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Inspection Summary


Overall summary & rating

Good

Updated 1 June 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Market Surgery on 15 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. The practice was proactive in ensuring that all staff had the opportunity to join meetings and had ownership of changes that resulted.

  • Feedback from patients about their care was consistently positive. Patient feedback scores from the NHS GP Survey, the Friends, and Family Test (FFT) and from our own comments cards was extremely positive about the practice. Patients expressed high satisfaction levels with the service citing attentive and caring staff. 95% of patients using the FFT would recommend the practice.

  • 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 provided care to several local residential and nursing home. Some of these homes were for specific groups of patients, (for patients with learning disabilities or who were experiencing poor mental health), the practice was proactive when working with the staff, and carers to ensure those patients’ needs were met.

  • The practice actively reviewed complaints and how they were managed and responded to, and made improvements as a result.

  • The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw an area of outstanding practice including:

  • The practice team worked in a well-co-ordinated manner to enable end-of-life care to take place at home. This was evidenced by the fact that 27% of the practice's patients died in hospital compared to a national average of 50%. Involvement in end-of-life care had provided very valuable training for all the GPs including the trainee GPs and had enabled them to gain confidence in managing complex cases.

However there was an area of practice where the provider could and should make an improvement:

  • Request that the patient or their representative sign for the collection of controlled drugs.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 1 June 2016

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. In addition the practice reported difficult events that were particular well managed ensuring that staff were reminded that systems and process, when used had positive outcomes.

  • The practice used every opportunity to learn from internal and external incidents, to support improvement. Learning was based on a thorough analysis and investigation. The practice would engage with the patient to enhance the learning further.

  • Information about safety was highly valued and was used to promote learning and improvement. We saw evidence that the health and safety of staff was well managed.

  • Risk management was comprehensive, well embedded and recognised as the responsibility of all staff.

  • Non-clinical staff were given additional training in safeguarding including deprivation of liberty safeguard(DOLS).

Effective

Outstanding

Updated 1 June 2016

  • The practice is rated as outstanding for providing effective services.

  • Our findings at inspection showed that 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. In addition the GPs hosted regular journal clubs, attended by other local GPs and locum GPs. We also saw evidence to confirm that the practice used these guidelines to positively influence and improve practice and outcomes for patients.

  • Data showed that the practice was performing highly when compared to practices nationally.

    For indicators relating to diabetes the practice performance was 100%, this was 6.3% above the CCG average and 10.8% above the national average. Exception reporting for this indicator was in line with the CCG and national average.

    For indicators relating to rheumatoid arthritis the practice performance was 100% this was 7.9% above the CCG average and 4.6% above the national average. Exception reporting for this indicator 4.8%, this was below the CCG average of 12.5% and the national average of 7.4%.

  • The practice used innovative and proactive methods to improve patient outcomes and worked with other local providers to share best practice. The practice had a robust and effective palliative care team. Through co-ordinated team work only 27% of patients died in hospital (this may have been the preferred choice for some patients), the national average was 50%.

  • Clinical audits demonstrated quality improvement. The practice undertook a wide range of audits, these included audits by the nursing and administrative teams.

  • 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. Administration and reception staff were encouraged to undertake NVQ qualification.

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs which included mental health care. The practice looked after a number of young patients who had been admitted to secure units. The GPs worked closely with the staff to ensure that the young people’s health needs were addressed.

Caring

Good

Updated 1 June 2016

The practice is rated as good for providing caring services.

Data from the national GP patient survey showed patients rated the practice higher than others for almost all aspects of care. Data from the patient survey dated January 2016 showed that:

  • 91% of patients said the last GP they saw or spoke to was good at giving them enough time. (Local (CCG) average 88%: National average 87%.

  • 100% of patients had confidence and trust in the last nurse they saw or spoke to. (Local (CCG) average 98%: National average 97%.

  • 95% of patients completing the Friends and Family test said that they would recommend the practice.

  • Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this. Reception staff undertook additional training for example, safeguarding issues relating to deprivation of liberty and enhanced customer care which was embedded in the practice as patient comments reflected that they were always treating kindly and that staff looked after them.

  • Views of external stakeholders were very positive and aligned with our findings. We spoke with staff of care homes where the GPs cared for patients. The staff all reported positive feedback about the practice, they were particularly positive about the GPs and staff involving them in the palliative care meetings.

Responsive

Good

Updated 1 June 2016

The practice is rated as good for providing responsive services.

  • There were innovative approaches to providing integrated patient-centred care. The practice provided a GP to undertake home visits throughout the whole day, ensuring that patients received timely care.

  • 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 patients identified that they did not have sufficient privacy when speaking with dispensary staff about their medicines. A ticket system for patients was introduced and rather than queue at the dispensary desk, patients sat in the waiting area until called. Patients commented that they found this an excellent improvement.

  • Patients could access appointments and services in a way, and at a time that suited them. The practice offered a GP clinic each week at the nearby village of Cawston. This enabled patients who had difficulty with public transport to access health care more easily. Appointments were available online and 20% of patients had registered to use this service. To ensure easier telephone access for patients, the practice did not close the phone lines or building during the lunch period.

  • 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 patients, staff, and other stakeholders.

Well-led

Good

Updated 1 June 2016

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

  • The practice had a clear vision with quality and safety as its top priority. The strategy to deliver this vision had been discussed and was regularly reviewed with staff.

  • 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.

  • The practice gathered feedback from patients, and had an engaged patient participation group and surgery support group which influenced practice development. The group worked with the practice to promote preventive health and held awareness days. The events were attended by community services such as a carers support group, health trainers and smoking cessation advisors.

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

Checks on specific services

People with long term conditions

Good

Updated 1 June 2016

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

Nursing staff had roles in chronic disease management; data showed that patient outcomes were in line when compared with other practices in the locality. Patients that had attended appointments had a structured annual review to check that their health and medication needs were being met. The practice held weekly meetings attended by GP, nurse and administration staff to ensure that patients received appropriate re-calls and follow up.

Home visits were available to those patients who could not attend the surgery.

Longer appointments were available if required. Practice staff followed up patients who did not attend their appointments by telephone.

Patients taking long term medicines were routinely followed up to ensure safe prescribing and compliance.

Families, children and young people

Good

Updated 1 June 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 patients who had a high number of A&E attendances. Immunisation rates were in line with local averages for all standard childhood immunisations. Young children were given priority appointments for urgent needs.

The practice was part of the C-Card scheme; this scheme enabled young patients to access free condoms. Any children identified by the school nurse were given priority appointments. All staff were aware and applied appropriate use of the Gillick competency framework.

Appointments were available outside of school hours and the premises were suitable for children and babies. We saw examples of joint working with midwives, health visitors, and school nurses.

Young patients being care for in specialist units were given personalised care if they attended the practice. Joint working with the staff ensured that medical records were shared for example; medicines and care plans.

Older people

Good

Updated 1 June 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 proactive in care planning, not only for those patients that were on the vulnerable registers. To ensure that patients were cared for in the place they wished to remain, the practice was proactive in identifying and recording this information. We saw evidence that the practice had worked to the Gold Standards Framework for those patients with end of life care needs.

Continuity of care was maintained for older people through a stable GP workforce and personalised patient centred care. The practice provided visits to local care homes.

The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. A GP was available throughout the day to visit those patients that needed it. A GP held a weekly clinic in a nearby village to accommodate those patients that had difficulty with transport.

There was a delivery service for patients who were unable to collect their medicines from the pharmacy or dispensary.

Working age people (including those recently retired and students)

Good

Updated 1 June 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, including 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 did not restrict patients to certain appointment times to attend for their annual reviews; patients who worked were able to book at times that were convenient to them. Telephone consultations were available for those patients who wished to seek advice from a GP.

NHS health checks were available.

People experiencing poor mental health (including people with dementia)

Good

Updated 1 June 2016

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

The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.

The practice looked after a large number of patients living in care homes; all of these patients received an annual review undertaken by a GP.

Staff told us that all patients with dementia had received advance care planning and had received an appropriate review. The patients that lived in care homes had advance care planning and had regular reviews with GPs as well as an annual review. All patients with dementia had a named GP and continuity of care was prioritised for them.

Same day appointments and telephone triage with a GP was offered to ensure that any health needs were quickly assessed for this group of patients.

The practice told patients experiencing poor mental health about how to access various support groups and voluntary organisations. Staff had knowledge on how to care for patients with mental health needs and dementia.

The practice supported a local initiative which ensured the town of Aylsham was dementia friendly and several staff members were dementia friends. The practice had advised on a dementia friendly leaflet, this leaflet was circulated to all shops in Aylsham. The practice had received advice from a dementia specialist on appropriate signage for the practice. All staff at the practice had received training in dementia awareness.

People whose circumstances may make them vulnerable

Good

Updated 1 June 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 those with a learning disability. It offered longer appointments and carried out annual health checks.

The practice had 96 patients on the register of patients with learning disabilities, living both in their own home and residential care, all of these patients had received a review.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable patients. We saw the practice provided vulnerable patients with information about how to access various support groups and voluntary organisations.

Staff knew how to recognise signs of abuse or neglect 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.

Practice staff were intuitive to the needs of this group of patients and demonstrated that they had a personalised approach to helping them.