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The Castle Medical Centre Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 2 July 2015

Letter from the Chief Inspector of General Practice

We carried out a comprehensive inspection of Castle Medical Centre on 5 March 2015. Overall the practice is rated as outstanding.

Specifically we found the practice to be good for providing safe and caring services. It was outstanding for providing effective, responsive and well led services. The practice was outstanding for providing services to families, children and young people, working age people and those whose circumstances may make them vulnerable. It was also outstanding for providing services to people with long term conditions, older people, and people experiencing poor mental health (including people with dementia).

Our key findings were as follows:

  • Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Information about safety was recorded, monitored, appropriately reviewed and addressed.
  • The practice assessed patients’ needs and planned their care following best practice guidance.
  • Staff had received training appropriate to their roles and any further training needs had been identified and planned. The practice valued the importance of quality, improvement and learning and were actively involved in GP education and training and in primary care research.
  • Patients said they were treated as individuals and that they were involved in their care and decisions about their treatment. Patients described the practice as caring, helpful and friendly.
  • Information about services and how to complain was available and easy to understand.
  • Patients could speak on the telephone and make an appointment with a named GP. Routine as well as urgent appointments were available on the same day.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. Plans were in hand for extending and improving the building to enable the practice to respond to future patient needs.
  • There was a clear leadership structure and staff felt supported by management. The practice worked closely with its patient participation group and proactively sought feedback from staff and patients. They listened to what patients told them and made improvements accordingly.

We saw several areas of outstanding practice including:

  • The practice had effective assessment, care planning and recall arrangements for patients with long term conditions. Their emergency admission rates for a number of long term conditions including chronic heart disease and chronic obstructive pulmonary disease (COPD) were significantly below the national average. The practice also had low accident and emergency admission rates.
  • The practice team included a part time pharmacist employed by the practice to support the clinicians in providing safe and effective medicines management. Their role included supporting the GPs and nurses with pharmacy advice, reviewing prescribing and monitoring medication safety alerts to make sure these were acted on in a timely way. The practice told us that having a pharmacist had resulted in them being one of the most cost effective prescribers within the CCG. National data showed prescribing levels for specific types of medicines where caution should be exercised were lower than the national average.
  • The practice was working to develop the service it provided to patients with dementia and their carers. In addition to care planning and reviews of their care they had arranged a talk for patients and carers by staff from the Office of the Public Guardian (OPG) about how to make a lasting power of attorney (LPA) and another by the Alzheimer’s Society. These were the first of a series of patient education evenings the practice planned to arrange for patients each year.
  • The practice attended a weekly multi-disciplinary meeting at a local care home that was involved in an early discharge from hospital initiative. One of the GPs visited patients staying at the home under this scheme every day. Appointments for older patients’ health reviews were 30 minutes long and hour long appointments were booked for those most at risk.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 2 July 2015

The practice is rated as good for providing safe services. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. The practice used every opportunity to learn from internal and external incidents to help them improve. Information about safety was highly valued and was used to promote learning and improvement. Risks to patients and within the practice were assessed and well managed. There were enough staff to keep people safe. Arrangements for the management of medicines were clear and overseen by a part time pharmacist employed by the practice.

Effective

Outstanding

Updated 2 July 2015

The practice is rated as outstanding for providing effective services. Our findings at inspection showed that systems were in place to ensure that all clinicians were up to date with National Institute for Heath and Care Excellence (NICE) guidelines and other locally agreed guidelines. We saw evidence to confirm that the GPs used these to influence and improve practice and outcomes for patients. The practice used locally agreed protocols for ensuring that patents received the care and support they needed at the end of life.

The practice used clinical audit to monitor the effectiveness of the care and treatment they provided and had

been a host practice since February 2011

as part of an NHS primary care research initiative.

The practice’s emergency admission rates for a number of long term conditions including chronic heart disease (3.7% compared to 7.5%) and chronic obstructive pulmonary disease (COPD) (4.6% compared to 12.88%) were significantly below the national average. The practice’s review rates for COPD were also higher than the local and England averages (90% of patients with these conditions compared to 88% within the CCG and 81.4% for England). Data showed that the practice was effective in supporting patients with diabetes to manage their health and had low accident and emergency admission rates.

Caring

Good

Updated 2 July 2015

The practice is rated as good for providing caring services. Data showed that patients rated the practice higher than others for several aspects of care. Patients told us their GP gave them the time and attention they needed and several mentioned feeling well supported over the years or during extended periods of treatment. Patients used words such as brilliant, superb, caring and considerate to describe the team. Managers of local care homes confirmed that the practice cared about patients and treated them as individuals.

Responsive

Outstanding

Updated 2 July 2015

The practice is rated as outstanding for providing responsive services. The practice was aware of the needs of their local population and engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure service improvements where these were identified. The practice had made changes to the appointment system based on feedback from patients and a period of research. The new system had been well received. Patients could arrange appointments with the GP of their choice and could expect to see a GP on the day they telephoned the practice whether this was for routine or urgent appointments. Appointments were available on Saturdays mornings.

There was a clear complaints system with evidence demonstrating that the practice responded to issues raised. The practice had a positive approach to using complaints and concerns to improve the quality of the service. Managers of local care homes confirmed that the patients living in those homes received responsive care. The GPs provided a specific service to patients in one care home as part of an initiative to enable patients to be discharged from hospital for ongoing care and assessment of their future needs. This involved daily visits to the care home and weekly meetings with other health and care professionals.

The practice had begun to arrange education evenings at the practice for patients and carers and these had commenced with talks about lasting power of attorney arrangements by the Office of the Public Guardian and one about dementia by the Alzheimer’s society.

Well-led

Outstanding

Updated 2 July 2015

The practice is rated as outstanding for providing well-led services. The practice had an open and supportive leadership and a clear vision with quality, improvement and learning as its top priorities. The practice promoted high standards and the team took pride in delivering a high quality service to its patients. There was a clear leadership structure and staff felt supported by management. The practice had well organised management systems and met regularly to review the delivery of care and the management of the practice. The practice had systems in place to monitor and improve quality and identify risk.

The practice proactively sought feedback from staff and patients and responded to suggestions made. The practice had an active patient participation group (PPG). A PPG is made up of a group of patients registered with a practice who work with the practice team to improve services and the quality of care.

There was evidence that the practice had a culture of learning, development and improvement including their involvement in GP education and primary care research. An example of this was that both practice managers had master’s degrees in primary care management and the practice was supporting the reception manager to undertake a level five diploma in primary care management.

Checks on specific services

People with long term conditions

Outstanding

Updated 2 July 2015

This practice is rated as outstanding for the care of people with long term conditions. The practice had effective assessment, care planning and recall arrangements for patients with long term conditions. Practice nurses and GPs had lead roles for the management of patients with long term conditions and the practice had identified patients at risk of unplanned hospital admissions. They had identified the 2% of patients registered with the practice who were at the highest risk and had developed written care plans for those patients following a minimum of 30 minutes appointment to review their health and discuss their care and treatment needs with them. Those patients and others with long term conditions had annual reviews of their health and medicines. Longer appointments or home visits were arranged for these according to individual need.

The practice’s emergency admission rates for a number of long term conditions including chronic heart disease (3.7% compared to 7.5%) and chronic obstructive pulmonary disease (COPD) (4.6% compared 12.88%) were significantly below the national average. The practice’s review rates for COPD were also higher than the local and England averages (90% of patients with these conditions compared to 88% within the CCG and 81.4% for England). Data showed that the practice was effective in supporting patients with diabetes to manage their health and had low accident and emergency admission rates.

Families, children and young people

Outstanding

Updated 2 July 2015

This practice is rated as outstanding for the care of families, children and young people. The practice provided childhood immunisations and appointments for these could be booked throughout the week and on Saturday mornings to provide flexibility for working families. The practice provided a family planning service and a range of options for contraception. The GPs and nurses worked with other professionals where this was necessary, particularly in respect of children living in vulnerable circumstances.

Older people

Outstanding

Updated 2 July 2015

This practice is rated as outstanding for the care of older people. Patients over the age of 75 had a named GP and GPs carried out visits to patients’ homes if they were unable to travel to the practice for appointments. The practice exceeded the national average for providing flu vaccinations to patients over the age of 65. The practice provided a responsive service to patients living in two local care homes. The practice provided other professionals and its own staff with clear information about patients receiving end of life care who might need an urgent response if they requested medical assistance. They had a register of patients who needed care and support at the end of their lives and took part in meetings with other professionals involved in their care. Patients over 75 were offered a 30 minute appointment to discuss their health and plan their care with the aim of avoiding unplanned hospital admissions. The practice was about to begin a review of all of their patients aged over 75 in partnership with Age UK. The aim of this work was to empower patients and to identify those most at risk due to their levels of frailty. The practice explained that they planned to carry out more preventative care and as part of this offered one hour appointments for those older patients at highest risk. They provided a specific service to patients in one care home as part of an initiative to enable patients to be discharged from hospital for ongoing care and assessment of their future needs. This involved daily visits to the care home and weekly meetings with other health and care professionals.

Working age people (including those recently retired and students)

Outstanding

Updated 2 July 2015

This practice is rated as outstanding for the care of working age people, recently retired people and students. Appointments were available from 8am for patients unable to visit the practice later in the day and on Saturday mornings. The practice appointment system aimed to enable patients to speak direct with a GP on the telephone and arrange an appointment at a time to suit them or to have telephone consultations with a GP where this was suitable. Patients could book telephone calls with a GP and order prescriptions online. We had some information to suggest that some working patients did not find the new system convenient because they could not arrange time out of work in advance.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 2 July 2015

This practice is rated as outstanding for the care of people experiencing poor mental health (including people with dementia). The practice held a register of people experiencing poor mental health and invited them to attend for an annual health check. Longer appointments were arranged for this and patients were seen by the GP they preferred. The annual reviews took into account patients’ employment, home circumstances and support networks in addition to their physical health. One of the GPs monitored progress in seeing all of these patients during the year and data showed that in the year ending April 2014 92.11% of patients with mental health needs had a care plan in place compared to the national average of 86.09%.

The practice had taken steps to ensure they had identified patients at the practice living with dementia and provided annual reviews for them. These were booked as 30 minute appointments and patients’ main carers were invited to attend with them. The GPs went to patients’ homes for these reviews if this was easier for the patient and their carer.

The practice had arranged a talk for patients and carers by staff from the Office of the Public Guardian (OPG) about how to make a lasting power of attorney (LPA) and another by the Alzheimer’s Society. GPs and other staff were completing ‘Dementia Friends’ training provided by the Alzheimer’s Society with a view to becoming a dementia friendly organisation.

People whose circumstances may make them vulnerable

Outstanding

Updated 2 July 2015

This practice is rated as outstanding for the care of people living in vulnerable circumstances. The practice had a learning disability (LD) register and all patients with learning disabilities were invited to attend for an annual health check. Longer appointments were available for this and the practice used information in suitable formats to help them explain information to patients. Staff told us that the practice did not have any homeless people or traveller families currently registered at the practice. Staff at the practice worked with other professionals to help ensure people living in difficult circumstances had opportunities to receive the care, support and treatment they needed. The staff team were aware of their responsibilities regarding information sharing and dealing with safeguarding concerns.