceding 12 months was 86%, which was above the CCG average of 80% and national average of 78%, the proportion of these patients with a record of a foot examination and risk classification in the preceding 12 months was 95% (CCG average 91%, national average 88%), and the percentage of diabetic patients who had received influenza immunisation was 97% (CCG average was 90% and national average was 94%).
  • Longer appointments and home visits were available when needed. A flag was put on the system to identify patients who routinely required a longer appointment so that reception staff would be alerted when booking appointments.
  • 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.
  • The appointments system had been tailored to ensure that patients with certain long-term conditions who were attending nurse-led clinics could access allied services on the same day if necessary. For example, on the day of the nurse-led diabetic clinic a number of GP and dietician appointments were set-aside for diabetic patients so that those who the nurse had seen in her clinic and identified as needing further input could be seen by a GP or dietician on the same day.

Families, children and young people

Good

Updated 8 July 2016

The practice is rated as good 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, the practice was in the process of providing patients with online access to their medical records, and we were told that the GPs had discussed at length how best to ensure that permission for parents to view their child’s medical records is removed once the child reaches an appropriate level of maturity.
  • Cervical screening had been carried-out for 81% of women registered at the practice aged 25-64, which was comparable to the CCG average of 84% and national average of 82%.
  • The practice provided a full range of family planning services including emergency contraception and the fitting of intra-uterine devices and contraceptive implants.
  • 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.

Older people

Good

Updated 8 July 2016

The practice is rated as good 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 provided care plans for elderly patients who were at risk of unplanned hospital admission, and entered a flag on their computer system so that these patients were routinely offered a longer appointment.

Working age people (including those recently retired and students)

Good

Updated 8 July 2016

The practice is rated as good 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.

People experiencing poor mental health (including people with dementia)

Good

Updated 8 July 2016

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

  • The published QOF figures showed that the practice had 23 patients diagnosed with dementia and 75% had had their care reviewed in a face to face meeting in the last 12 months, compared to the CCG average of 86% and national average of 84%; however, an error in coding some of these patients had been identified, which after correction showed that the practice had achieved 86% for this indicator.

  • The practice had 56 patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses, and had recorded a comprehensive care plan for 95% of these patients, compared to a CCG average of 94% and 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.
  • The practice carried out advance care planning for patients with dementia.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.

People whose circumstances may make them vulnerable

Good

Updated 8 July 2016

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

  • The practice held a register of patients living in vulnerable circumstances including carers and those with a learning disability.
  • The practice offered longer appointments for patients with a learning disability.
  • 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.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff 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.