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Barnoldswick Medical Centre Good

Inspection Summary


Overall summary & rating

Good

Updated 12 September 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Barnoldswick Medical Centre on 22nd March 2016. The overall rating for the practice was requires improvement as arrangements to monitor and improve quality and identify risks were not in place.

The full comprehensive report on the March 2016 inspection can be found by selecting the ‘all reports’ link for Barnoldswick Medical Centre on our website at www.cqc.org.uk.

This announced comprehensive follow up inspection was undertaken on 20th July 2017. Overall the practice is now rated as good.

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

  • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events.

  • Risks to patients were assessed and managed.

  • 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 were treated with compassion, dignity and respect.
  • The practice was above average for its satisfaction scores on consultations with GPs and nurses.
  • The health and wellbeing of patients in relation to their caring responsibilities was reviewed when they attended for a consultation or health check. They were directed to the various avenues of support available to them.
  • Information about the services provided 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.
  • Patients told us they found it easy to make an appointment with the GP and there was continuity of care, with urgent appointments available the same day.
  • The practice facilities were well equipped to treat patients; however access was restricted due to the structure of the building.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

There were areas where the provider should make improvements:

  • Develop clinical team work by holding regular clinical meetingswith the practice nurses

  • Consistently obtain written consent for minor operations

  • Continue to identify and provide support for patients who are also carers.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 12 September 2017

In March 2016 the practice was rated as requires improvement for providing safe services as risks were not always adequately identified and managed. Our inspection in July 2017 showed that improvements had been undertaken and the practice is now rated as good for providing safe services.

There was an effective system in place for reporting and recording significant events, however the systems in place to monitor trends and ensure timely review of these events required formalising to involve the whole staff group.

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

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

  • The practice generally had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.

  • Risks to patients were assessed and managed.

  • The practice had effective systems in place for the management of repeat prescriptions.

  • Repeat prescriptions were reviewed and organised monthly, weekly or daily as required. They were then passed to the GPs for action, and the patient was seen where necessary.

Effective

Good

Updated 12 September 2017

In March 2016 the practice was rated as requires improvement for providing effective services, as although clinical audits were carried out the evidence did not clearly show that audits were driving improvements in patient outcomes.

These arrangements had improved when we undertook a follow up inspection on 20 July 2017. The practice is now 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 and analysis of significant events demonstrated quality improvement.

  • Staff were aware of updated policies which helped them to carry out their roles effectively.

  • Staff had the skills, knowledge and experience to deliver effective care and treatment.

  • There was evidence of appraisals and personal development plans for all staff.

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

Caring

Good

Updated 12 September 2017

In March 2016 the practice was rated as good for providing caring services. The practice is still rated as good for providing caring services.

  • Data from the national GP patient survey (published in July 2017) showed patients rated the practice higher than others for several aspects of care. 94% of respondents stated that the GP was good at listening to them compared to a Clinical Commissioning Group (CCG) average of 88% and a national average of 89%.

  • Carers were identified and staff ensured that their needs were assessed and monitored at consultations and health checks.

  • Patients said they were treated with compassion, dignity and respect.

  • Information for patients about the services available was accessible including a translation service suitable for patients who did not speak English as a first language.

  • We saw staff treated patients with kindness and respect.

Responsive

Good

Updated 12 September 2017

In March 2016 the practice was rated as good for providing responsive services. The practice is still rated as good for providing responsive services.

  • Staff reviewed the needs of the practice 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 engaged with the medicines optimisation team to reduce the rate of prescribing.

  • Patients told us said they found it easy to make an appointment either by telephone or in person. Data from the GP Patient Survey indicated 89% of patients who responded stated that the last time they wanted to see or speak to a GP or nurse from the surgery they were able to get an appointment. (CCG average 83 % national average 84%) There was continuity of care, with the majority of appointments available the same day.

  • The practice building and facilities were under discussion with the local CCG and NHS Estates as the structure and size of the building limited access and expansion.

  • Information about how to complain was available in the reception area and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Good

Updated 12 September 2017

In March 2016 the practice was rated as requires improvement for being well-led, as

risks were not always fully managed, there was little evidence that audit activity was driving quality improvement and some policies were in need of review. The governance arrangements were not fully embedded and this had led to gaps in safe management of the service.

These arrangements had improved when we undertook a follow up inspection on 20 July 2017 and the practice is now rated good for being well led.

  • The GPs stated they 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 and we saw that these had been reviewed and updated. There were regular staff team meetings; however the full team met rarely to share information and learning. All senior staff had clearly defined key areas of responsibility.

  • 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 GPs 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 met regularly to discuss ways in which the needs of the local population might be better met. This included attempts to widen representation on the group.

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

Checks on specific services

People with long term conditions

Good

Updated 12 September 2017

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.

  • The practice requested that  all newly registering patients completed a health questionnaire which helped to identify any long term conditions early in the relationship with the practice.

  • Performance for diabetes related indicators was comparable to the national average. For example the percentage of patients with diabetes, on the register, in whom the last blood pressure reading was 140/80 mmHg or less in the period April 2015 to March 2016 was 77%. (CCG average 82% National average 78%).

    The diabetic nurse specialist was regularly contacted for advice and diabetic patients with complex problems were referred to the external diabetes service. One of the practice nurses had attended training to initiate and manage patients on injectable insulin with the support of the diabetic nurse specialist. This meant that patients need not travel to the hospital for this treatment.

  • Clinics were held in the practice for patients with

    heart disease, chronic obstructive pulmonary disease (COPD) and asthma.

    This was also an opportunity to provide flu and pneumonia vaccination and issue patients with rescue packs including antibiotics for respiratory conditions.

  • A smoking cessation service was offered by a local pharmacy.

  • Longer appointments and home visits were available when needed.

  • All these patients had 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.

  • The practice offered 24 hour ambulatory blood pressure monitoring and had blood pressure monitors to loan to patients.

Families, children and young people

Good

Updated 12 September 2017

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

  • There were comprehensive 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 and those who did not attend secondary care appointments.

  • Immunisation rates for all standard childhood immunisation programmes achieved the targets set for 2016/17 according to unvalidated figures provided by the practice.

  • 87% of women aged 25-64 were recorded as having had a cervical screening test in the preceding 5 years. This compared to a CCG average of 82% and a national average of 82%.Appointments were available outside of school hours and the premises were suitable for children and babies.

  • We saw positive examples of joint working with midwives and health visitors.

  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.

  • Young people were signposted or referred to appropriate services such as Child and Adolescent Mental Health..

  • The practice promoted the local “pharmacy first” scheme for patients who had minor ailments.

 Telephone appointment availability had been reviewed to increase access for this population group.

Older people

Good

Updated 12 September 2017

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. It offered home visits, longer appointments and urgent appointments on the same day. Health checks were available for the over 75 years.

  • The practice was providing an enhanced service in shingle and pneumococcal vaccination to this group of patients. The practice proactively identified patients who were entitled to this vaccination and then contacted them. There were leaflets available at the reception regarding shingles vaccination.

  • Staff sign-posted older patients who were at risk of social isolation to a befriending service run by a voluntary sector agency.

  • The health care assistant carried out home visits to review those who were unable to attend the surgery.

  • Nationally reported data showed that outcomes for patients for conditions commonly found in older people were similar to national averages, 77% of patients diagnosed with dementia had a face-to-face review, which was comparable with the national average of 84%.

  • 20 minute appointments were given to patients aged over 75 years old as routine.

  • The practice actively identified older carers during annual immunisation campaigns.

Working age people (including those recently retired and students)

Good

Updated 12 September 2017

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

  • 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. This included pre-bookable appointments from 8.30am and an on-call doctor available until 6.30pm.

  • The practice was proactive in offering online services including repeat prescriptions as well as a full range of health promotion and screening that reflected the needs for this age group.

  • Health checks were available for patients aged between 40-74years.

  • Telephone consultations were offered daily. There was flexible timing for telephone call backs from the GP. Urgent extra appointments were always available to see clinicians at the practice during opening hours. Patients were directed to Pharmacy first, NHS 111, or the local walk in centre when appropriate.

  • Smoking cessation advice was available at a local pharmacy.Community physiotherapists worked in the practice two days per week and the practice offered weekly minor surgery clinics.

  • Telephone appointments were available for patients who were working and unable to attend the surgery.

  • Travel advice and immunisation was offered by the practice nurse.

People experiencing poor mental health (including people with dementia)

Good

Updated 12 September 2017

The practice is rated as Good for the care of people experiencing poor mental health.

  • 77% of patients diagnosed with dementia had their care reviewed in a face-to-face meeting in the last 12 months, which was below the CCG average of 85% and the national average of 84%. Memory assessment was carried out either opportunistically or as part of the chronic disease review process.
  • 100% of patients with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the record in the preceding 12 months. This was above the clinical commissioning group average of 88% and the national average of 89%. 87% of patients with mental health conditions had their alcohol consumption recorded in the preceding 12 months. This was comparable with the CCG average of 90% and the national average of 89%.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations such as alcohol and drug services and registered patients who were resident at a local drug and alcohol rehabilitation service.
  • Counselling and Improving Access to Psychological Treatment (IAPT) services were available within the practice.
  • Staff had a good understanding of how to support patients with mental health needs and dementia. One of the receptionists had attended training in dementia.

People whose circumstances may make them vulnerable

Good

Updated 12 September 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 those with a learning disability. Alerts for direct access to GPs or nursing staff were added to records of these patients.

  • The practice undertook health checks for patients with learning disabilities at an extended appointment when a nurse and a health care assistant wrote an individual care plan.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients including hospice staff, palliative care nurses and district nurses. This included multidisciplinary integrated care meetings to ensure patients received safe, effective and responsive care.

  • Staff knew how to recognise signs of abuse in vulnerable adults and children.

  • Carers were identified during appointments with practice staff who carers were offered health checks and flu vaccination.

  • Home visits were available if the patient could not attend appointments at the surgery.

  • There were interpreter services available which could be booked for specific appointments for patients who did not speak English as a first language. During the inspection we saw no written information appropriate for patients who did not speak English; however this was rectified within two days following the inspection.

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