5 March 2019
During a routine inspection
We carried out an announced comprehensive inspection at the Nayar Practice on 5 March 2019 as part of our inspection programme.
We based our judgement of the quality of care at this service on a combination of:
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what we found when we inspected
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information from our ongoing monitoring of data about services and
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information from the provider, patients, the public and other organisations.
We have rated this practice as good overall.
We found that:
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The practice provided care in a way that kept patients safe and protected them from avoidable harm.
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Patients received effective care and treatment that met their needs.
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Staff dealt with patients with kindness and respect and involved them in decisions about their care.
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The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
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The way the practice was led and managed promoted the delivery of high-quality, person-centre care.
We saw several areas of outstanding practice including:
- Staff, teams and services were committed to working collaboratively and have found innovative and efficient ways to deliver more joined-up care to patients. In March 2017 the practice and six neighbouring practices developed the proactive primary coordinated care pathway. The practices hosted the pro-active care team, which included three pro-active care nurses, who visited frail, vulnerable or older patients in their own homes and implemented an advanced care plan with the patient/family/carers. The service involved working with other agencies such as social prescribing, admiral nurses, occupational therapists and community geriatrician to enable the patient to remain in either the home/community setting to reduce hospital admissions. Initially, patients were assessed using a risk stratification tool which included a review of patients living with dementia, learning difficulties, frailty, at risk of hospital admission, housebound, residing in care home or those with multiple long term conditions. The pro-active care nurse had identified 109 patients at risk and 102 of these have care plans in place. Of that 65 patients had consented to an enriched summary care record. Each patient with a care plan in place was asked to rate their confidence in their health needs and repeated when the care plan is reviewed. 80% of patients' are in the range of fairly confident/very confident in terms of managing their own health.
Whilst we found no breaches of regulations, the provider should:
- Consider completing a risk assessment in the absence of keeping some emergency drugs.
Details of our findings and the evidence supporting our ratings are set out in the evidence tables.
Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice