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Inspection Summary


Overall summary & rating

Good

Updated 1 October 2018

This practice is rated as Good overall.

The key questions at this inspection are rated as:

  • Are services effective? – Good

When we visited Trowbridge Health Centre on 22 and 23 February 2018, to carry out a comprehensive inspection, we found the practice was not compliant with the regulation relating to staffing. Overall the practice was rated as Good. They were rated as good for providing safe, caring, responsive and well-led services, and as requires improvement for providing effective services. The full report on the February 2018, inspection can be found by selecting the ‘all reports’ link for Trowbridge Health Centre on our website at www.cqc.org.uk.

This report covers the announced follow up focused inspection we carried out at Trowbridge Health Centre on 15 August 2018, to review the actions taken by the practice to improve the quality of care and to confirm that the practice was meeting legal requirements.

At this inspection we found:

  • New ways of working were becoming embedded in the practice culture. At our last inspection the practice was coming out of a significant period of change which including merging with two other local practices and moving into a new main surgery building that had not been completed on time. The practice told us the disruption caused by these changes was now behind them. The evidence we saw and our conversations with staff during this inspection confirmed this.
  • The practice had a clear system for staff records which had been reviewed since our last inspection in February 2018.
  • Since our last inspection the practice had reviewed the mandatory training requirements for all staff. There was a clear system for monitoring all mandatory and non-mandatory training.

Trowbridge Health Centre is now rated as good overall and in all key questions.

  • Are services safe? – Good
  • Are services effective? – Good
  • Are services caring? – Good
  • Are services responsive? –Good
  • Are services well-led? - Good

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Please refer to the detailed report and the evidence tables for further information.

Inspection areas

Safe

Good

Updated 29 March 2018

Effective

Good

Updated 1 October 2018

At our previous inspection on 22 and 23 February 2018, we rated the practice as requires improvement for providing effective services. We found the practice was not compliant with the regulation relating to staffing. Specifically, we found the practice systems did not ensure that all staff had received the training they considered essential for their role.

We also noted some other areas where the provider should make improvements. These were:

  • Improve the uptake of cervical screening.
  • Review their exception reporting for mental health criteria within the Quality Outcome Framework, which were above the national average. (Exception reporting is the removal of patients from QOF calculations where, for example, the patients decline or do not respond to invitations to attend a review of their condition or when a medicine is not appropriate.)
  • Review staff knowledge of how to access meetings minutes on the practice IT system.

These arrangements had significantly improved when we undertook a follow up inspection on 15 August 2018. The practice is now rated as good for providing effective services.

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. Clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.
  • The practice used computer based guidance templates for most standard activities, such as health checks, referrals and assessing patients capacity to consent to treatment. These templates ensured GPs were aware of the latest guidance, recorded clinical data in a uniform way and provided links to further information, including patients leaflets which could be printed out during the consultation.
  • The practice ran a community cardiology unit that was led by one of the practice GP partners who had received additional training in cardiology and received regular review of their practice from a visiting cardiology consultant. There was a dedicated service suite that offered echocardiograms, exercise tolerance tests and 24 hour ECG monitoring. This meant that patients needing this service avoided travelling to the nearest hospital.

Older people:

  • The practice worked with another GP practice in Trowbridge to meet the needs of older people through a jointly managed service. The service, funded by the clinical commissioning group (CCG), included a nurse, a care coordinator and a pharmacist specialising in older people’s medicine.
  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. Those identified as being frail had a clinical review including a review of medication.
  • Patients aged over 75 were invited for a health check. If necessary they were referred to other services such as voluntary services and supported by an appropriate care plan.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.

People with long-term conditions:

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.

Families, children and young people:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme.
  • The practice had arrangements to identify and review the treatment of newly pregnant women on long-term medicines.
  • The practice held regular clinics to insert contraceptive devices.

Working age people (including those recently retired and students):

  • At our last inspection we told the practice they should improve the uptake of cervical screening. At this time the practice’s uptake rate for cervical screening was 73%. On this inspection we were shown unverified data for the year April 2017 to March 2018, showing this had increased to 82%.
  • Flexible appointments were available to patients attending the screening program. Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.

People whose circumstances make them vulnerable:

  • End of life care was delivered in a coordinated way which took into account the needs of those whose 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 used a recognised system for health checks for patients with learning disabilities.

People experiencing poor mental health (including people with dementia):

  • 99% of patients diagnosed with schizophrenia, bipolar affective disorder and other psychoses had a comprehensive, agreed care plan documented in the previous 12 months. This is better than the national average of 90%. The exception reporting rate was 22% compared with a national average of 13%.
  • The practice specifically considered the physical health needs of patients with poor mental health and those living with dementia. For example, the percentage of patients experiencing poor mental health who had received discussion and advice about alcohol consumption (practice 93%; CCG 94%; national 91%). The exception reporting rate was 24% compared with a national average of 11%.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed review the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

The most recent published Quality Outcome Framework (QOF) results were for the year 2016/17 (QOF is a system intended to improve the quality of general practice and reward good practice.) Data from this time period was taken prior to the merger with the local practices and therefore only relates to one GP practice (previously know as Adcroft Surgery). On this inspection the practice was able to provide some unverified QOF data from the year April 2017 to March 2018. The data for this period includes approximately six months data for the single practice of Adcroft, when they had approximately 14,000 patients and six months following the merger (and name change) when patient numbers increased to approximately 30,000. For technical reasons, the unverified data does not include exception reporting rates. (Exception reporting is the removal of patients from QOF calculations where, for example, the patients decline or do not respond to invitations to attend a review of their condition or when a medicine is not appropriate.)

  • The practice had focused on making improvements to their update of the cerivical screening programme. The practice told us they had had clinical discussions around this and were actively encouraging women to attend. Unverified data from the practice for the year 2017/2018 suggests that the practices uptake rate had improved.
  • The practice demonstrated what actions they had taken to improve the exception reporting rate for patients with mental health issues. For example, discussions in team meetings about the importance of discussing with patients alcohol consumption. For technical reasons due to the merger the practice were unable to provide numerical data to evidence the impact this had had (in terms of exception reporting levels).
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives.

Effective staffing

Staff had the skills, knowledge and experience to carry out their roles.

  • On our previous inspection in February 2018, the practice was unable to verify that all staff had the skills, knowledge and experience to carry out their roles. We were told this was because the staff records of the three practices that had recently merged had not yet been collated into a single record structure. The staff we spoke to during the inspection were able to evidence knowledge appropriate to their role.
  • On this inspection we saw evidence the practice had reviewed the system for staff records and had completed the task of merging the previous three systems into one. They had reviewed the mandatory training for all staff and had a clear spreadsheet which they used to keep track of training requirements and which alerted them to mandatory training that had not been completed.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Staff we spoke to confirmed this.
  • The practice provided staff with ongoing support. This included an induction process, one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. Some staff from the two recently merged practices had not had an appraisal in the previous 12 months. We saw that these were scheduled in the practices appraisal system. The practice provided in-house appraisals for salaried GPs.

  • The induction process for healthcare assistants included the requirements of the Care Certificate. The practice ensured the competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing.
  • On our last inspection some staff told us they sometimes had difficulty accessing team minutes on the new IT system. On this inspection the practice told us they had taken a range of actions to ensure all staff knew how to access meeting minutes. These included, written guidance, reminders and checking with each member of staff individually. We saw evidence to support this and the staff we spoke to also confirmed this.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients receiving end of life care, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their health.
  • There were large TV screens in the waiting rooms giving a range of health awareness information, such as advice on alcohol consumption and sexual health.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.

Caring

Good

Updated 29 March 2018

Responsive

Good

Updated 29 March 2018

Well-led

Good

Updated 29 March 2018

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good