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Roundwood Surgery Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 17 September 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Roundwood Surgery on 11 March 2015. Overall the practice is rated as outstanding

Specifically, we found the practice to be good for providing safe, effective and caring services. It was outstanding for providing responsive and well-led services. We found the practice to be good for providing services for people with long-term conditions, families, children and young people, working age people (including those recently retired) and people experiencing poor mental health (including people with dementia). It was outstanding for providing services for older people and people whose circumstances might make them vulnerable.

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

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • Risks to patients were assessed and well managed.
  • Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had received training appropriate to their roles and any further training needs had been identified and planned.
  • 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 (PPG).
  • Information about services and how to complain was available and easy to understand.
  • The practice was the only one to offer an enhanced service to homeless people in the CCG area. They took a proactive approach towards meeting the needs of this vulnerable group of patients and took the service out to a local church which provided meals for homeless people and offered nursing services including dressings, health advice and monitoring as well as opportunistically offering the flu vaccination to prevent ill health. This service had led to some homeless patients feeling comfortable enough to attend the practice to see the GPs.
  • Leaders were both visible and supportive. They were committed to improving the services for patients within the practice and the wider community and repeatedly volunteered to pilot new ideas and innovations before such innovations were rolled out across the CCG. They invested in their staff and shared this expertise with other practices to improve standards across the wider practice community. For example the electronic system super user offered support, training and guidance to other practice managers.
  • The practice had a clear vision which had patient care as its top priority. The practice held regular meetings to discuss business direction and forward planning. High standards were promoted and owned by all practice staff with evidence of team working across all roles.

We saw some areas of outstanding practice:

  • The practice was the only practice in the area to offer a service for homeless people and treated these patients in an environment where they felt comfortable by visiting a local church at lunchtimes offering a range of nursing services and opportunistic immunisation against flu.
  • The practice had introduced a minor injuries walk-in clinic in response to a review of information about A&E attendances to provide a local service to all patients in the locality and prevent them having to travel and wait for treatment. This had resulted in a reduction in A&E attendances by practice patients of 100 over a 12 month period.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 17 September 2015

The practice is rated as good for providing safe services. The practice had systems in place for reporting, recording and monitoring incidents and significant events. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses and felt encouraged to do so. Lessons were learned and communicated internally and externally to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed. Risks to patients were assessed and well managed. There was enough staff to keep people safe.

Effective

Good

Updated 17 September 2015

The practice is rated as good for providing effective services. Data showed patient outcomes were at or above average for the locality. The practices performance for non-elective emergency admissions and A&E attendances was better than the CCG average.

People’s needs were assessed and care was planned and delivered in line with current legislation. This included assessing capacity and promoting good health. For example capacity assessments had recently been undertaken for patients who would be involved in the practice pilot of Skype based consultations.

Staff worked with other health and care professionals to improve patient outcomes. Regular multi-disciplinary meetings were held and actions identified to benefit patients. Staff had received training appropriate to their roles and any further training needs have been identified and planned.

Caring

Good

Updated 17 September 2015

The practice is rated as good for providing caring services. Data showed that patients rated the practice higher than others for several aspects of care. Comment cards we reviewed indicated that patients found the practice staff helpful and polite.

The practice survey results from 2014 indicated that 98% of respondents were happy with the care they received.

Information to help patients understand the services available was easy to understand. We also saw that staff treated patients with kindness and respect, and maintained confidentiality.

Responsive

Outstanding

Updated 17 September 2015

The practice is rated as outstanding for providing responsive services. The practice had initiated positive service improvements for its patients that were over and above its contractual obligations. It acted on suggestions for improvements and changed the way it delivered services in response to discussions with the local group of practices and the Clinical Commissioning Group (CCG). For example the practice offered a community micro suction service for patients across the CCG and other practices can refer patients to this service rather than to secondary care.

The practice acknowledged an area of weakness was telephone access to the practice. Patient feedback indicated that it was difficult to get through the practice via the telephone. The practice was seeking to address these issues and had implemented text messaging and a dedicated cancellation line.

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 that the practice responded quickly to issues raised. Learning from complaints with staff and other stakeholders.

Well-led

Outstanding

Updated 17 September 2015

The practice is rated as outstanding for being well-led. The practice had a clear vision with quality and patient care as its top priority. The practice held regular meetings to discuss the business direction and forward planning. High standards were promoted and owned by all practice staff and teams worked together across all roles. The practice had a clear and organised leadership structure with GPs, nurses and administrative staff being grouped in teams to lead on specific areas.

The practice engaged proactively with the CCG, the local commissioning group and other external stakeholders. External engagement was used to drive improvement within the practice and the practice embraced change and innovation. For example, the practice was a pilot site for FLO (telehealth) and won an award for their work in this area.

Staff felt supported by management and the practice commitment to learning and development was evident. For example, the practice worked with a local college to develop apprentices and had taken on six apprentices since 2012. The practice had policies and procedures in place to govern activity and governance was discussed regularly at practice meetings.

The patient participation group (PPG) was active. Staff had received inductions and were issued with a comprehensive staff handbook. Staff had support from management and received regular performance reviews and attended staff meetings, training and events.

Checks on specific services

People with long term conditions

Good

Updated 17 September 2015

The practice is rated as good for the care of people with long-term conditions. There were emergency processes in place and referrals were made for patients whose health deteriorated suddenly. Longer appointments and home visits were available when needed and a dedicated nurse visited house bound patients on a fortnightly basis.

The practice had a clear system in place for the management of chronic diseases. Nursing staff led clinics in areas such as diabetes, heart disease and respiratory disease. Nurse leads were supported by a named GP lead and a named administrative lead. Patients received an annual invitation (on or near to the month of their birthday) for screening and review. The practice had a system in place to follow up patients who failed to respond to invitations by text message or telephone call. Published data showed that 91.8% of patients with chronic obstructive pulmonary disease (COPD) had received a review in the preceding 12 months which was 5.5% above the CCG average and 2.2% above the national average. The practice had not performed as well in respect of diabetes; however they were aware of this and explained that this was due to the fact that they did not routinely exception report patients who were on maximum tolerated medication and those who did not attend. This is supported by data which showed that the practice exception reporting rate for diabetes indicators was lower than the CCG average rate for 11 of 15 indicators.

The practice offered its patients access to a telehealth system called FLO. The practice had been a pilot for this system and had won an award for its work in this area. This system enabled certain conditions, such as hypertension (elevated blood pressure), to be self-monitored. If patients got a reading which fell outside of their range they were advised to see medical advice.

All these patients had a named GP and a structured annual review to check that their health and medication needs were being met. For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Good

Updated 17 September 2015

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 who did not attend for immunisations and vaccinations. The practice had a lead GP and a lead nurse for childhood vaccinations and immunisations. The lead nurse had dedicated time allocated to contact families who were behind with vaccinations. If this was unsuccessful, the lead GP was alerted who would do a home visit to try and vaccinate the children. The health visitor would also be alerted. The practice performed well in relation to vaccinations and immunisations consistently achieving over 90% at 12months and 24 months.

The practice had named leads for safeguarding. Staff we spoke with demonstrated knowledge and understanding in relation to safeguarding children and were aware of their responsibilities to report concerns. We saw evidence of quarterly multi-disciplinary meetings to discuss children who were at risk. Meetings were attended by the lead GP, the health visitor, midwife, school nurse, practice nurse and the administrative lead for that area.

The practice offered extended hours which enabled parents with children to be seen at convenient times before and after school hours. Sick children were always seen on the same day.

Older people

Outstanding

Updated 17 September 2015

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

All patients over 75 had a named GP for continuity of care. The practice invited these patients in to review whether a care plan was needed. Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people.

The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example preventing unplanned admissions into hospital. To support this, the practice held monthly multidisciplinary meetings to discuss patients who were identified as being at high risk of unplanned hospital admissions based on their previous high A&E attendance. We saw records which demonstrated the professionals attending the meeting discussed and agreed preventative measures to minimise the risks of further unplanned admission and to try and maintain the person in the community safely.

The practice had a lead nurse who visited patients who were house bound and those who were in a care home on a fortnightly basis. The purpose of these visits was to provide care specific for the patient in addition to vaccinations where these were indicated. The practice had also introduced Skype consultations for patients in care homes.

Working age people (including those recently retired and students)

Good

Updated 17 September 2015

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 reflected the needs for this age group.

The practice offered extended hours opening. This enabled more flexibility for patients wishing to access appointments outside of standard working hours.

The practice offered NHS health checks to patients aged 40-74 and had undertaken 238 health checks in the previous nine months.

The practice used technology and IT to communicate with this population group and recently introduced a text messaging service.

People experiencing poor mental health (including people with dementia)

Good

Updated 17 September 2015

The practice is rated as good for the care of people experiencing poor mental health (including people with dementia). 93.1% of people with a mental health condition had a comprehensive care documented in their records in the previous 12 months. The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. It carried out advance care planning for patients with dementia. The practice achievement for dementia was below the CCG and national average. The practice had achieved 76.9% of available QOF points which was significantly below the CCG and national average. The practice was aware of this and planned to change their processes to ensure that patients have all tests carried out before a referral is made.

The practice was part of a pilot project for offering Skype consultation. The practice was planning to offer this service to patients living in a care home who experienced mental health issues. The patients would be reviewed on a weekly basis. The practice told us the aim of these consultations was to provide preventative medicine rather than reactive medicine.

The practice had GP, nursing and administrative leads for mental health.

People whose circumstances may make them vulnerable

Outstanding

Updated 17 September 2015

The practice is rated as outstanding for the care of people living in vulnerable circumstances.

An example of outstanding practice was how the practice offered care to homeless patients. The practice was the only practice in the area to offer a service to homeless patients and recognised that they do not always engage well so felt it was best for staff to visit them in an environment where they felt safe. The practice delivered two clinic sessions per week held at meal times to maximise attendance. Each clinic lasted two hours and staff offered nursing care including wound dressing. These clinics averaged 40 patient attendances per month. Outside of these clinic times homeless patients attended the practice for treatment as required with an average of 16-20 homeless patients registered with the practice at any time.

The practice had a system to register homeless patients with the same address to enable recognition of this on their system. We saw evidence from a patient’s record to show that the patient had a wound and that over time as a result of treatment provided by the practice led to the wound healing. The practice staff opportunistically vaccinated patients who were homeless against influenza and tetanus.

The practice worked with the local deaf centre to provide training for staff, including learning basic signs to communicate with people who were hearing impaired.

Patients with a learning disabilities were offered a detailed annual review which included a structured care plan, needs assessments and health and wellbeing check.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. The practice provided information for 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.