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Inspection Summary


Overall summary & rating

Good

Updated 28 October 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Crescent Surgery on 16 August 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. There was an open and transparent approach to safety and a system in place for reporting and recording significant events. However, discussions of these events were not always documented and the practice did not always make whole system changes or systematically review actions taken.
  • Feedback from patients about their care was consistently positive. All of the patient comment cards that we received praised the practice and said that staff were kind and professional.
  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs. They offered a bookable treatment room service every day that was shared with the neighbouring practice and the community district nursing service.
  • The information needed to plan and deliver care and treatment was available to staff through the practice’s patient information system, however, not all written communication was seen by the GPs or senior clinical staff as would be expected.
  • 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, they had introduced a same day clinic for minor ailments that was run every day by the nurse practitioners.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. The GP partners, together with the neighbouring practice partners had invested in extending the property, aided by National Health Service funding and building work was underway at the time of our inspection.
  • 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.
  • The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.
  • The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw several areas of outstanding practice:

  • The practice employed a qualified nurse as a care co-ordinator who contacted all patients who had been discharged from hospital, providing a home visit and full assessment if necessary. This had achieved a reduction of 22% in unplanned admissions to hospital in the year prior to June 2016. The clinical commissioning group (CCG) adopted this model of care for other practices for 2016-2017.
  • The practice proactively identified any patients who were over 75 years of age and had not been seen in the practice for healthcare within the last year. They reviewed the needs of these patients and invited them for a health assessment.
  • The practice had purchased a light box to facilitate staff training and hand hygiene. (A light box enables staff to identify poor hand hygiene practices).
  • The practice had recognised patient difficulties in accessing appointments and had introduced an open clinic for patients with minor ailments every day from 8.30am to 11.30am run by nurse practitioners. Patients told us that they thought this was an excellent service. We were told that the practice planned to introduce an open clinic at a later time for working patients.
  • The practice had identified 404 patients as carers (4.7% of the practice list) and had been recognised as carer friendly by the local carers’ network organisation. That organisation also held a weekly clinic for carers in the practice.

However there were areas of practice where the provider should make improvements:

  • The practice should put systems in place so that all items of communication received by the practice were seen by the GPs or senior clinical staff before being filed.
  • Discussions of significant events should be recorded and actions identified by significant event reports should be put in place and checked to be effective.


Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 28 October 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events. However, the practice did not always make whole system changes or systematically review actions taken. Lessons were shared to make sure action was taken to improve safety in the practice although these discussions were not always recorded.
  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.
  • Risks to patients were assessed and well managed. The practice had purchased a light box to facilitate staff training and hand hygiene. (A light box enables staff to identify poor hand hygiene practices).

Effective

Good

Updated 28 October 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were above average compared to local and national averages. The practice had achieved 100% of points available and exception reporting was 7.8%, which was low compared to the local clinical commissioning group (CCG) figure of 11.3% and national average of 9.2%. (Exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects). We saw QOF results for 2015/16 which showed that the practice had also achieved 100% of the total number of points available although these figures had not been validated at the time of our inspection.

  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement. We saw evidence that the practice had made improvements to prescribing since the employment of the practice pharmacist in April 2016.
  • 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.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
  • The practice used innovative and proactive methods to improve patient outcomes and was working with other local providers to share best practice.
  • The information needed to plan and deliver care and treatment was generally available to relevant staff in a timely and accessible way. However, the practice did not have a thorough system for dealing with all communication received. Not all written communication was seen by a GP or senior clinical staff as would be expected.

Caring

Good

Updated 28 October 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 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.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
  • The practice had identified 404 patients as carers (4.7% of the practice list) and a local carers’ network organisation held a weekly clinic for carers in the practice. That organisation had recognised the practice as carer friendly.

Responsive

Outstanding

Updated 28 October 2016

The practice is rated as outstanding for providing responsive services.

  • 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. They offered a treatment room service for patients every day that was shared with the neighbouring practice and the community district nursing service.
  • The practice was working on a new project to provide patients suffering from dementia with small devices that could provide information should the patient be found wandering, to enable them to return home.
  • The practice had arranged a later collection for blood samples during its commuter clinics with a local charitable organisation.
  • 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. They had introduced an open clinic for patients with minor ailments every day from 8.30am to 11.30am run by nurse practitioners. Patients told us that they thought this was an excellent service.
  • The practice employed a full-time care co-ordinator nurse who contacted patients when they were discharged from hospital. The nurse liaised with practice GPs, the pharmacist and other clinical staff and community and health and well-being services to ensure that patient care was co-ordinated. A home visit was arranged if necessary to conduct a full assessment of patient needs. We saw evidence that patient emergency admissions to hospital had been reduced from 179 in the year prior to June 2015, to 139 in the year prior to June 2016, a reduction of 22%. The CCG had adopted this model of care for other practices to put in place during 2016-2017.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. The GP partners, together with the neighbouring practice partners had invested in further extending the property, aided by National Health Service funding.
  • 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

Good

Updated 28 October 2016

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. Staff were clear about the vision and their responsibilities in relation to it.
  • 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. This included arrangements to monitor and improve quality and identify risk.
  • 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.
  • 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. One of the practice nurse practitioners participated in research projects.
Checks on specific services

People with long term conditions

Good

Updated 28 October 2016

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

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. The practice had reduced the emergency admissions of patients suffering from chronic obstructive pulmonary disease (a respiratory disease) from 32 in the year prior to June 2015, to 17 in the year prior to June 2016, a reduction of 53%.
  • Performance for diabetes related indicators was better than the local and national averages. For example, blood measurements for diabetic patients showed that 85% of patients had well controlled blood sugar levels compared with the CCG average of 83% and national average of 78%. Also, the percentage of patients with blood pressure readings within recommended levels was 87% compared to the CCG average of 84% and national average of 78%.
  • Two of the nurse practitioners were trained to initiate insulin for diabetic patients thus ensuring that only patients with the most complex needs were referred to hospital services.
  • Longer appointments and home visits were available when needed.
  • All these patients 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.

Families, children and young people

Good

Updated 28 October 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 people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.
  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.
  • The practice’s uptake for the cervical screening programme was 92%, which was higher than the CCG average of 81% and the national average of 82%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • Due to changes in the community health visiting service, the practice started to send its own congratulations card to all new mothers to congratulate them and provide details of available services and how to access them.
  • The practice offered a nurse-led contraception service. They had increased the uptake of some contraceptive methods in the practice and had reduced patient waiting times and increased GP appointment availability. The practice nurse also offered sexual health services to patients during the practice extended opening hours.
  • We saw positive examples of joint working with midwives, health visitors and school nurses.

Older people

Outstanding

Updated 28 October 2016

The practice is rated as outstanding 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 responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • A charity providing memory screening for patients held clinics every fortnight in the practice and patients were able to self-refer to these clinics as required.
  • The practice had identified that 17 out of 1350 patients who were over 75 years of age had not been seen in the practice for healthcare within the last year. They reviewed the needs of these 17 patients and invited them for a health assessment.
  • The practice had identified 404 patients as carers (4.7% of the practice list) and had been recognised as carer friendly by the local carers’ network organisation. That organisation also held a weekly clinic for carers in the practice.

Working age people (including those recently retired and students)

Good

Updated 28 October 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, 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.
  • There were appointments offered outside of normal working hours on Mondays and Thursdays.
  • Telephone appointments were also available for patients who needed advice but were unable to attend the surgery.
  • 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. We saw that online appointments were available for all GPs.

People experiencing poor mental health (including people with dementia)

Good

Updated 28 October 2016

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

  • The practice had a high percentage of patients with dementia and they worked with the neighbouring practice to provide better care for these patients. They were working on a new project promoted by the local police early action team to provide patients suffering from dementia with small devices that could provide information should the patient be found wandering, to enable them to return home.
  • 97% of patients diagnosed with dementia had their care reviewed in a face to face meeting in the last 12 months, which was better than the local average of 85% and national average of 84%.
  • 92% of people experiencing poor mental health had a comprehensive, agreed care plan documented in the record compared to the local average of 93% and national average of 88%.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice carried out advance care planning for patients 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.

People whose circumstances may make them vulnerable

Outstanding

Updated 28 October 2016

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

  • The practice held a register of patients living in vulnerable circumstances including those with a learning disability and those receiving end of life care. The practice prioritised the needs of patients who were experiencing end of life care. They ensured that they had identified all patients in need of these services and had increased the register of patients in need of palliative care from 26 patients in March 2013 to 94 patients at the time of inspection. They discussed patient place of death at palliative care meetings to identify any learning points. The practice had also run an education meeting at the local hospice for care home staff.
  • The practice employed a full-time care co-ordinator nurse who contacted patients when they were discharged from hospital. The nurse liaised with practice GPs, the pharmacist and other clinical staff and community and health and well-being services to ensure that patient care was co-ordinated. A home visit was arranged if necessary to conduct a full assessment of patient needs. A personalised care plan was completed for all these patients. The practice had achieved a reduction of 22% in unplanned hospital admissions for these patients in the year up to June 2016.

  • The practice offered longer appointments for patients with a learning disability.
  • The practice regularly worked with other health care professionals in the case management of vulnerable 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.