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Inspection Summary


Overall summary & rating

Good

Updated 19 July 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Fleetwood Surgery on 13 May 2016. Overall the practice is rated as good.

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

  • Throughout our inspection we noticed a strong theme of positive feedback from staff, patients and other organisations who worked with the practice. Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.The practice used innovative and proactive methods to improve patient outcomes and working with other local providers to share best practice. The practice was committed to working collaboratively and worked closely with other organisations in planning how services were provided to ensure that they meet patients’ needs.
  • The practice implemented suggestions for improvements and made changes to the way it delivered services because of feedback from patients and from the patient participation group (PPG).
  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. The provider was aware of and complied with the requirements of the duty of candour.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.

  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • The practice had a clear vision which had quality and safety as its top priority and was regularly reviewed and discussed with staff.

We saw several areas of outstanding practice including:

  • The practice used social media to reach their younger patients. They shared health promotion advice (such as self care and smoking cessation) and practice specific information such as feedback and improvements made. The page had 94 followers at the time of our inspection. The practice has identified a lack of young people representation in their Patient Participation Group (PPG) and used this media to encourage younger people to join the group. The practice manager regularly reviewed the page for patient feedback in order to address issues and improve the service. 

  • A GP at the practice had developed a comprehensive Personal Care Plan template which had been shared with the CCG and adopted by other health care providers. This plan was then co-written with patients through discussion and completion of a questionnaire. Based on the plan a number of ‘what if’ scenarios were documented to assist the patient, their carers and other health care providers to provide safe and effective care in accordance with the patient’s wishes.

  • The practice took a proactive approach to understanding the needs of their patients who were carers. Practice data highlighted that there were 168 carers on the practices register and 3.7% of the practices list had been identified as carers. There was a dedicated carer’s lead in place and carers were offered support and regularly reviewed by the practice.The practice recognised the links between carers experiencing other conditions such as depression and offered opportunistic depression screening.

  • The practice used various innovative IT methods to improve patient care. One GP developed a system which automatically generated a printed paper slip when a patient was prescribed opiates. This reminded patients of the side effects of this medicine. Patients diagnosed with COPD (Chronic Obstructive Pulmonary Disease) were encouraged and educated to use a telecare system. Currently four patients monitored their own vital signs and text these to the practice. A further 72 patients had been invited to take part in this scheme. This gave patients greater autonomy over the care of their condition and helped to identify issues early. The practice had also recently begun to take part in a local pilot to provide video consultations to patients.

  • A transient population of overseas students from the local Nautical College were registered with the practice. A Health Care Assistant attended registration sessions at the college to allow students to be registered in a timely manner with limited disruption to their educational timetable.

However there were areas of practice where the provider should make improvements.

  • The practice website should be updated to reflect current opening hours.
  • Continue to ensure all staff have annual appraisals.

  • Infection Control Audits should be conducted annually.

  • Systems to ensure all policies are regularly reviewed and updated should be strengthened.

  • Documentation of complaints should provide a clear audit trail of the responses given.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 19 July 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events

  • Lessons were shared to make sure action was taken to improve safety in the practice.

  • When things went wrong patients received reasonable support, truthful information, and a written or face-to-face apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • We observed the premises to be visibly clean and tidy, with regular room checks and cleaning schedules in place. However there had not been a full infection control audit conducted since 2014.

  • The practice had arrangements in place to respond to emergencies and major incidents.

  • The arrangements for managing emergency medicines, in the practice kept patients safe. Vaccines were in date, rotated and stored appropriately. However staff did not routinely lock the fridges or the room they were located in, which meant the security of the vaccines could be compromised.

Effective

Good

Updated 19 July 2016

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were at or above average compared to the national average.

  • 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.

  • The practice used innovative and proactive methods to improve patient outcomes and working with other local providers to share best practice.

  • The practice had developed a service directory which included voluntary services in the local area. Staff told us they looked at patients and their needs holistically and referred them to appropriate services.

  • The practice had begun work to provide staff with formal appraisals. This needed to continue to ensure all staff received yearly formal appraisals.

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.

  • The practice educated patients to use a telecare system to remotely monitor patients with COPD (chronic obstructive pulmonary disease) to anticipate exacerbations and help to avoid hospital admissions. Patients informed the practice by text of their own vital signs giving them greater autonomy over their care.

Caring

Outstanding

Updated 19 July 2016

The practice is rated as outstanding for providing caring services. Data from the national GP patient survey showed patients rated the practice higher than CCG and national averages for almost all aspects of care.

We observed a strong patient-centred culture:

  • Staff were motivated and inspired to offer kind and compassionate care and worked to overcome obstacles to achieving this.

  • We found many positive examples to demonstrate how patient’s choices and preferences were valued and acted on.

  • Views of external stakeholders were very positive and aligned with our findings.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. Feedback from patients was consistently positive.

  • 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

  • Staff proactively identified carers and recorded this on the practice computer system. At the time of our inspection the practice had identified 168 patients as carers (3.7% of the practice list). Clinicians were aware of the link between caring and diagnosis of depression and proactively screened for this. They also offered a yearly flu vaccination to all carers.

  • Personal Care Plans were co-written with patients through discussion and completion of a questionnaire. Based on the plan a number of ‘what if’ scenarios were documented to assist the patient, their carers and other health care providers to provide safe and effective care in accordance with the patient’s wishes. Care plans were not restricted to patients with particular conditions.

Responsive

Good

Updated 19 July 2016

The practice is rated as good for providing responsive services.

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the patient participation group. For example, the practice employed a regular female locum as some patients feedback suggested that they were not always comfortable seeing amale GP.

  • Patients can access appointments and services in a way and at a time that suited them. Extended opening hours were available which were advertised in the practice. The practice website required updating to reflect current opening times.
  • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.

  • Clinical staff carried out home visits for older patients and patients who would benefit from these. Immunisations such as flu and shingles vaccines were also offered to vulnerable patients at home, who could not attend the surgery.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand. Learning from complaints was shared with staff and other stakeholders. However, the practice did not always fully document responses to complaints and the complaints procedure did not make it clear that patients should expect a written response to their complaint.
  • 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. The practice was beginning a pilot scheme to provide video consultations to patients. The practice offered a ‘zero tolerance’ violent patient scheme which meant patients from across Fylde and Wyre and North Lancashire who had been removed from patient lists at other practices were guaranteed not to be turned away.

  • The practice used social media to reach their younger patients. Health promotion, practice specific information such as feedback and improvements were shared. This media was also used to encourage membership of the Practice PPG group. The practice manager regularly reviewed the page for patient feedback in order to address issues and improve the service.

Well-led

Good

Updated 19 July 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 it.

  • There was a clear leadership structure and staff felt supported by management.

  • The practice had a number of policies and procedures to govern activity, but some of these were overdue a review.

  • 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 had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken

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

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

  • All staff had received inductions but most staff had not received formal appraisals.

  • The practice gathered feedback from patients using new technology, and it had a very engaged patient participation group which influenced practice development.
Checks on specific services

People with long term conditions

Good

Updated 19 July 2016

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

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.

  • Longer appointments and home visits were available when needed.

  • Patients with a long-term condition 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. Regular multi-disciplinary team meetings took place with representation from other health and social care services. We saw that discussions took place to understand and meet the range and complexity of people’s needs and to assess and plan ongoing care and treatment.

  • The practice encouraged and educated patients to use IT to monitor and manage their own health. A telecare system was available for patients with Long-term conditions including heart failure and Chronic Obstructive Pulmonary Disease (COPD). At the time of our inspection 4 patients had begun to use this service with a further 72 patients identified and encouraged to partake. Patient’s text the practice with details of their vital signs which allowed clinicians to anticipate exacerbations and potentially avoid hospital admissions.

Families, children and young people

Good

Updated 19 July 2016

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

  • There were systems in place 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 A&E attendances.

  • The practice routinely offered new patient health checks to children. They used this to proactively identify any safeguarding concerns particularly in transient families. Family relationships were linked within computer records so known relationships could be documented.

  • Systems were in place to identify and follow up children who were considered at risk of harm or neglect. For example, the needs of all at-risk children were regularly reviewed at practice multi-disciplinary meetings involving child care professionals such as health visitors and school nurses. We saw positive examples of joint working with midwives, health visitors and school nurses.

  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this.

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

  • Vaccination rates for 12 month and 24 month old babies and five year old children were in line with CCG averages. Practice staff proactively contacted families who at failed to attend immunisation appointments and followed up any concerns.

Older people

Good

Updated 19 July 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. All patients over the age of 75 had a named GP.

  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. The practice was proactive in offering those older patients who could not attend clinic for Flu vaccinations or health checks this service in their own home.

  • Older patients at risk of hospital admission and in vulnerable circumstances had care plans. Patients and or their carers were asked to complete a questionnaire which was used to inform the personalised care plan. A number of what if scenarios specific to the patient were documented to aid patients, carers and other health services to respond to their needs appropriately.

  • Older patients in need of additional support were identified and assisted to book hospital appointments on their behalf.

  • The practice worked together with the ‘Rapid Response’ community team, aimed at treating people in their own homes if at risk of needing hospital admission. Social Workers were available for the prompt coordination of any social needs alongside the patients’ health issues.

  • The practice maintained a palliative care register. A GP chaired the monthly Gold Standards Framework Palliative Care meetings attended by a wide multidisciplinary team to enable sharing of information relating to patients to improve Palliative and End of Life care.

  • Staff actively referred patients to the local Integrated Care Co-Ordinator to undertake a comprehensive and holistic assessments of needs. At the time of the inspection 25 patients were open to the service and had received a completed holistic needs assessment . The feedback from this service was extremely positive and confirmed high and appropriate referral rates from the practice.

Working age people (including those recently retired and students)

Good

Updated 19 July 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.

  • Extended hours surgeries were offered between 6pm and 8.30pm every Thursday and between 8.30am and 12pm every Saturday for working patients who could not attend during normal opening hours. Appointments were available with GPs, nurses and HCAs. Telephone consultations were also available. The practice was due to act as a pilot site for video consultation

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

  • The practice encouraged online Patient Access for booking appointments, ordering prescriptions, viewing medical records. Patients could contact the practice by a secure email. The practice had developed a social media page where information about health, the practice, and organisations in the local area were shared. This medium was also used to actively recruit PPG members from this age group and to monitor patient feedback.

  • A transient population of overseas students from the local Nautical College were registered with the practice. A Health Care Assistant attended registration sessions at the college to allow students to be registered in a timely manner with limited disruption to their educational timetable.

People experiencing poor mental health (including people with dementia)

Good

Updated 19 July 2016

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

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

  • Self-directed care plans had been sent to all patients on the practice mental health register in order to create personalised care plans.

  • The practice had in-house mental health staff available via referral for counselling and Cognitive Behavioural Therapy.

  • Staff had a good understanding of how to support patients with mental health needs and dementia. Staff had recently undertaken online dementia training and received face-to-face training to become ‘dementia friends’.

  • The practice promoted and referred patients to ‘The Big White Wall’ a 24/7 online confidential mental health website providing support, counselling and information.

People whose circumstances may make them vulnerable

Outstanding

Updated 19 July 2016

The practice is rated as outstanding for the care of people who 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 and other complex needs. Patients with serious social phobias were given the first appointment of the session to avoid busy waiting rooms.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.

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

  • 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.

  • Arrangements were in place to identify and support carers

  • The practice had effective working relationships with multidisciplinary teams in the case management of vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies.

  • The practice took part in a ‘zero tolerance’ violent patient scheme. This meant that patients from across Fylde and Wyre and North Lancashire who had been removed from patient lists at other practices were guaranteed not to be turned away. 21 people from across the Fylde Coast and Lancashire had registered as patients at the practice and had access to the service. The practice risk assessed and put measures in place to ensure the safety of patients and staff.

  • Patients at risk of developing medication addiction or abuse were referred to the Practice Pharmacist for management.  These patients were placed on weekly prescriptions and/or a mutually agreed reducing management plan