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Inspection Summary


Overall summary & rating

Good

Updated 16 February 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Boughton Surgery on 7 December 2016. This inspection was a follow up to our previous comprehensive inspections at the practice in January 2015 and May 2016 where breaches of regulation had been identified. The overall rating of the practice following the May 2016 inspection was Inadequate and the practice was placed into special measures for a period of six months.

Following our inspection in May 2016 we issued a warning notice to the provider requiring improvements in in relation to good governance. A visit was undertaken on 12 August 2016 to ensure that the specific improvements had been made.

At our inspection on 7 December 2016 we found that the practice had improved. The ratings for the practice have been updated to reflect our recent findings. The practice is rated as good for providing safe, effective, caring, responsive and well led services.

Our key findings across all the areas we inspected 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 had implemented new systems and processes to ensure that risks to patients were assessed and well managed. For example, comprehensive recruitment checks were now in place for new members of staff.
  • The practice was proactive in safeguarding children, and had implemented a protocol for the monitoring of children who did not attend hospital appointments.
  • Extensive work had been undertaken to ensure that there was an effective system in place to support patients who were prescribed drugs that required monitoring. Furthermore, a protocol had been developed to ensure that reviews of safety updates from the Medicines and Healthcare Products Regulatory Agency (MHRA) were undertaken.
  • 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.
  • Feedback from patients about their care was positive. Patients said they were treated with compassion, dignity and respect and that they were involved in their care and decisions about their treatment.
  • Information about services and how to complain was available and easy to understand. Improvements were made to the quality of care as a result of complaints and concerns.
  • The practice had analysed patient feedback and made changes to the appointment system to ensure that patients had improved access to appointments.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • There was a clear leadership structure in place and staff felt well supported by the GP partners.
  • Policies and procedures had been reviewed and updated to the requirements of the practice.
  • The provider was aware of and complied with the requirements of the duty of candour.

I confirm that this practice has improved sufficiently to be rated good overall. This practice will be removed from special measures.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 16 February 2017

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 and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.
  • The practice had an effective system in place for identifying and managing risks to patients and staff. For example, health and safety risk assessments had been completed and staff had been provided with relevant training.
  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse. The practice was proactive in safeguarding children, and had implemented a protocol for the monitoring of children who did not attend hospital appointments.
  • Extensive work had been undertaken to ensure that there was an effective system in place to support patients who were prescribed medicines that required monitoring. Furthermore, a protocol had been developed to ensure that reviews of safety updates from the Medicines and Healthcare Products Regulatory Agency (MHRA) were undertaken.

Effective

Good

Updated 16 February 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were in line with local and national averages.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits were carried out and contributed to quality improvement at the practice. The practice also participated in research which resulted in improved outcomes for patients.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment. A training programme had been developed to ensure that staff received training relevant to their job roles. Furthermore, a clear induction process had been implemented for new staff and locums.
  • A schedule of appraisals had been commenced and written evidence of these had been retained in personnel files.
  • The process for obtaining consent prior to minor surgery being undertaken at the practice had improved to ensure consistency. This had been audited to ensure that the process was embedded.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs. Improvements had been made to the record keeping of minutes from multidisciplinary team meetings.

Caring

Good

Updated 16 February 2017

The practice is rated as good for providing caring services.

  • Data from the National GP Patient Survey published in July 2016 showed patients rated the practice in line with local and national averages for most aspects of care.
  • Feedback from patients about their care was positive. Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • The practice was proactive in identifying patients with caring responsibilities. The practice had identified 32 patients as carers (1% of the practice list) and were working on recognising previously registered patients who may have not identified themselves as carers. A monthly carers drop-in clinic was held in the practice. Written information was available to direct carers to the various avenues of support available to them. The practice carers co-ordinator had worked with young carers to arrange local one to one support services.

  • 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.

Responsive

Good

Updated 16 February 2017

The practice is rated as good for providing responsive services.

  • 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. For example, the practice offered pre-school readiness checks to patients aged between four and five.
  • 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 analysed patient feedback and made changes to the appointment system to ensure that patients had improved access to appointments.
  • Data from the National GP Patient Survey published in July 2016 showed that 93% of patients surveyed found it easy to get through to the practice by phone, compared to the CCG average of 81% and the national average of 73%.
  • The practice had good facilities and was well equipped to treat patients and meet their needs. A hearing loop had been installed in reception for patients who had a hearing impairment.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 16 February 2017

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.
  • Governance arrangements had been successfully implemented and embedded into practice to ensure that the issues identified at the previous inspections had been resolved.
  • Staff at the practice were engaged with local healthcare services and worked within the wider health community. For example, the lead GP regularly engaged with the West Norfolk Clinical Commissioning Group.
  • There was a clear leadership structure in place and staff felt well supported by the GP partners.
  • Policies and procedures had been updated to become reflective of the requirements of the practice.
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient reference group was active.
  • An ethos of learning and improvement was present amongst all staff.
Checks on specific services

People with long term conditions

Good

Updated 16 February 2017

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

  • Both GPs and nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
  • The practice used the information collected for the Quality and Outcomes Framework (QOF) to monitor outcomes for patients (QOF is a system intended to improve the quality of general practice and reward good practice). Data from 2015/2016 showed that performance for diabetes related indicators was 95%, which was above the local average of 93% and the national average of 90%. Exception reporting for diabetes related indicators was 8%, which was lower than the local and national averages of 11% (exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects).
  • Longer appointments and home visits were available when needed.
  • Patients with complex needs had a named GP and a structured annual review to check their health and medicines needs were being met. There was a robust recall system in place to ensure that patients were invited and attended annual reviews.
  • 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.

Families, children and young people

Good

Updated 16 February 2017

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.
  • Immunisation rates were high for all standard childhood immunisations.
  • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals.
  • The percentage of women aged 25-64 whose notes recorded that a cervical screening test had been performed in the preceding five years was 82%, which was in line with the local average of 84% and the national average of 82%.
  • The practice worked with a local residential school for children with additional needs. A GP from the practice supported the school in reviewing a planned home remedies policy.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • The practice offered a full range of contraception services and chlamydia screening.
  • We saw positive examples of joint working with midwives, health visitors and school nurses.
  • The practice offered pre-school readiness checks to patients aged between four and five.

Older people

Good

Updated 16 February 2017

The practice is rated as good for the care of older people.

  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. All home visits were triaged by a clinician to prioritise visits and ensure appropriate and timely intervention.
  • The practice contacted all patients after their discharge from hospital to address any concerns and assess if the patient needed GP involvement at that time.
  • Nationally reported data showed that outcomes for patients for conditions commonly found in older people, including rheumatoid arthritis and heart failure, were above local and national averages.
  • The practice offered a prescription delivery service for housebound patients.

Working age people (including those recently retired and students)

Good

Updated 16 February 2017

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 where possible.
  • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group.
  • Although the practice did not offer extended hours appointments, there were appointments available from 8am to 6pm daily. The practice was in the process of adding additional appointments in the early evenings for patients returning from work.
  • Practice staff carried out NHS health checks for patients between the ages of 40 and 74 years. The practice was able to refer patients to a health trainer to encourage lifestyle changes.

People experiencing poor mental health (including people with dementia)

Good

Updated 16 February 2017

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

  • 82% of patients diagnosed with dementia had received a face to face care review in the last 12 months, which was in line with the local and national averages of 84%.
  • 100% of patients experiencing poor mental health had a comprehensive care plan, which was above the local average of 91% and the national average of 88%.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia.
  • The practice carried out advance care planning for patients with dementia.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations.
  • The local Wellbeing Service held a weekly clinic at the practice.
  • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health.
  • Staff had a good understanding of how to support patients with mental health needs and dementia.
  • The practice had provided training on dementia awareness and the Mental Capacity Act 2005 to all members of staff to ensure that mental health and psychological wellbeing was considered at every contact.

People whose circumstances may make them vulnerable

Good

Updated 16 February 2017

The practice is rated as good for the care of people whose circumstances may make them vulnerable.

  • The practice held a register of patients living in vulnerable circumstances including travellers and those with a learning disability.
  • The practice regularly worked with other health care professionals in the case management of vulnerable patients, and held regular multidisciplinary team meetings.
  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations.
  • The practice was engaged with the local carers support group, which provided guidance, support and respite for carers. A monthly carers drop-in clinic was held in the practice. Written information was available to direct carers to the various avenues of support available to them. The practice carers co-ordinator had worked with young carers to arrange local one to one support services.
  • 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.