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Inspection carried out on 20 Feb to 20 Feb 2020

During an inspection looking at part of the service

We undertook an inspection of this service on 20 February 2020. At our previous inspection in March 2019, we rated the practice as good overall and requires improvement for providing safe services. We issued the practice with a breach of regulation 17 (good governance). This inspection was to follow up on the breach of regulation identified at our previous inspection in March 2019 and we looked at the safe key question only.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.

At the previous inspection, we rated the practice as requires improvement for providing safe services because:

  • We found out of date medicines in the emergency medicine kit. The practice did not stock atropine, an emergency medicine recommended for practices that fit coils. At all sites, the practice kept glucagon in the emergency kit; it was not refrigerated, and the date of when it was taken out of the fridge was not recorded, nor was the new expiry date. After the inspection, the practice sent an updated protocol for the management of the emergency kit.

At this inspection, we rated the practice as good for providing safe services and found these issues had been rectified.

We have rated this practice as good overall.

At this inspection we found that the provider was proving safe services because:

  • The emergency medicines stocked in the practice were appropriate and within their expiry date. Where medicines were not stocked, there was an appropriate risk assessment in place.

In addition, we found that the practice had made improvement to areas identified at our last inspection where the practice should make improvements:

  • The practice had improved their Quality and Outcomes Framework (QOF) achievement and were in line with averages for indicators relating to diabetes, chronic obstructive pulmonary disease (COPD) and mental health. We viewed data for 2019/20 and found the practice was on a positive trajectory.

  • The practice had identified 151 patients with a learning disability. The practice had two named learning disability lead nurses and offered double appointments for reviews. An annual review had been completed for 82 patients. We saw that 10 patients were booked in for a review and 31 patients had declined a review. The practice was in the process of contacting the other patients. Where patients had declined a review, the practice liaised with the learning disabilities team to ensure the team were aware of these patients. They had also contacted a local learning disabilities nurse to give training to staff and raise awareness of the needs of these patients. They had worked with a local hospital to flag any patients that had not attended for cancer screening and reviewed these patients. The practice had a service development group, including members of staff from all groups and the patient participation group (PPG), and had invited a learning disabilities charity to attend the group to give advice on the management of patients with autism. They were in the process of advertising “quiet hours” for a local supermarket on their website, for patients who may benefit from this.

  • The practice had recognised and prioritised carers and their health and wellbeing within their population group. The practice had drafted a declaration on how to identify and support carers which was in line with NHS England quality markers and best practice. This had been devised in the service development group with the patient participation group and the carers lead from the local hospital for a full multidisciplinary team approach. The practice had invited representatives from local young and older carers charities to join the Practice Carers Group and representatives were due to attend the next meeting. The practice had designed a poster to inform patients on what defines a carer and ensured patients had access to a carers’ handbook. They had identified 800 patients as carers (3.2% of the practice population), which was a marked improvement from our last inspection where the practice had identified 71 patients as carers. The practice had achieved this with a whole team approach, changing their registration forms and updating clinical templates to remind clinicians to ask patients if they were a carer. The practice told us they had reviewed the list and had removed 32 patients as they were no longer carers and strived to ensure the list was accurate. The practice had set up carers health checks and had offered 50 of these to patients and had also administered 298 flu vaccines to carers. The practice had identified 10 young carers and worked with the local young carers charity representative to offer them care and support. The practice had a team approach to managing carers and had a carers champion in place and a lead GP for carers. There was a board in reception for carers including posters and carers information and the website linked to national carers websites. In conjunction with the PPG, the practice were setting up events for national carers week and were planning a regular carers support group. Carer awareness was also included in the practice induction and was part of all staff training. The practice also had a carers employment policy to support any staff with caring responsibilities.

Details of our findings and the evidence supporting our ratings are set out in the evidence table.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of General Practice

Inspection carried out on 04 Mar to 04 Mar

During a routine inspection

We carried out an announced comprehensive inspection at Newtown Surgery on 4 March 2019 as part of our inspection programme. Our inspection team was led by a CQC inspector and included a GP specialist advisor and a practice manager specialist advisor.

We previously inspected the practice in October 2014 and rated the practice as good overall and outstanding for providing well-led services.

Our judgement of the quality of care at this service is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information from the provider, patients, the public and other organisations.

I have rated this practice as good overall and requires improvement for providing safe services.

This means that:

  • People were generally protected from avoidable harm and abuse and that legal requirements were met.
  • Patients had good outcomes because they received effective care and treatment that met their needs.
  • The practice was fully engaged with reviewing and monitoring the clinical service they offered and used this information to make changes and improvements in care. For example, the practice regularly reviewed data from the Clinical Commissioning Group and used this to drive improvement within the practice.
  • Patients were supported, treated with dignity and respect and were involved as partners in their care.
  • People’s needs were met by the way in which services were organised and delivered. For example, the practice had engaged with the local food bank charity and completed several health events.
  • The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
  • The practice encouraged continuous improvement and innovation. For example, the practice had a diverse skill mix within the practice and encouraged staff to undertake further education such as nurses undertaking prescribing courses and phlebotomists training to become a Health Care Assistant.
  • Staff reported they were proud to work within the practice.

We rated the practice as requires improvement for providing safe services because:

We found out of date medicines in the emergency medicine kit. The practice did not stock atropine, an emergency medicine recommended for practices that fit coils. At all sites, the practice kept glucogon in the emergency kit; it was not refrigerated, and the date of when it was taken out of the fridge was not recorded, nor was the new expiry date. After the inspection, the practice sent an updated protocol for the management of the emergency kit.

We rated the practice as outstanding for providing effective services for older people because:

  • The practice had led a pilot to identify and care for older patients at risk of rapid decline or crisis. A multidisciplinary team meeting (MDT) was held weekly to discuss patients and support required and included a lead GP, a community matron, social services care co-ordinator and a social isolation link worker. In the first four months, 37 patients were referred, 14 received support, 13 were still receiving support, nine were being assessed and one patient was declined. The pilot had been extended to another local practice.
  • Each care home had a named GP who was supported by a paramedic which had enabled to the practice to respond to urgent need in a timely manner and the practice told us this had helped reduce admissions to hospital from 64 in 2017/18 to 33 in 2018/19.

We rated the practice as outstanding for providing responsive care for people whose circumstances make them vulnerable because:

  • The practice had a Homeless Care Service, which included an outreach service at the Salvation Army, street work and multidisciplinary team working based from the local housing trust. Services included immediate access for homeless patients. The practice had 81 homeless patients on their practice list. The practice had helped to find housing for 20 patients and were working with agencies to get a further 18 re-housed. Some of these patients were in prison, however the practice kept them on their list to actively follow up once released. The practice held regular events to gain money for ‘kip bags’ which included items such as sleeping bags and a toothbrush and had purchased 22 of these for the Salvation Army. The practice had a system whereby if a patient presented as homeless, a member of staff was allocated to fully assess their needs and signpost them to a clinician if required, offer food vouchers and assist with emergency accommodation and housing needs.
  • The practice had established in-house Hepatitis C clinics and TB clinics which were also open to patients outside of the practice list. For the Hepatitis C clinic, 28 patients had attended, 18 of which had been discussed at a specialist meeting, ten had been started on treatment and six had finished treatment. The remaining patients were awaiting starting treatment or had not engaged.
  • The practice held a Christmas Stocking campaign where patients and staff brought toys for children and essential items for people in need. The practice originally donated 200 stockings and due to the success, were able to fill another 250.
  • The practice held a ‘start my week’ campaign which identified 12 people over the age of 50 who did not belong to an activity or group to make friends and become more active. The outcomes were positive for patients recently bereaved, carers and visually impaired patients joining groups. The practice facilitated this by visiting the local library with the group to identify groups in the local areas, such as walking football, crafts, singing groups and others.

We saw another area of outstanding practice:

  • The practice had life connectors at each site who were able to refer patients to local charities, groups and external agencies. The practice had 140 agencies they could refer to. The practice had run a pilot for this role which was successful and had been rolled out across the CCG and recognised nationally. The practice were able to give examples where this had been positive in securing housing, reducing emergency calls and reducing social isolation for patients.

We found the provider must:

  • Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We found the provider should:

  • Review the system for coding carers and the support provided to them.
  • Continue to embed the plan to improve outcomes relating to the Quality and Outcomes Framework, particularly for outcomes relating to diabetes, COPD and mental health.
  • Embed the action plan to improve the uptake of health checks for patients with a learning disability.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of General Practice

Inspection carried out on 7 October 2014

During a routine inspection

Letter from the Chief Inspector of General Practice

East Norfolk Medical Practice has a practice population of approximately 12200 patients.

We carried out a comprehensive inspection at Newtown Surgery on 7 October 2014.

We have rated each section of our findings for each key area. We found that the practice provided a safe, effective, caring, responsive and well led service for the population it served. The overall rating was good and this was because improvements had been made that had a positive impact on patient care.

Our key findings were as follows:

  • We found evidence that the practice staff worked together to make on-going improvements for the benefit of patients.

  • Each day there was an assigned duty doctor and a doctor on call to respond to any unexpected peaks in patient’s requests to be seen. The feedback we received from patients informed us they could get appointments when they needed to.

  • The practice was able to demonstrate a good track record for safety. Effective systems were in place for reporting safety incidents. Untoward incidents were investigated and where possible improvements made to prevent similar occurrences.

  • We found that patients were treated with respect and their privacy was maintained. Patients informed us they were satisfied with the care they received.

We saw several areas of outstanding practice including:

  • In April 2014 practice staff established the ‘Service Development Group’ Committee. The group consists of staff from each grade within the practice and external professionals. The purpose of the group was to implement changes that affect more than one staff grade. The meetings take place monthly and we saw they had investigated and made changes to the way that patients obtain their repeat prescriptions and how patients were informed about urine test results.

  • The nurse practitioner offered open access by mobile phone to teenagers who were insulin dependent diabetics. They were able to text their blood test results if they had any concerns about management of their diabetes and the nurse practitioner would respond.

  • A recent restructuring of management and administration staff resulted in more clinical time to invest in patient care. The staff skill mix was closely monitored. Clinical staff roles were analysed to ensure work and responsibilities were evenly distributed. If clinic sessions run late the cause is investigated and changes made to prevent future delays for patients.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice