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Drs. Morris, Hamilton, Earl & Sowden Good Also known as Saltash Health Centre

Inspection Summary


Overall summary & rating

Good

Updated 4 October 2018

This practice is rated as Good overall. (Previous rating April 2015 – 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

We carried out an announced comprehensive inspection at Saltash Health Centre on 31 July 2018 as part of our inspection programme.

At this inspection we found:

  • The practice had 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.
  • Patients found the appointment system easy to use and reported that they could access care when they needed it.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.
  • The practice worked closely with a military charity to display a heroes’ mural for the new extension at the practice. This was part of the practice’s support for military veterans and their families in the area. Saltash had a higher than average number of families with members in the armed forces due to the proximity of military bases in the area.
  • The practice was one of the first GP practices in the area to have employed three specialist paramedics. The practice had introduced its acute assessment clinic run by the paramedics and overseen by the duty GP. This clinic provided urgent care and allowed GPs to see patients with more complex needs.
  • The practice had achieved notable results in its childhood immunisation programme. The World Health Organisation target of 95% for childhood immunisations had been exceeded by 1.5% in all four key areas.

We identified areas of outstanding practice:

  • The practice had successfully continued to develop their secondary school outreach clinic called TicTac since our previous inspection in April 2015. TicTac clinics with practice GPs and nurses and a dedicated TicTac co-ordinator were held daily at the local secondary school. TicTac improved access to healthcare and contraception, anxiety and mental health issues, improved emotional and mental health and wellbeing, reduced unwanted teenage pregnancy, childhood obesity, helped young people give up smoking, reduced substance misuse and alcohol abuse and promoted collaborative and multi-agency working through direct links with the school’s safeguarding system. TicTac had provided over 1,000 appointments in the last 12 months.

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 4 October 2018

We rated the practice 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.
  • 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 all staff tailored to their role including temporary staff.
  • The practice was equipped to deal with medical emergencies and staff were suitably trained in emergency procedures.
  • 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.
  • Staff prescribed and administered or supplied medicines to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance.
  • There were effective protocols for verifying the identity of patients during remote or online consultations.
  • 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.

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.

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 4 October 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.
  • The practice maintained a social media page to keep patients informed about activities and events organised by the practice to promote good health and wellbeing.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • 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.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

  • 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)

Families, children and young people:

  • Childhood immunisation uptake rates were 1.5% higher than the World Health Organisation (WHO) target percentage of 90%. Childhood immunisations were carried out adhering to the appropriate schedule. Saltash Health Centre was proactive in reminding parents when childhood immunisations were due and following up those which became overdue. The practice used a three-step approach. Initially administration staff contacted the child’s parent or guardian, followed by a practice nurse if this was unsuccessful. Finally, the patient’s GP chased up non-attenders.

  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.
  • Antenatal care was provided by community midwives and the practice conducted new born baby checks and post-natal checks.
  • The practice provided contraceptive services, including IUD (intrauterine device) provision and long acting reversible contraceptives (LARC).
  • Monthly multi-disciplinary safeguarding meetings were held with the lead GP and lead paramedic for safeguarding, practice nurses and the local school nurse and health visitors. The practice had also successfully reached out to a wider scope of professionals such as primary and secondary school SENCO (special educational needs co-ordinator) officers as well as safeguarding leads from the local schools in Saltash.
  • The practice was “Savvy” Kernow approved and registered at level two, the next to highest level. Savvy quality standards ensured that the practice was young people friendly and respected young people’s rights to talk to someone in confidence and at times that were best for them. There was a notice board at the practice which displayed health promotion information relevant to young people such as sexual health and counselling for anxiety or eating disorders.

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

  • The practice’s uptake for cervical screening was 82%, which was similar to the national average target of 80% but higher than local averages coverage achievement of 76%.
  • The practice’s uptake for breast and bowel cancer screening was comparable with the national average.
  • Minor illness clinics are held every morning and afternoon. These were run by the Practice Nurse and a GP. The practice also provided a GP paramedic acute assessment clinic every morning and afternoon. Clinics were overseen by the on-call GP.
  • 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:

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

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. There was a system for following up patients who failed to attend for administration of long term medication.
  • 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 percentage of patients with schizophrenia, bipolar affective disorder and other psychoses who have a comprehensive, agreed care plan documented in the record, in the preceding 12 months was 100% which was higher than the local clinical commissioning group average of 94% and the national average of 90%.

Caring

Good

Updated 4 October 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 practice’s GP patient survey results were in line with or above 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 proactively identified carers and supported them.
  • The practice’s GP patient survey results were in line with or above local and national averages for questions relating to involvement in decisions about care and treatment. Some indicators were significantly above average.

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.
  • The practice identified military veterans in line with the Armed Forces Covenant 2014. This enabled priority access to secondary care to be provided to those patients with conditions arising from their service to their country. The practice worked with military veterans and the local school to display a heroes’ mural in the new extension of the practice. Saltash was an area with a larger than average number of military families due to the proximity of military bases in the area.

Please refer to the evidence tables for further information.


Responsive

Good

Updated 4 October 2018

We rated the practice, and all of the population groups, as good for providing responsive services apart from families, children and young people which we rated as outstanding.

Responding to and meeting people’s needs

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

  • The practice understood the needs of its population and tailored services in response to those needs.
  • Telephone and web GP 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. The GP and practice nurse also accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability.
  • There was a medicines delivery service 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 the local district nursing team to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • Saltash Health Centre was proactive in reminding parents when childhood immunisations were due and following up those which became overdue. The practice used a three-step approach. Initially administration staff contacted the child’s parent or guardian, followed by a practice nurse if this was unsuccessful. Finally, the patient’s GP chased up non-attenders.
  • 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. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

  • The practice provided GP led health clinics for young people at the local secondary school which had 1,300 pupils. This scheme was known as TicTac. The practice had continued to grow this scheme since our previous inspection. TicTac offered a daily two-hour drop-in clinic at the school, with a dedicated co-ordinator, to ensure daily clinics with GPs, practice nurses, school nurses and a youth worker. The Tic Tac co-ordinator was a trusted face, encouraging access and the concept of bringing a friend for support when talking about issues that were distressing or embarrassing or with safeguarding or criminal consequences. TicTac played a key role in safeguarding children participating in risky behaviours by supporting early medical intervention and prevention and directly linking with the school's safeguarding system. The scheme also provided early recognition and support for mental health needs, including suicidal thoughts, sexual orientation issues or eating disorders.
  • TicTac completed approximately 1,000 appointments in the last 12 months. Issues included sexual health, emergency contraception, pregnancy tests, chlamydia tests, health, mental health, school problems, bullying, relationships, family problems, drugs, smoking, counselling and the C card (condom) scheme. At the time of our previous inspection, many visits from students were under the C card scheme and contraception. However, the service now dealt with far more complex issues as outlined above.
  • GPs were not commissioned nationally or locally to provide in-reach services to secondary schools and the practice had met the costs itself. The practice ran the scheme to ensure barriers to access were no longer a reason not to access their services. The service co-ordinator collected prescriptions from pharmacies for young people where issued by the clinical team to ensure there was no barrier to collecting medications. Without this service, some children faced having to find a way of discreetly accessing both a GP practice and a pharmacy before their health needs could be met. Young people faced psychological as well as physical barriers to accessing GP services for support with health needs and the TicTac service provided helped to ensure accessing GP services was less of a big step as it avoided them being seen in GP waiting rooms or having to explain their needs over the phone. It reached a hard-to-reach group, namely young people going through a difficult life stage and who would otherwise present in a crisis.

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, extended opening hours.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode.

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 GP led dedicated monthly mental health and dementia clinics. Patients who failed to attend were proactively followed up by a phone call from a GP.
  • The practice discussed the introduction of a psychologist starting at the practice. The practice was in the process of acting upon feedback in the introduction of the psychologist due to the high demand identified by the patient participation group (PPG).

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.
  • Patients reported that the appointment system was easy to use.
  • The practice’s GP patient survey results 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 4 October 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. All staff received regular annual appraisals in the last year. 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 had introduced a new online consultation system (e-consult) which it was trialling on behalf of the CCG, with the aim of improving access to GP advice and primary care.
  • The practice submitted data or notifications to external organisations as required.
  • There were robust 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.
  • The practice had continued to develop its TicTac clinics to support young people attending the local secondary school across a wide range of health and lifestyle issues relevant to this hard to reach population group.
  • 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 worked closely with East Cornwall colleagues on how to provide a sustainable option for improving access (evening & weekend appointments).
  • The practice was one of the first GP practices in the area to have employed three specialist paramedics. The practice had introduced its acute assessment clinic run by the paramedics and overseen by the duty GP. This clinic provided urgent care and allowed GPs to see patients with more complex needs. Future plans included the training of the paramedics to triage patients for GPs in the near future. The aim was to ensure that an initial assessment has been done and any early investigations (e.g. blood/urine tests, ECG) arranged so that the patient saw the GP with that information already available, thus improving efficiency for both patient and service.

Please refer to the evidence tables for further information.


Checks on specific services

People with long term conditions

Good

Families, children and young people

Outstanding

Older 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