You are here

Kilburn Park Medical Centre Good

Inspection Summary


Overall summary & rating

Good

Updated 30 March 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at 8.30am on 16 February 2016. Overall the practice is rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.
  • Risks to patients were assessed, however they were not in all instances well managed.
  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand.
  • Patients said there was continuity of care, with routine and urgent appointments available the same day. However, patients reported that it was difficult to get through on the phone and therefore had to come in to the practice in order to get same day appointments.In addition appointments with a preferred GP could take up to three weeks.
  • The practice facilities were clean and equipped to treat patients and meet their needs, however the premises was in need of repair/upgrade.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the Duty of Candour.

The areas where the provider must make improvements are:

  • Implement the recommendations from the legionella risk assessment (Legionella is a term for a particular bacterium which can contaminate water systems in buildings).
  • Complete the infection control audit started in December 2015.
  • Take appropriate steps to assure the risk of fire evacuation is assessed.

In addition the provider should:

  • Improve telephone access to appointments.
  • Take action to improve Quality Outcomes and Framework (QOF) exception reporting rate.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 3 October 2016

The practice is rated as good for providing safe services as improvements had been made in relation to assessing, monitoring, managing and mitigating risks to the health and safety of service users.

Effective

Good

Updated 30 March 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework showed patient outcomes were above average for the locality and compared to the national average. However, QOF exception reporting was high at 21.2%.

  • Staff assessed needs and delivered care in line with current evidence based guidance.

  • Clinical audits demonstrated quality improvement.

  • 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, however not all mandatory training had been completed.

  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs.

Caring

Good

Updated 30 March 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.

Responsive

Good

Updated 30 March 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified.

  • Patients said there was continuity of care, with routine and urgent appointments available the same day. However, patients reported that it was difficult to get through on the phone and therefore had to come in to the practice in order to get same day appointments. In addition appointments with a preferred GP could take up to three weeks.

  • The practice facilities were clean and equipped to treat patients and meet their needs, however the premises was in need of repair/upgrade.

  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff.

Well-led

Good

Updated 30 March 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 this.

  • 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 proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.

  • There was a focus on continuous learning and improvement at all levels.

Checks on specific services

People with long term conditions

Requires improvement

Updated 30 March 2016

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

  • QOF (Quality and Outcomes Framework) performance for diabetes related indicators was 97.7% which was above both local and national averages. However, QOF exception reporting for diabetes was high at 33% (CCG average 9% and national average 11%).

  • QOF performance for hypertension related indicators was 100% which was above both local and national averages. However, QOF exception reporting for hypertension was high at 9% (CCG/national averages 4%).

  • QOF performance for cardiovascular disease – primary prevention was 100% which was above both local and national averages. However, QOF exception reporting was high at 67% (CCG average 28% and national average 30%).

  • A GP with a special interest in diabetes, the practice nurse and a specialist diabetic nurse worked together to provide a weekly diabetic clinic.

  • 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 30 March 2016

The practice is rated as good for the care of families, children and young people.

  • Immunisation rates were comparable to other practices for all standard childhood immunisations.

  • The percentage of patients diagnosed with asthma, on the register, who had an asthma review in the last 12 months was 72.1% compared to the national average of 75.3%.

  • Patients told us that children and young people were treated in an age-appropriate way.

  • The practice’s uptake for the cervical screening programme was 78%, which was similar to the national average of 82%. However, QOF exception reporting was high at 22% (CCG average 8%, national average 6%).

  • Appointments were available outside of school hours and the premises were suitable for children and babies.

Older people

Good

Updated 30 March 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 responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.

  • Since 2014 the practice had consistently exceeded targets for care planning set by NHS England and the local network.

Working age people (including those recently retired and students)

Good

Updated 30 March 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.

  • The practice offered online services as well as a full range of health promotion and screening that reflects the needs for this age group.

People experiencing poor mental health (including people with dementia)

Good

Updated 30 March 2016

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

  • 88.5% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which was better than the national average of 84%.

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

  • The practice carried out 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.

  • All 124 patients on the mental health register received annual health checks.

People whose circumstances may make them vulnerable

Good

Updated 30 March 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 homeless people and those with a learning disability.

  • The practice offered longer appointments for patients with a learning disability.

  • The practice had 36 patients on the learning disabilities register all of which had received annual health checks.

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

  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations.

  • The practice ran a methadone clinic in collaboration with local substance misuse services.

  • The practice provided care for a local hostel which housed vulnerable patients.

  • 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.