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Brownlow Group Practice Outstanding Also known as Ropewalks General Practice

Inspection Summary


Overall summary & rating

Outstanding

Updated 21 February 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Brownlow Group Practice on 14 & 15 December 2016. Overall the practice is rated as outstanding.

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

  • Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.

  • The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the support given to homeless patients and the support given by student services.

  • Feedback from patients about their care was consistently positive.

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they meet patients’ needs.

  • Regular meetings and discussions were held with staff and multi-disciplinary teams to ensure patients received the best care and treatment in a coordinated way.

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

  • The practice actively reviewed complaints and how they were managed and responded to, and made improvements as a result.

  • The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.

  • The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw several areas of outstanding practice including:

  • The practice had a contract to support a number of local intermediate care homes and in 2015 this number increased from 45 to 100 inpatient beds. Key changes were made to the practice team to ensure continuity of care and targeted treatments could be achieved. As the roles developed and services were put in place the practice audited their performance to monitor patient experience and outcomes. A review across April to October 2015 showed improvements in the number of patients having letters sent on to their GPs, improved number of pharmacy led medication reviews (37% to 96%) and low numbers of patients being admitted to hospital (only 4% in the audit period) amongst other positive outcomes.

  • The practice had a cancer support service. This was a nurse led service providing prompt and targeted cancer support and advice to patients and this was achieved within one week of their cancer diagnosis. The nurse acted as a central point of contact for cancer patients and their families across the practice. Communications improved as the nurse developed close links with local hospitals and cancer and Macmillan support agencies and for this development the practice was nominated as a finalist in the Nurse of the Year award in Innovations in Practice 2014.

  • The practice had commissioned a diabetes nurse for two sessions each week to support diabetic students, in particular Type 1 patients. As part of this the nurse had contacted the patients’ previous GPs across the country to ensure that all required treatments and screening had been completed. If not, this would be undertaken at the Student Health location. We found the nurse also provided personalised support via email and mobile number access. These examples had a very positive impact on ensuring continuity of care but also on improving patient outcomes so that a transfer of care could be coordinated safely and effectively.

  • The practice had a significant homeless and hostel dwelling population with drug and alcohol dependent needs and access to services for these patients was good. The practice ran a combination of open same day access clinics, along with booked appointments, as this flexible approach best suited the needs of people who often found it difficult to keep to rigid timetabling and appointments. The practice had experienced clinicians including two dedicated homeless nurses, an alcohol nurse, shared drugs workers, two specialist GPs and close links with the local homeless organisations. During the inspection we observed a flexible, sensitive, confidential and responsive approach when dealing with patients with complex health and mental health needs. We found the practice had good links with a local homeless hostel and daily support was given by a support worker who acted as a waiting room mentor to support patients when they first and subsequently attended the homeless clinic.

  • The learning needs of staff were kept under constant review. The management team and all staff was supported to undertake training and development appropriate to their roles. For example, to support the patients attending the homeless clinic run each week staff had completed training for undertaking ultrasonic liver function tests. This enabled these patients to have a fuller assessment within the practice rather than having to attend hospital which might cause them anxiety.

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

  • Review the systems in place for reporting and analysing the risks, adverse incidents and near misses.

  • Review the monitoring of all areas of the building to ensure cleanliness standards are maintained in all areas including store cupboards.

  • Review the medicines procedures to ensure robust arrangements are in place for doctors taking prescriptions pads to home visits when required

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 21 February 2017

The practice is rated as good for providing safe services. Our findings at inspection showed that:

  • 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 apology. They were told about any actions to improve processes to prevent the same thing happening again.

  • The practice 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 well managed.

Effective

Outstanding

Updated 21 February 2017

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 both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines. A number of management meetings took place to monitor this and ensure compliance. Evidence to confirm that the practice used these guidelines to positively influence and improve practice and outcomes for patients was shown.

  • The practice had a contract to support a number of local intermediate care homes and in 2015 this number increased from 45 to 100 inpatient beds. To support this development a lead GP was identified for intermediate care, there was an increase in sessions undertaken at the care homes, this was carried out across the week at set times and by the same GPs to ensure continuity. Also a team of prescribing clerks worked with the practice pharmacist to review discharged patients and the medicines they had been and were now taking.

  • The information needed to deliver effective care and treatment was available to relevant staff in a timely and accessible way. We saw two very good examples of this. One included how staff that treated homeless patients were having regular contact with hospitals when patients were admitted to ensure their care could be continued after discharge when they had no home address. The other included outstanding care and support given to young diabetic student patients who had started at the university and registered with the practice. These examples had a very positive impact on ensuring continuity of care, but also on improving patient outcomes so that a transfer of care could be coordinated safely and effectively.

Caring

Good

Updated 21 February 2017

The practice is rated as good for providing caring services. Our findings at inspection showed that:

  • Data from the national GP patient survey showed patients rated the practice comparable to other practices for several aspects of care.

  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • Information for patients about the services available was easy to understand and accessible. 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 saw this at the homeless access clinic when Christmas presents had been collected and were given out to all homeless people attending.

  • 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.

  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

Responsive

Outstanding

Updated 21 February 2017

The practice is rated as outstanding for providing responsive services. Our findings at inspection showed that:

  • The practice worked closely with other organisations and with the local community in planning how services were provided to ensure that they met patients’ needs. For example, the practice had monitored and developed a psychology service working alongside Liverpool University. As the service expanded, this included the practice commissioning the support of a clinical psychologist one day each week.

  • There were innovative approaches to providing integrated patient-centred care. For example, the practice had a cancer support service which was a nurse led service providing prompt and targeted cancer support and advice to patients within one week of their canner diagnosis. The nurse provided a central point of contact for cancer patients and their families across the practice. Close links were developed with local hospitals.

  • Patients could access appointments and services in a way and at a time that suited them. The practice had four GP locations, once registered, all patients used any site, with the exception of one which was for University of Liverpool students and staff only. We saw that weekly access meetings and regular systems information reports took place to with the senior management team to closely review patient demand and how flexible this could be met by the practice.

  • The practice had a significant homeless and hostel dwelling population with drug and alcohol dependent needs and they were commissioned to provide an enhanced service to these patients. This included a specialist drop in service called the Homeless Access Clinic (HAC) which ran every Thursday. The practice ran a combination of open access (walk-in) clinics, along with booked appointments, as this flexible approach best suited the needs of people who often find it difficult to keep to rigid timetabling and appointments.

  • The needs of the student population 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, we observed outstanding care and support given to young diabetic student patients who had started at the university and registered with the practice.

  • Information about how to complain was available and easy to understand, and the practice responded quickly when issues were raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Outstanding

Updated 21 February 2017

The practice is rated as outstanding for being well-led. Our findings at inspection showed that:

  • The practice had a clear vision with quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. High standards were promoted and owned by all practice staff and teams worked together across all roles.

  • Governance and performance management arrangements had been proactively reviewed and took account of current models of best practice. A comprehensive understanding of the performance of the practice was maintained.

  • A programme of continuous clinical and internal audit was used to monitor quality and to make improvements. For example, the development and investments made in the delivery of care and treatments for the intermediate care services have been closely monitored to ensure the right skill mix, training for staff and resources were put in to support the practice.

  • The practice was aware of and complied with the requirements of the duty of candour. A culture of openness and honesty was encouraged. The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken.

  • There was a high level of constructive engagement with staff and a high level of staff satisfaction. Staff described a clear leadership structure and they felt supported by management. Staff said they felt respected, valued and supported, particularly by the partners in the practice.

  • A good staff newsletter was published monthly and this covered feedback from patients, welcome comments to new staff, service and staff developments, top tips for staff amongst others.

Checks on specific services

People with long term conditions

Good

Updated 21 February 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.

  • All patients diagnosed with a long term condition had a named GP and a structured annual review to check that their health and medicine needs were being met.

  • Data from the 2015/2016 QOF performance showed the practice achieved % of the total points available for all performance indicators. This was above the CCG and national average.

  • Longer appointments and home visits were available when needed. All these patients 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.

Families, children and young people

Good

Updated 21 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.

  • 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.

  • The practice had recently developed the receptionist role to provide added support to new mums and their babies. These staff named ‘Care Navigators’ had been trained to develop closer links with mums in an effort to improve the practice uptake of children’s vaccination programmes.

  • 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, health visitors and school nurses.

  • The practice had worked hard in recent months to develop their communications with students and young people via a social media platform. At the time of inspection the practice website was receiving a very high number of visits per day (300) and they had achieved 2,715 followers on social media Twitter, which is more than any other practice in the country.

Older people

Good

Updated 21 February 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.

  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs. They had a contract to support a number of local intermediate care homes and in 2015 this number increased from 45 to 100 inpatient beds. We saw a report that identified the challenges the practice faced and the development of staff to meet the increasing needs of their services. A lead GP was identified for intermediate care, there was an increase in sessions undertaken at the care homes, and this was carried out across the week at set times and by the same GPs to ensure continuity. Administration roles were developed and a team of prescribing clerks worked with the practice pharmacist to review discharged patients and the medicines they had been and were now taking.

  • All the older patients had a named GP who coordinated their care and contacted patients over 75 following discharge from an unplanned hospital admission.

  • Nationally reported data showed that outcomes for patients were good for conditions commonly found in older patients.

  • The practice provided care for patients at three local nursing homes. GPs visited weekly and also responded to urgent heath care needs when required.

  • The practice had signed up to the admissions avoidance service, which identified patients who were at risk of inappropriate hospital admission.

Working age people (including those recently retired and students)

Outstanding

Updated 21 February 2017

The practice is rated outstanding 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. For example, we observed outstanding care and support given to young diabetic student patients who had started at the university and registered with the practice. The practice had commissioned the support of a diabetes nurse who had contacted the patients previous GPs across the country to ensure that all required treatments and screening had been completed. If not this would be undertaken at the Student Health location. We found the nurse also provided personalised support via email and mobile number access.
  • The practice monitored and developed a service effectively which included the establishment of a psychology service with Liverpool University. As the service expanded, this included the practice commissioning the support of a clinical psychologist 2.5 days per week. 
  • The practice also worked closely with psychiatry services in Liverpool to secure the support of a community psychiatric nurse and they liaised with university services, including university welfare and counselling services to provide mental health services to students across the city. The practice identified a designated GP partner to liaise with Liverpool University when new students arrived and at the time of inspection approximately 16,000 students had registered with the practice.
  • We saw that health promotional days had been set up for students (e.g. a student mental health and well-being day) with support from the practice GP and health trainer to raise awareness of mental health issues and services available at the practice.

People experiencing poor mental health (including people with dementia)

Good

Updated 21 February 2017

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. The Homeless Access Clinic (HAC) provided all of the full range of medical and health care in a standard GP practice but in addition they provided specialised mental health and alcohol and drug treatment services, therapeutic interventions, welfare rights support and housing advice. The service worked closely with a social work team to provide integrated care plans for users and a waiting room manager ensured access was straight forward during the open access clinic. Workers provided outreach clinics in a number of partner agencies, but also worked with clients from local hostels and voluntary services providing support to the homeless across the centre of Liverpool. We spoke with staff and found a tenacious attitude to making sure the access to treatments was kept going for patients before, during and after they had been admitted to hospital

  • The practice carried out advanced 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 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.

People whose circumstances may make them vulnerable

Outstanding

Updated 21 February 2017

The practice is rated outstanding for the care of people 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 offered longer appointments for patients with a learning disability.

  • 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.

  • The practice had a significant homeless and hostel dwelling population with drug and alcohol dependent needs and they were commissioned to provide an enhanced service to these patients. This included a specialist drop in service called the Homeless Access Clinic (HAC) which ran every Thursday. The practice ran a combination of open access (walk-in) clinics, along with booked appointments, as this flexible approach best suited the needs of people who often found it difficult to keep to rigid timetabling and appointments. The practice had experienced clinicians including two dedicated homeless nurses, an alcohol nurse, shared drugs workers two specialist GPs and close links with the local homeless organisations. These staff members attend multi-disciplinary meetings across the city for this population group. During the inspection we observed a flexible, sensitive, confidential and responsive approach when dealing with patients with complex health and mental health needs.