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Inspection Summary


Overall summary & rating

Outstanding

Updated 12 April 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Worthing Medical Group on 6 January 2017. Overall the practice is rated as outstanding.

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. Opportunities for learning from internal and external incidents were maximised.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • The practice supported and encouraged staff training and development. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Most 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 provided staff with training on methods to promote positive interactions with patients.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs. For example, the practice had been instrumental in making a successful bid to obtain funding through the Prime Minister’s Challenge Fund for additional patient appointments at four sites. They had written and won the bid and implemented the whole service for two localities.

  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, in developing a dedicated service for homeless patients, providing comprehensive care and support for patients living in nursing and care homes, and developing a measure to identify and support frail patients.

  • 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.
  • Most patients said they found it easy to make an appointment with a GP. Where difficulties had been identified the practice had been proactive in reviewing and improving patient access to appointments.
  • There was a strong and visible leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on. There were high levels of staff satisfaction and staff spoke highly of the culture.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw three areas of outstanding practice:

  • The practice developed a system to identify severely frail patients who were not identified by other risk programmes. The practice had used this system to identify an additional 187 severely frail patients. They offered these patients comprehensive reviews and had worked with other professionals to support these patients and develop care plans. The practice was liaising with their computer supplier to roll out this system to other practices in the area and nationally.
  • The practice offered a dedicated service for homeless patients based at Health Central Surgery. Approximately 150 homeless patients used this service. There were dedicated GPs and advanced nurse practitioners working at this service and also a number of staff with additional expertise in mental health and substance misuse. All newly registered patients had an initial 30 minute GP appointment and a 30 minute nurse appointment. Support was provided for substance misuse and alcohol difficulties, sexual health advice, as well as routine health assessments and treatments. The service provided outreach to homeless shelters and participated in a forum for services providing support to homeless people to share local knowledge. The practice had received positive feedback from patients using this service. As a result of patient feedback, the practice had developed cards explaining patients’ right to register at other practices despite having no fixed address. Patients were given copies of these cards to give other practices if they encountered difficulties.
  • The practice provided services to 777 older patients living in nursing and care homes. There was a dedicated GP and advanced nurse practitioner each day at the practice and a separate phone line was provided so that staff at nursing and care homes could quickly contact the practice for advice. Practice staff provided monthly education sessions and training events to nursing and care home staff. Approximately 20 staff from 20 homes attended a recent training event. Training topics included Deprivation of Liberty Safeguards, wound care, end of life care, and support for workers undertaking phlebotomy training. We saw evidence of positive feedback about this service from other health care professionals.

  • The practice had a well-developed business plan which set out its vision, supporting objectives and the strategy for achieving them. There were a number of examples of how the practice had turned its vision in to reality. For example, playing an instrumental role in setting up and successfully bidding to obtain funding from the Prime Minister’s Challenge Fund to provide additional minor illness and minor injuries clinics at four sites across Worthing. They had written and won the bid and implemented the whole service for two localities. As a result this provided increased access for all patients in these localities to urgent appointments during weekdays from 8am until 8pm and at weekends from 10am until 2pm. This helped ensure patients were seen by the right person at the right time.

The area where the provider should make improvement is:

  • Introduce systems to ensure that all necessary building risk assessments and maintenance actions are undertaken and documented for all sites.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 12 April 2017

The practice is rated as good for providing safe services.

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses.

  • The practice proactively used opportunities to learn from internal and external incidents to support improvement. Learning was based on a thorough analysis and investigation. Information about safety incidents was highly valued and was used to promote learning and improvement.

  • Risks to patients were mostly assessed and well managed and there were thorough systems in a number of areas to ensure patient safety. However, an electrical installation check had not been undertaken at the primary site. The practice had already arranged for this to take place in February 2017. There were not systems to ensure that thorough premises risk assessments and actions had been undertaken and documented at all premises.

  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safeguarded from abuse.

Effective

Good

Updated 12 April 2017

The practice is rated as good for providing effective services.

  • 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.

  • Published Quality and Outcomes Framework (QOF) for 2015 to 2016 showed patient outcomes were below average. The practice told us that this was due to a merger with a low QOF scoring practice in 2016. The practice showed us evidence on the day of the inspection that to date QOF scores had improved. The practice presented data showing that before the merger they had consistently achieved high QOF scores.

  • The practice supported and encouraged staff training and staff had the skills, knowledge and experience to deliver effective care and treatment.

  • There was evidence of appraisals and personal development plans for staff.

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

Caring

Good

Updated 12 April 2017

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice as comparable to clinical commissioning group (CCG) and national averages for several aspects of care.

  • Most patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. The practice had provided staff with training on methods to promote positive interactions with patients.

  • 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.

  • The practice had a proactive approach to identifying and supporting carers.

Responsive

Outstanding

Updated 12 April 2017

The practice is rated as outstanding for providing responsive services.

  • There was a proactive approach to understanding the needs of different groups of people and to deliver care in a way that meets these needs and promotes equality. This included people who were in vulnerable circumstances or who had complex needs. For example, the practice provided holistic care and treatment to patients living in nursing and care homes and had developed and provided a dedicated service for patients with no fixed address.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs. The practice had been instrumental in successfully bidding to obtain funding from the Prime Minister’s Challenge Fund to provide additional minor illness and minor injuries clinics at four sites across Worthing. They had written and won the bid and implemented the whole service for two localities.

  • There were innovative approaches to providing patient-centred care. For example, the practice had developed and used a system to identify and support 187 severely frail patients who were not identified through other systems. They were liaising with computer developers to roll this system out to other practices locally and nationally.

  • 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.

  • Patient feedback on access to appointments was varied. However, the practice had been proactive in taking measures to monitor, review, and improve patient access to appointments through the introduction of new technologies, processes and protocols, and reviews of staffing.

  • Information about how to complain was available and easy to understand, and the practice responded quickly when issues were raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Outstanding

Updated 12 April 2017

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

  • The practice had a clear vision and strategy to be a large, multi-disciplined practice that focuses on the patient. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

  • There were a number of examples of how the practice had turned its vision in to reality including supporting of and then subsequent merger with a struggling, neighbouring practice. This enabled a service to patients to be maintained, continuity of employment for staff and a growth in practice size.

  • Staff were clear about the vision and their responsibilities in relation to it.

  • A systematic approach was taken to working with other organisations to improve care outcomes, tackle health inequalities and obtain best value for money.

  • 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.

  • Leaders had an inspiring shared purpose, strive to deliver and motivate staff to succeed.

  • There was an overarching governance framework which had been proactively reviewed and supported the delivery of the strategy and good quality care in a number of areas. High standards were promoted and all practice staff worked together in clearly defined roles.

  • 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.

  • There were high levels of staff satisfaction. Staff were proud of the organisation as a place to work and spoke highly of the culture.

  • There were consistently high levels of constructive staff engagement. Staff at all levels were actively encouraged to raise concerns. For example, there were staff surveys, a staff newsletter and an elected staff council.

  • There was a strong focus on continuous learning and improvement at all levels.

Checks on specific services

Older people

Outstanding

Updated 12 April 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

  • 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.
  • There were facilities for patients with mobility difficulties and a hearing loop. Patients with difficulties communicating due to hearing or speech difficulties could use a text message service to arrange appointments.
  • The practice provided services to 777 older patients living in nursing and care homes. Staff provided weekly visits to all nursing and care homes and they also provided consultations, treatments, and advice in response to new concerns. A separate phone line was provided so that staff at nursing and care homes could quickly contact the practice to seek advice on prescriptions and medical concerns. Practice staff provided monthly education sessions and training events to nursing and care home staff.

  • The practice had conducted an audit of care and treatment provision for newly registered patients living in nursing and care homes. This showed that between May 2016 and November 2016 there were improvements in the percentage of newly registered patients with care plans, medicine reviews, and resuscitation status recorded within two weeks of admission to the home.

  • The practice proactively supported staff to undertake training relating to the needs of older people. For example, one member of staff was undertaking a fellowship relating to the needs of older patients.
  • The practice identified patients who were at high risk of hospital admission and took steps to enable appropriate treatment and support at home. This included home visits from nurses or GPs and the development of holistic and personalised care plans.
  • The practice had developed and used a system to identify an additional 187 severely frail patients who were not identified by other risk programmes. They offered these patients comprehensive reviews and had liaised with other professionals to support these patients and develop care plans. The practice was liaising with their computer supplier to roll out this system to other practices in the area and nationally.
  • The practice had adopted the Gold Standard Framework for end of life care. They held regular multidisciplinary meetings for patients receiving end of life care. The practice had a dedicated phone line and had developed a specific computer template so that patients receiving end of life care and their carers could request prescriptions and receive these at short notice.

People with long term conditions

Outstanding

Updated 12 April 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
  • Published QOF 2015/2016 performance for diabetes related indicators was 97% which was similar to the clinical commissioning group (CCG) average of 96% and national average of 90%.
  • The practice referred patients to a pilot project to provide comprehensive health education for patients with pre-diabetes.
  • Longer appointments and home visits were available when needed.
  • All patients with long term conditions 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 most recent published QOF results from 2015/2016 were 79% of the total number of points available which was low compared to the CCG average of 96% and national average of 95%. The practice reported that these results were due to a merger with Heene Road Surgery in January 2016. The practice showed us evidence on the day of the inspection they had achieved a high number of possible QOF points to date for a number of clinical indicators
  • There were machines to check blood pressure and body mass index in the waiting area for patient use with guidance on how to operate the machines and when to seek advice regarding results.

Families, children and young people

Outstanding

Updated 12 April 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

  • 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.

  • Childhood immunisation rates for the vaccines given were variable compared to clinical commissioning group (CCG) and national averages. For example, childhood immunisation rates for the vaccines given to under two year olds ranged from 45% to 78%, which was below average. Rates for five year olds ranged from 88% to 90%, which was in line with CCG averages of 90% to 93% and national averages of 88% to 94%. The practice showed us more recent unverified immunisation data on the day of the inspection. This showed that childhood immunisations given to under two year olds were 94% and immunisations given to five year olds were 94%.

  • Children and young people were treated in an age-appropriate way and were recognised as individuals.

  • 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.

  • Same day appointments were available for children.

  • The practice’s uptake for the cervical screening programme was 79%, which was slightly lower than the CCG average of 82% and the national average of 81%. The practice demonstrated how they encouraged uptake of the screening programme.

Working age people (including those recently retired and students)

Outstanding

Updated 12 April 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

  • 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.

  • The practice offered appointments outside of normal working hours so working patients could attend.

  • The practice provided the option to cancel appointments via text message or through a 24 hour cancellation line.

  • Three GPs at the practice provided a minor surgery service and GPs trained other GPs in this area.

People whose circumstances may make them vulnerable

Outstanding

Updated 12 April 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.

  • There were longer appointments for patients with a learning disability. The practice had completed the highest number of learning disability reviews compared to clinical commissioning group (CCG) averages.

  • The practice produced 

    the highest number of care plans in the locality to prevent avoidable hospital admissions.

  • The practice offered a dedicated service for homeless patients based at Health Central Surgery. All newly registered patients had an initial 30 minute GP appointment and a 30 minute nurse appointment. Support was provided for substance misuse and alcohol difficulties, sexual health advice, as well as routine heath assessments and treatments. The practice had received positive feedback from patients using this service.

  • The practice provided twice weekly visits and ward rounds to a home for patients with acquired brain injury living in a nursing/hospital home and visits in response to new concerns. GPs also attended multidisciplinary meetings with other involved professionals and developed care plans for 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.

  • The practice offered a dedicated service for homeless patients based at Health Central Surgery. Approximately 150 homeless patients used this service. There were dedicated GPs and advanced nurse practitioners working at this service and also a number of staff with additional expertise in mental health and substance misuse. The service provided outreach to homeless shelters and participated in a forum for services providing support to homeless people to share local knowledge.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 12 April 2017

The practice was rated as outstanding for responsive and well led services. These ratings apply to everyone using the practice, including this population group.

  • Published QOF results for 2015/2016 showed that 59% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which is low compared to the clinical commissioning group (CCG) and national average. However, more recent QOF data provided by the practice showed high QOF performance for dementia related indicators. This reflected the work the practice had done to deliver their previous high achievement into the practice they took over.
  • The practice had conducted a project to ensure appropriate dementia diagnosis. They visited patients in local nursing and care homes to determine appropriate diagnosis and ensure that patients received appropriate care and treatment. Results showed that as a result of the project 45 additional patients had been diagnosed with dementia. Feedback from nursing and care home staff was that the project had been useful in identifying patient support needs. The practice hosted a drop in service to provide support for patients with dementia and their carers, provided by an external organisation. They had also arranged and held a forum with local dementia services to discuss ways to enhance patient care.
  • Published QOF 2015/2016 performance for mental health related indicators was 50% which was lower than the CCG average of 91% and national average of 93%.On the day of the inspection the practice showed us more recent data indicating that QOF performance for mental health related indicators was 62% on the day of the inspection.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those 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. The practice was a Dementia Friendly practice.
  • The practice proactively supported staff to undertake training relating to the needs of patients with mental health difficulties. For example, a Royal College of General Practitioners qualification in substance misuse.
  • The practice provided medical appointments for patients attending a rehabilitation centre for drug and alcohol difficulties. They provided comprehensive medical checks for patients when they were admitted to the centre. Three GPs were trained to provide a substitute prescribing service for patients experiencing substance misuse difficulties, and the practice offered medical treatment and monitoring for patients experiencing alcohol difficulties.