You are here

Enderley Road Medical Centre Good

Inspection Summary


Overall summary & rating

Good

Updated 8 November 2018

We carried out an announced comprehensive inspection at Enderley Road Medical Centre on 20 July 2017. The overall rating for the practice was good. The practice was rated as requires improvement for providing safe services as the practice had not taken action on a number of areas related to safety within the practice environment. The full comprehensive report on the July 2017 inspection can be found by selecting the ‘all reports’ link for Enderley Road Medical Centre on our website at www.cqc.org.uk.

This inspection was an announced comprehensive inspection carried out on 18 September 2018 to confirm that the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulations that we identified in our previous inspection on 20 July 2017. This report covers our findings in relation to those requirements and also additional improvements made since our last inspection.

The practice is now rated as good for providing safe services. Overall the practice remains rated as good.

The key questions at this inspection are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Good

At this inspection we found:

  • Since our last inspection the practice had taken action to improve safety of the environment and for patients and staff. There were clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.
  • The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence-based guidelines.
  • Staff involved and treated patients with compassion, kindness, dignity and respect.
  • Some patients reported difficulty accessing the practice by telephone. The practice had reviewed this feedback and were taking action to improve telephone access. Other feedback from patients relating to their experience during consultations was positive.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

We saw an area of outstanding practice:

  • Unverified practice data showed the practice’s catchment area of patients in Wealdstone was one of the highest sources of new referrals to children’s services. The practice proactively contacted social services every two weeks to receive an update on patients on the safeguarding register. We were told this was to ensure safety given the transient population.

The areas where the provider should make improvements are:

  • Review and improve the system for documenting staff annual appraisals.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Safe

Good

Updated 8 November 2018

At our previous inspection on 20 July 2017, we rated the practice as requires improvement for providing safe services as the practice had not taken remedial action following a legionella risk assessment, there was some lack of clarity over which member of staff was the infection prevention and control lead and who the fire marshals were, there was no evidence of action taken when vaccine fridge temperatures exceeded the required range, there were gaps in records for emergency lighting checks, the outcome of fire evacuation drills had not been recorded, staff had not received updated fire safety training, the electrical safety check of the premises was overdue, there was no CO2 monitor by a boiler in the staff toilet, there was a lack of appropriate signage for the storage of nitrogen and oxygen, and the business continuity plan did not set out arrangements in the event of the premises being inoperative and a copy was not stored off-site.

These arrangements had significantly improved when we undertook a comprehensive inspection on 18 September 2018. The practice is now rated as good for providing safe services.

Safety systems and processes

The practice had clear systems to keep people safe and safeguarded from abuse.

  • The practice had appropriate systems to safeguard children and vulnerable adults from abuse. All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Learning from safeguarding incidents were available to staff. Staff who acted as chaperones were trained for their role and had received a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable.)
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, discrimination and breaches of their dignity and respect.
  • The practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control. Since our last inspection, action had been taken in response to the most recent legionella risk assessment carried out in 2018. Staff were also aware of who the infection prevention and control lead was.
  • The practice had arrangements to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

There were adequate systems to assess, monitor and manage risks to patient safety.

  • Arrangements were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, including planning for holidays, sickness, busy periods and epidemics.
  • There was an effective induction system for staff tailored to their role.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures. Since our last inspection, all staff now underwent annual basic life support training and the practice had updated their business continuity plan to include arrangements in the event of the premises being inoperative. The business continuity plan had been sent to all staff so it could be accessed off-site.
  • Staff understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians knew how to identify and manage patients with severe infections including sepsis.
  • When there were changes to services or staff the practice assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

The practice had reliable systems for appropriate and safe handling of medicines.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks. Since our last inspection, the practice had implemented a new electronic system to monitor the three vaccine fridge temperatures and the protocol in the event of a breach in the required temperatures was kept by the fridges.
  • Staff prescribed, administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. We reviewed prescribing data and found the practice performed in line with local and national averages except for non-first line antibiotics (co-amoxiclav, cephalosporins and quinolones) where prescribing was above local and national averages. We were told a contributing factor for this was the management of patients with complex conditions from local nursing homes. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.
  • Prescription paper was stored securely. Prescription paper was logged when taken out of the practice for home visits. However, there was no monitoring when they were distributed in the practice. Following our inspection, the practice sent us a template they had implemented to monitor prescription paper distributed in the practice.

Track record on safety

The practice had a good track record on safety.

  • There were comprehensive risk assessments in relation to safety issues.
  • The practice monitored and reviewed safety using information from a range of sources.
  • Since our last inspection, staff had received updated fire safety training and were aware of who the fire marshals were, the practice consistently recorded the outcome of fire drills and emergency lighting checks, an electrical check of the premises had also been undertaken, there was appropriate signage for the storage of nitrogen and oxygen, and a CO2 monitor for the boiler in the staff toilet was in use.

Lessons learned and improvements made

The practice learned and made improvements when things went wrong.

  • Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts.

Please refer to the evidence tables for further information.

Effective

Good

Updated 8 November 2018

We rated the practice and all of the population groups as good for providing effective services overall.

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.
  • The practice used online technology to support patients’ independence. For example, the new website allowed for patients to complete health reviews and assessments which were sent electronically to the practice for monitoring or in preparation for an appointment.

Older people:

  • The practice had a higher percentage of patients aged 75 and over (9%) when compared with the local average (7%).
  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs. These visits were carried out by the GPs or enhanced practice nurses.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

  • The practice offered dedicated clinics for diabetes, COPD, and asthma.
  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention. People with suspected hypertension were offered ambulatory blood pressure monitoring and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • The practice was able to demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension. There was a register of patients at risk of diabetes, and they were recalled annually and could be referred to a diabetes prevention programme.
  • The practice had a higher prevalence of diabetes (10%) when compared to the national average (7%). Joint clinics with a diabetic specialist nurse were available in-house and patients could be referred to expert diabetes education and exercise schemes.
  • Nurse-led clinics were offered for asthma, diabetes and INR monitoring.
  • The practice’s performance on quality indicators for long term conditions was in line with local and national averages.

Families, children and young people:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates for vaccines given were below the target percentage of 90% (2016/17 data). The practice was trying to improve uptake rates by offering appointments out of school hours, identifying gaps in immunisation history for newly registered children, and offering immunisation information leaflets in languages relevant to the patient population.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment for immunisation. For example, a nurse would contact the family by telephone to rebook the appointment.
  • Family planning services such as intrauterine contraceptive device (IUCD) insertions and implant fitting were available.

Working age people (including those recently retired and students):

  • The practice’s uptake for cervical screening was 61%, which was below the 80% coverage target for the national screening programme. We were told the patient demographic, where there was a wide ethnic mix and high turnover of patients, had contributed to low uptake rates. To engage these patients the practice carried out opportunistic reminders during consultations and at reception, offered appointments at different times including during the commuter clinic, ensured a female sample taker was available, text message reminders for non-responders, and displaying health promotion material in the waiting area.
  • The practice’s uptake for breast and bowel cancer screening was comparable to the national average.

  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • Patients had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.
  • The practice held a register of patients living in vulnerable circumstances including homeless people and those with a learning disability.
  • The practice cared for residents in two large nursing homes (approx. 75 - 94 beds each). Both homes received biweekly ward rounds with two dedicated GPs. One of the homes looked after high dependency residents with complex care needs including brain injuries, tracheostomies, peg feeding and severe learning disabilities. Unverified practice data showed 1.4% of the practice population were in a nursing home.
  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.

People experiencing poor mental health (including people with dementia):

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness, and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • The practice offered annual health checks to patients with a learning disability.
  • The practice worked with hospital and community mental health teams to support people experiencing poor mental health.
  • The practices performance on quality indicators for mental health was in line with local and national averages.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • The most recent published QOF results (2016/17) were 100% of the total number of points available compared with the clinical commissioning group (CCG) and national average of 96%.
  • Overall exception reporting was 8% (CCG average 5%; national 6%) and clinical exception reporting was 12% (CCG average 7%; national 10%). (Exception reporting is the removal of patients from QOF calculations where, for example, the patients decline or do not respond to invitations to attend a review of their condition or when a medicine is not appropriate). Unverified practice data for 2017/18 showed clinical exception reporting was 11% and exception rates had improved in some areas. The practice was aware that they had higher than average exception rates for some clinical domains and checked annually whether exemptions were appropriate. We were also told that many patients from the nursing homes were not appropriate for QOF reporting due to their conditions.
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation. However, ‘agreed action points’ for the year ahead had not been completed on the staff appraisals we reviewed.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.
  • We received feedback from other health and social care professionals (health visitor, clinical specialist nurse, and nursing home manager) that was positive. Practice staff were complimented for their partnership working, accessibility and communication.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes and in-house access to an automated blood pressure machine for self-monitoring. The practice also promoted weekly walks in the local area which commenced outside the practice.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns and tackling obesity. Smoking cessation clinics were available in-house.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.

Please refer to the evidence tables for further information.

Caring

Good

Updated 8 November 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The practices GP patient survey results were in line with local and national averages for questions relating to kindness, respect and compassion.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given).

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice identified carers and supported them.
  • The practices GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues or appeared distressed reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.

Responsive

Good

Updated 8 November 2018

We rated the practice, and all of the population groups, as good for providing responsive services.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs. For example, there were walk-in flu vaccination clinics for eligible patients.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were appropriate for the services delivered.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs.
  • There was a medicines delivery service, organised by pharmacies, for housebound patients.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with a multidisciplinary team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • We found there were systems 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 accident and emergency (A&E) attendances.
  • Unverified practice data showed the practice’s catchment area of patients in Wealdstone was one of the highest sources of new referrals to children’s services. The practice proactively contacted social services every two weeks to receive an update on patients on the safeguarding register. We were told this was to ensure safety given the transient population.
  • All parents or guardians calling with concerns about a child under the age of five were offered a same day appointment when necessary.
  • A phlebotomy service was available for all children over the age of two.

Working age people (including those recently retired and students):

  • The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example, a commuter surgery for booked appointments with a GP or nurse on Tuesday evenings from 18:30 to 21:00.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, children on protection plans, and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.
  • The practice offered migrants blood test screening for tuberculosis.
  • Housebound patients could contact the practice on a dedicated telephone line to book appointments, visits or seek advice from the duty doctor.
  • Victims of domestic violence had a confidentiality tab attached to their medical record to ensure safety of the person if they were to attend with another family member. The practice had produced a patient leaflet (available in the waiting room) on domestic violence which was shared with other local practices. This leaflet offered information and contact details of local support services.
  • The practice participated in a local improvement scheme for the enhanced practice nurse (EPN) pilot. The remit of the EPN was to case manage high risk patients, provide care for them in their own homes and assist in reducing unscheduled hospital admissions. Unverified practice data from the past 12 months showed a reduction in unscheduled hospital admissions despite an increase in the list size of this vulnerable patient group over the same period
  • The practice cared for patients with complex health conditions residing in two large nursing homes (approx. 75 - 94 beds each). Both homes received biweekly ward rounds with two dedicated GPs. The practice was involved in the ‘red bag’ pilot scheme at one of the nursing homes to improve patients’ transition between care homes and an inpatient hospital setting. The nurses and manager at the home had access to the GPs direct mobile number which meant the GP could be accessed quickly to avoid ambulance call-outs. Feedback received from a clinical specialist nurse and nursing home manager was largely positive regarding the support received from the practice and access to the GPs. The practice also sought feedback from other health professionals working at the nursing homes and received positive feedback regarding the care provided.

People experiencing poor mental health (including people with dementia):

  • Staff interviewed had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • The practice held weekly clinics led by a mental health nurse.

Timely access to care and treatment

Patients were able to access care and treatment from the practice within an acceptable timescale for their needs.

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • Some patients reported difficulties with access to the practice via telephone and this was reflected in the national GP patient survey results. The practice was aware of this feedback and had reviewed ways to improve patient satisfaction with telephone access.
  • Other results from the national GP patient survey were in line with local and national averages for questions relating to access to care and treatment.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 8 November 2018

We rated the practice as good for providing a well-led service.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care.

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.

Culture

The practice had a culture of high-quality sustainable care.

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • The practice focused on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed.
  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. Staff received regular annual appraisals. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Practice leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The practice used performance information which was reported and monitored and management and staff were held to account.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved patients, the public, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.
  • The practice was a training practice for newly qualified doctors and registrars completing their GP specialist training.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good