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Sett Valley Medical Centre Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 11 October 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Sett Valley Medical Centre on 21 July 2016. Overall the practice is rated as outstanding.

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

  • There was an effective system in place for the reporting and recording of significant events. Learning was applied from events to enhance the delivery of safe care to patients.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. An ongoing programme of clinical audit reviewed patient care and ensured actions were implemented to improve services as a result.
  • The practice planned and co-ordinated patient care with the wider multi-disciplinary team to deliver effective and responsive care to keep vulnerable patients safe.
  • The practice was committed to staff training and development and the practice team had the skills, knowledge and experience to deliver high quality care and treatment. The practice had an effective appraisal system in place.
  • There was a good staff skill mix in place which included three nurse practitioner roles. The practice also contracted a pharmacist and a community matron to provide weekly sessional input at the practice.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. The practice analysed and acted on feedback received from patients.
  • Patients provided generally positive views on their experience in making an appointment to see a GP or nurse.
  • Longer appointments were available for those patients with more complex needs. An advanced nurse practitioner triaged calls and ensured that any patient requiring an urgent appointment was seen on 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 in place and the practice had a governance framework which supported the delivery of good quality care. Regular practice meetings occurred, and staff said that GPs and managers were approachable and always had time to talk with them.
  • The practice had a clear vision for the future and included the practice team in reviewing and planning service delivery. The aspirations of the partners were in line with the CCG strategy of delivering high quality care closer to the patient’s home.
  • Information about how to complain was available upon request and was easy to understand. Improvements were made to the quality of care as a result of any complaints received.

We saw the following areas of outstanding practice:

  • The practice had worked in collaboration with the UK Sepsis Trust over the last 18 months to promote the awareness and treatment of sepsis in primary care. This recognised that the early identification of symptoms and the use of effective safety netting was paramount within the primary care setting. This had led to the publication of an article written by the advanced nurse practitioner in the British Journal of General Practice in March 2016. A second project was underway to assess GP perception and knowledge of sepsis prior to the publication of NICE guidance on sepsis in July 2016. The ANP and GPs delivered training on sepsis to other primary care colleagues within their area, and aspired to influence a national sepsis promotional campaign.
  • The practice was located in a semi-rural location and had configured its services to be responsive to the needs of their own patients and the wider patient community. For example, the practice provided a vasectomy service which enabled patients from other practices to receive this service, and to improve patient choice and access to local treatment.

The areas where the provider should make improvement are:

  • Develop cleaning schedules to determine the extent and frequency of cleaning for each room, and review how this will be monitored.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 11 October 2016

  • Staff reported all significant events, and learning was applied from incidents to improve safety in the practice. The practice demonstrated a commitment to safety through additional training and identifying a designated lead GP for incident reporting.
  • The practice had robust systems in place to ensure they safeguarded vulnerable children and adults from abuse.
  • The practice adhered to written recruitment procedures to ensure all staff had the skills and qualifications to perform their roles, and had received appropriate pre-employment checks.
  • Risks to patients and the public had been identified with systems in place to control these. For example, the practice had a designated infection control lead who undertook regular audits, and worked with the hospital microbiologist and local infection prevention and control teams for advice when required.
  • The practice had undertaken significant work on the sepsis pathway to keep deteriorating patients safe within a primary care environment.
  • There were effective systems in place to manage medicines and prescriptions kept on site appropriately. Patients on high risk medicines were monitored on a regular basis, and there were processes to follow up any patients who had not collected prescriptions within six weeks. Actions were taken to review any medicines alerts received by the practice, to ensure patients were kept safe.
  • The practice had robust and highly effective systems in place to deal with medical emergencies, and we were provide with examples of this.
  • The practice ensured staffing levels were sufficient at all times to effectively meet their patients’ needs.
  • The practice had developed contingency planning arrangements, supported by a comprehensive and up to date written plan which was regularly updated. 

Effective

Good

Updated 11 October 2016

  • The practice delivered care in line with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines.
  • The practice had achieved an overall figure of 94.9% for the Quality and Outcomes Framework 2014-15. This was marginally below the CCG average of 98.1%, and consistent with the national average of 94.7%.
  • The practice had developed comprehensive support for their patients with diabetes. This included the identification and support of patients with signs of pre-diabetes, and establishing a weekly multi-disciplinary meeting to review patients with diabetes.

  • The practice had undertaken a project to standardise the way that suspected urinary tract infections were treated based upon national guidelines. The outcome was a decrease in the number of inappropriate samples being sent for urinalysis by one third and identified the practice as having one of the highest proportions of appropriate rationale for requests.
  • A regular programme of clinical audit demonstrated quality improvement, and we saw examples of how audit was being used to enhance safe patient care and treatment.
  • The practice had a good skill mix including advanced nurse practitioner roles. The practice employed their own care co-ordinator, and contracted a community matron and a pharmacist to provide care to their patients.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. New employees received inductions, and all members of the practice team had received an appraisal each year, which included a review of their training needs.
  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs, in order to deliver care effectively. This was supported by weekly meetings attended by a range of health and care professional staff.

Caring

Good

Updated 11 October 2016

  • Staff treated patients with kindness and respect, and maintained confidentiality throughout our inspection. We observed a patient-centred culture and approach within the practice.
  • Patients we spoke with during the inspection, and feedback received on our comments cards, indicated they were treated with compassion, dignity and respect and felt involved in decisions about their care and treatment.
  • Data from the latest GP survey showed that patients generally rated the practice in line with local and national averages in respect of care.
  • We were informed of many examples in which staff had provided personalised care and support for individual patients, in response to their needs.
  • Feedback from community based health care staff and care home staff was positive with regards to the high standards of care provided by the practice team.
  • The practice had identified 2% of their list as being carers, which was in line with expected averages. Information was available on the various types of support available to carers.
  • The practice helped raise funds for the local hospice by selling books donated by patients.

Responsive

Outstanding

Updated 11 October 2016

  • Comment cards and patients we spoke with during the inspection provided generally positive experiences about obtaining a routine appointment with a GP, or being able to speak to someone regarding their concerns. The latest GP survey showed that patient satisfaction was generally in line with local and national averages with regards access to GP appointments.
  • There was in-built flexibility within the appointment system including pre-bookable slots; telephone consultations; and ‘on the day’ appointments. An advanced nurse practitioner (ANP) triaged requests for same day appointments and provided advice or made arrangements for that patient to be seen by a GP or the ANP. Patient feedback regarding the triage service was generally very positive.
  • Urgent appointments were available on the day. The practice offered an extended hours’ commuter surgery on one morning and one evening each week.
  • Patients could book appointments and order repeat prescriptions on line. The practice participated in the electronic prescribing scheme, so that patients could collect their medicines from their preferred pharmacy without having to collect the prescription from the practice.
  • The practice hosted a range of services on site which made it easier for their patients to access locally. This included ante-natal care; talking therapies for patients with mental health problems; and a Citizens Advice Bureau session.
  • The practice implemented improvements and made changes to the way it delivered services as a consequence of feedback from patients.
  • The premises provided modern and clean facilities and were well-equipped to treat patients and meet their needs. The practice accommodated the needs of patients with disabilities, including access to the building through automatic doors.
  • The practice provided care for residents at two local care homes, and weekly visits were undertaken to each home by the advanced nurse practitioner. Any urgent requests for a consultation were undertaken within 24 hours by a GP.
  • Information about how to complain was available. Learning from complaints was shared with staff to improve the quality of service.
  • If patients at reception wished to talk confidentially, or became distressed, they were offered a more private area to ensure their privacy.
  • Flu clinics were made available on Saturday and on some evenings to improve access.

Well-led

Outstanding

Updated 11 October 2016

  • The partners had a strong commitment to delivering high quality care and promoting good outcomes for patients. The practice had a clear vision with quality and safety as its top priority.
  • There was a clear staffing structure in place. GPs and ANPs had lead roles providing a source of support and expert advice for their colleagues
  • Due to its location on the edge of the High Peak, hospital services were often quite remote for practice patients. The partners had created an independent provider service with two other GP practices which delivered some NHS out-patient services into the community, making these more accessible for local residents. This approach was supportive of the local CCG strategy for 21st century patient care.
  • The partners worked collaboratively other GP practices in their locality, and worked proactively with their CCG.
  • The partners reviewed comparative data provided by their CCG and ensured actions were implemented to address any areas of outlying performance.
  • Staff felt well-supported by management, and the practice held regular staff meetings.
  • The practice had developed a wide range of policies and procedures to govern activity.
  • The practice proactively sought feedback from patients, which it acted on to improve service delivery. The practice had an active Patient Participation Group (PPG). This group worked well with the practice, and made suggestions to improve services for patients.
  • High standards were promoted and owned by all practice staff who worked together effectively across all roles. There was a strong focus on continuous learning and improvement at all levels.
  • The practice used innovative measures to shape service delivery, and we saw a number of initiatives that had impacted positively upon patient care. For example, the work undertaken in relation to sepsis. Some of the schemes developed within the practice had been adopted across a wider area with an impact on both primary and secondary care.
  • The practice participated in research projects. For example, they were working with Nottingham University to research the needs and experiences of patients with dementia in rural areas.
Checks on specific services

People with long term conditions

Outstanding

Updated 11 October 2016

  • The practice achieved 99.98% for diabetes QOF related indicators, in line with the local average of 96.7% and above the national average of 89.2%. This was achieved with a marginally lower exception reporting rate at 11.8% (local 13.4%; national 10.8%).

  • The practice undertook annual reviews for patients on their long-term conditions registers. For example, 72% of patients with chronic obstructive airways disease (COPD) had received a review of their condition in the last 12 months.
  • QOF achievement for 2014-15 for asthma and atrial fibrillation were below the CCG and national averages. However, the practice was able to explain the lower achievement and had developed actions to enhance their performance.
  • The majority of diabetes care was provided in-house and this included the initiation of insulin. A weekly internal multi-disciplinary meeting reviewed complex patients with diabetes. Specialists were occasionally invited to the meeting for training purposes.
  • The practice had established a pre-diabetes register and had delivered a programme of support for these patients since March 2016. The aim of this nurse-led programme was to reduce the associated cardiovascular risk factors which could result from diabetes. For example, by educating patients regarding diet, the promotion of an active lifestyle, and the proactive self-management of their condition.

  • The partners contracted a community matron to plan and oversee the management of their most vulnerable patients, including those who were at risk of a hospital admission. A practice-employed care co-ordinator worked with other services and agencies to plan and deliver patient care, particularly for those patients being discharged following a hospital admission.
  • The practice provided a range of services on site for patients with a long-term condition. This included spirometry (to assess breathing difficulties); foot checks for patients with diabetes; and INR monitoring both at the surgery and in patients’ homes. INR testing measures the length of time taken for the blood to clot to ensure that patients taking particular medicines were kept safe.
  • A specialist respiratory nurse attended the practice each month to review patients with complex breathing difficulties.

Families, children and young people

Outstanding

Updated 11 October 2016

  • A GP led clinic for six week baby checks was provided at the surgery. This helped to identify any concerns with the baby and to promote the child immunisation programme. It also provided an opportunity to review the parents for issues such as post-natal depression. The midwife held an ante-natal clinic on site every week.
  • Childhood immunisation rates were high with rates for the vaccinations given to children at five years of age ranging from 96% to 100% (local average 96.5% to 99.1%).
  • The health visitor attended a meeting with the lead GP for child safeguarding once a month to discuss any child safeguarding concerns. Child protection alerts were used on the clinical system to ensure clinicians were able to actively monitor any concerns.
  • Appointments were available outside of school hours.
  • Requests for child consultations were prioritised. Telephone advice was offered to parents when required.
  • There was an established teenager clinic which provided support on issues such as sexual health, healthy eating, and psychological concerns.
  • Family planning services were provided to fit and remove intrauterine devices (coils) and implants, and advice and support was available for all aspects of contraception.
  • The practice had baby changing facilities, and provided a low table and chairs with toys for younger children. The practice welcomed mothers who wished to breastfeed on site.

Older people

Outstanding

Updated 11 October 2016

  • The practice had developed a number of in-house services to prevent older patients from travelling to hospitals which were located some miles away with infrequent local public transport provision. The services included blood tests, 24 hour blood pressure and ECG monitoring, and hearing tests. In addition, some NHS out-patient clinics were held in a nearby town including rheumatology and gynaecology, through an independent initiative developed by the practice and two other local GP practices.
  • The practice contracted a community matron who managed a ‘virtual ward’ of vulnerable older patients with the aim of supporting these patients to be cared for in their own homes, and to avoid unnecessary admissions into hospital.

  • The practice worked closely with the wider health and care teams to plan and the co-ordinate care to best meet their patients’ needs.
  • Longer appointment times were available and home visits were available for those unable to attend the surgery.
  • An advanced nurse practitioner undertook weekly visits to two local care homes for older patients, one of which specialised in the care of dementia.
  • Uptake of the flu vaccination for patients aged over 65 was 69% which was in line with local (73.9%) and national (70.5%) averages.

Working age people (including those recently retired and students)

Outstanding

Updated 11 October 2016

  • The practice offered on-line booking for appointments and requests for repeat prescriptions. The practice provided electronic prescribing so that patients on repeat medicines could collect them directly from their preferred pharmacy.
  • Extended hours’ GP consultations were available at the main site. Early morning and evening appointments were available as a commuter clinic on one day each week to accommodate the needs of working people.
  • Clinics for patients with diabetes were held three times each week, including one evening to provide more flexibility for working patients.
  • The practice promoted health screening programmes to keep patients safe. Although performance for cervical and breast screening was slightly lower than average figures, the practice was able to explain this and describe how this was being addressed,
  • The practice offered health checks for new patients and NHS health checks for patients aged 40-74.
  • The practice held a ‘Fit and Trim Club’ for weight management run by an experienced practice nurse.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 11 October 2016

  • The practice achieved 99.4% for mental health related indicators in QOF, which was 1.3% above the CCG and 6.6% above the national averages, with exception reporting rates generally in line with averages.
  • 96.2% of patients with poor mental health had a documented care plan during 2014-15. This was 2.9% higher than the CCG average and 7.9% higher than the national average, although exception reporting rates were higher.
  • The practice provided access to a cognitive behavioural therapist twice a week at the main site, and once a week at their branch. CBT is a technique used to empower patients to resolve problems by changing their thinking and behaviours.
  • The practice had a lead GP for mental health. The practice had established good links with the mental health care team and crisis team. A community psychiatric nurse (CPN) attended the multi-disciplinary meetings on approximately a monthly basis to review and discuss any patients with ongoing mental health needs.
  • Appointments were available on the day for patients experiencing acute mental health difficulties.
  • 84.1% of people diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months. This was in line with local and national averages, although the practice had achieved slightly lower exception reporting rates.
  • A visiting consultant specialising in older age psychiatry provided memory clinics at the practice once a fortnight. In addition, patients could see an Adult Psychiatrist at the health centre, sited opposite the surgery
  • The practice undertook a significant event review in the event of a mental health-related death, or on cases which were deemed appropriate in terms of any lessons learnt.

People whose circumstances may make them vulnerable

Outstanding

Updated 11 October 2016

  • The practice had searched their clinical system to check for patients who had not been seen by the practice for some time, and reviewed their status. This led to the identification of some vulnerable patients who required support and care planning to keep them safe and well. For example, a patient with learning disability who was managing alone following the death of their carer.
  • The practice had undertaken an annual health review in the last 12 months for 32% of patients with a learning disability. The practice had identified the reasons for this comparatively low achievement and had a plan of action to address this.
  • Longer appointments and home visits were offered to vulnerable patients when required. For example, patients with a learning disability might be seen in their home or at a day centre, if attendance at the practice caused them anxiety.
  • The practice provided high quality end of life care. Patients with palliative care needs were reviewed at weekly multi-disciplinary team meetings, and had supporting care plans in place. Community nursing staff informed us that the GPs were caring and highly responsive to these patients, and ensured that any needs were acted upon promptly.
  • Clinicians attended case conferences and vulnerable adults’ review meetings to discuss their most vulnerable patients. We were provided with an example of how vulnerable patients who smoked were at risk from a potential fire. This led to joint working with the local fire service and the installation of sprinkler systems in vulnerable patients’ homes.
  • Staff had received adult safeguarding training and were aware how to report any concerns relating to vulnerable patients. There was a designated lead GP for adult safeguarding.
  • The practice staff had received training from the Alzheimer’s Society to become ‘Dementia Friends’. This had initiated a successful ‘tea dance’ event at the end of 2015 attended by patients with dementia and their carers. Over 70 people attended this successful event, which provided excellent support for carers. There were plans to repeat this in the future.