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Beauchamp House Surgery Good

Inspection Summary


Overall summary & rating

Good

Updated 10 March 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Dr Schultz and Partners, also known as Beauchamp House Surgery on 17 January 2017. Overall, the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. The provider was aware of and complied with the requirements of the duty of candour.
  • Risks to patients at the premises 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.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Data from the national GP patient survey showed patients were happy with the service that they were receiving.
  • There was a commitment to learning, sharing information and improvement.
  • Information about services and how to complain was available and easy to understand.
  • There was a clear leadership structure and staff felt supported by management.
  • The practice proactively sought feedback from patients, which it acted on.

The areas where the provider should make improvement are:

  • Ensure patients with learning disabilities are invited to an annual health check.
  • Improve the identification of patients who are carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 10 March 2017

The practice is rated as good for providing safe services.

  • There was an effective system in place for recording significant events. The provider was aware of and complied with the requirements of the duty of candour.

  • The practice responded to safety incidents, including Medicine and Health products Regulatory Agency (MHRA) alerts, which sought to ensure patients were safe.

  • Arrangements were in place to monitor, review and share information in relation to children and vulnerable adults who were at risk of abuse.

  • There were processes to monitoring and managing risks to patient and staff safety at the premises, including policies, checks and risk assessments.

  • The practice had adequate arrangements in place to respond to emergencies and major incidents.

Effective

Good

Updated 10 March 2017

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 average compared to 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 for all staff.

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 10 March 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice in line with 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.

  • The practice identified carers and provided them with additional support.

  • The practice had identified that improvements were needed to ensure that patients with learning disabilities had regular health checks.

Responsive

Good

Updated 10 March 2017

The practice is rated as good for providing responsive services.

  • Appointments could be booked on-line, on the telephone or in person.

  • A midwife held a weekly clinic at the practice.

  • Appointment reminders could be sent by text message to patients providing their mobile phone number.

  • Telephone consultations were available.

  • Repeat medicines could be requested online.

  • Patients were able to receive travel vaccinations available on the NHS as well as those only available privately.

  • There were translation services available for patients who did not speak English as a first language, as well as sign language services available for patients who were deaf.

  • Care plans were in an accessible format for patients who required additional support with their communication.

  • 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.

Well-led

Good

Updated 10 March 2017

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.

  • 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.

  • 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 10 March 2017

The practice is rated as good for the care of people with long-term conditions.

  • Performance for diabetes indicators was in line with CCG and national averages. Diabetic care was led by a named GP.

  • The percentage of patients with diabetes whose cholesterol was within specified limits was 81%, which was comparable to the CCG average of 76% and England average of 80%.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified.

  • There were monthly multi-disciplinary meetings with other healthcare professionals to discuss complex patients.

  • There were systems in place to ensure safe prescribing of repeat medicines, including those that were high-risk.

Families, children and young people

Good

Updated 10 March 2017

The practice is rated as good for the care of families, children and young people.

  • The midwife held a regular clinic at the practice.

  • There were appointments available out of school hours.

  • The practice carried out antenatal and postnatal checks.

  • Childhood immunisation rates for the vaccinations given were comparable to CCG and national averages. Childhood immunisation rates for the vaccinations given to under two year olds ranged from 94% to 97% and five year olds from 94% to 95%.

  • There were procedures in place to safeguard children from abuse.

  • The practice had policies and trained staff on consent and capacity for young patients.

Older people

Good

Updated 10 March 2017

The practice is rated as good for the care of older people.

  • All patients who were aged 75 years and over were offered a flu vaccination and advised of their named GP.

  • There were monthly frailty meetings attended by healthcare professionals to discuss the needs and share information about relevant patients.

  • There was a lead GP for care homes where patients were living, who made regular visits which sought to ensure continuity of care.

  • The practice used Information About Me (IAM) care plans where relevant to help patients to understand and be involved in their care.

Working age people (including those recently retired and students)

Good

Updated 10 March 2017

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.

  • Telephone consultations were available for patients who were unable to attend the practice

  • Data for the year 2015/2016 showed that 74% of females aged 25-64 had attended for their cervical screening which was in line with the CCG and national averages.

  • Appointment reminders could be sent by text message to patients providing their mobile phone number.

  • There was online access to records, appointments and ordering repeat prescriptions. Prescriptions could be sent to pharmacies which were convenient to the patient.

  • Appointments were available from 8.10am.

People experiencing poor mental health (including people with dementia)

Good

Updated 10 March 2017

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

  • Performance for mental health indicators was comparable and in some instances higher than CCG and national averages.

  • The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who had a care plan documented in the record in the 12 months was 99%, which was above the CCG average of 89% and England average of 89%.

  • The percentage of patients with schizophrenia, bipolar affective disorder and other psychoses whose alcohol consumption had been recorded in the preceding 12 months was 88%, compared to the CCG average of 85% and England average of 89%.

  • There was a counsellor at the practice one day a week.

  • The Alzheimer’s society held regular sessions at the practice to provide support for patients living with dementia and their families.

People whose circumstances may make them vulnerable

Good

Updated 10 March 2017

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

  • The practice had identified 105 patients as carers, which amounted to 0.9% of the practice list. Carers were invited for flu vaccinations and provided with flexible appointments.

  • Patient information leaflets and notices were available in the patient waiting area which told patients how to access a number of support groups and organisations.

  • The practice had 58 adults on the learning disability register. In the last year, 12 health checks had been completed, 12 patients had declined an invitation health check and one patient did not attend their appointment. The practice was in the process of securing training for nursing staff to improve uptake for these health checks.

  • The practice worked with local organisations to provide support and treatment for patients who were homeless or living with drug dependency issues.