Bolton General Practice

We carried out an announced inspection at Bolton General Practice on 14 March 2022. Overall, the practice is rated as Outstanding with the following key question ratings:

Safe - Good

Effective - Good

Caring - Outstanding

Responsive - Outstanding

Well-led - Outstanding

Following our previous inspection on 16 June 2017 the practice was rated Outstanding overall and for the key questions caring and responsive. Since that inspection the practice had moved to a new location.

Why we carried out this inspection

This was a full comprehensive inspection due to changes to the registration and location of the practice.

How we carried out the inspection/review

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection included:

• A site visit by the lead inspector.
• Conducting staff interviews remotely and on site.
• Completing clinical searches remotely on the practice’s patient records system and discussing findings with the provider.
• Reviewing patient records remotely to identify issues and clarify actions taken by the provider.
• Requesting evidence from the provider.
• Gaining feedback from staff by using staff questionnaires.

Our findings

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

Our findings

We have rated this practice as outstanding overall.

We rated the practice as outstanding for providing caring services because:

• Patients were truly respected and valued as individuals and were empowered as partners in their care, practically and emotionally, by an exceptional and distinctive service.
• The practice adopted a holistic approach to caring by addressing all the needs of the patient, including their physical, mental, and emotional health, while taking social factors into consideration.
• The practice demonstrated a truly patient-centred culture and staff were committed to delivering excellent care to meet the needs of individuals.
• The practice recognised that social isolation was a key issue for some patients and the practice had established a number of services to address this, for example, patients living in social isolation or new to the practice were invited to attend a weekly conversation café. The conversation café was run by the patient liaison worker, attended by staff, voluntary organisations and community workers. Patients could drop in for advice, guidance and support or to meet new people. Due to the constraints of the pandemic there was a period when the conversation café was closed, however staff kept in regular contact with the patients throughout and this facility has now reopened.
• The practice had also introduced welfare appointments with the health care assistant. These could be accessed by filling in a confidential ‘loneliness slip’ or speaking with a member of staff.
• The practice was working with the local Ukrainian residents supporting the Ukrainian glove appeal. The practice was a designated drop off centre for donations.

We rated the practice as outstanding for providing responsive services because:

• Services are tailored to meet the needs of individual people and are delivered in a way to ensure flexibility, choice and continuity of care.
• The practice organised and delivered services to meet patients’ needs. Patients could access care and treatment in a timely way.
• The practice adjusted how it delivered services to meet the needs of patients during the COVID-19 pandemic. Patients could access care and treatment in a timely way.
• The practice introduced an initiative to support parents, guardians and expectant parents. This was to provide professional advice and to empower them to deal with minor ailments and emergency situations.

We rated the practice as outstanding for providing well led services because:

• The practice management team were motivating, forward thinking, organised and innovative with a sensible approach and clear goals. Staff told us they received excellent support and encouragement from the SSP leadership team to do this. The practice management team were compassionate and caring. Quality and integrity were a high priority resulting in a caring culture within a strong practice. There were opportunities provided for all staff for their personal development.
• The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care.
• There was strong collaboration across all staff and a common focus on engaging with patients and other services to improve quality of care and the patient experience.
• The practice embraced social prescribing for the community to ensure patients received timely intervention when they needed it most, signposted them to services that could help them and ensured support was offered locally so the patient population could easily attend appointments.

We have rated this practice as good for providing safe and effective services because:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.

We saw several areas of outstanding practice including:

• Practice champions who were members of the administrative team, for example palliative care and carers’ champions, were trained to safeguarding vulnerable adults and children level three. This enabled champions to have a better understanding of the needs and vulnerabilities of some patients. They were familiar with these patients and trained to recognise any concerns. For example, the cancer champion contacted all newly diagnosed patients to ensure the patient had the systems, processes and support in place for their follow up treatment and medication.
• The practice recognised the need for advocacy and support services for patients to be provided in house and had a number of initiatives on-going, for example, the practice employed a patient liaison worker to provide advocacy for vulnerable patients especially those for whom English was not their first language and those new to the practice. They acted as a focal point for communication between patients, GPs and other health and social care teams.
• The practice recognised that social isolation was a key issue for some patients and the practice had established a number of services to address this, for example, patients living in social isolation or new to the practice were invited to attend a weekly conversation café. The conversation café was run by the patient liaison worker, attended by staff, voluntary organisations and community workers.
• The practice identified patients who were isolated and lonely as a result of the Covid-19 pandemic. Some patients did not have close family in Bolton and, due to their significant comorbidity, had to shield for health reasons which confined them to their accommodation and increased their feelings of isolation. In response to this practice staff took it in turns to ring patients to have an informal chat and check on their well-being. The practice identified some patients had extended family in other areas and encouraged them to contact them and the practice monitored this. Patients were referred to the social prescribing scheme and practice staff worked with the social prescribers to support them in specific areas. Patients had expressed a wish to move closer to the family and the practice on their behalf wrote supporting letters to ask for priority in housing. The practice in co-operation with the social prescribing team supported patients in seeing their family, enabling some to spend time with them. The practice and the social prescribing team also supported patients by increasing activities locally. Some patients were currently on the waiting list for a property in the other area. We saw that patients expressed they felt hopeful for the future and had expressed thanks for the support and approach the practice took.
• We saw several examples of the practice providing outstanding care to vulnerable patients. This included patients with a complex combination of cognitive impairment and mental health issues, who were also in the criminal justice system. We saw examples of practice intervention which provided detailed reports for court, which led to a positive outcome for patients, leading to no prison time and better mental ill health care for patients. From this the practice had been and are continuing to support patients and their family members with their mental health, and this was more manageable since the crisis was resolved. There were also patients facing the threat of deportation. Some were diagnosed with post-traumatic stress disorder (PTSD) and depression with significant memory impairment. These symptoms were compounded by the threat of deportation. The practice worked with these patients to access assessments and support from both the mental health team and the memory clinic. They prescribed anti-depressant medication and patients were was reviewed regularly. The practice wrote to the home office detailing their medical and mental health problems. They advised they would need access to medical care, frequent review and support from both GP and psychological therapy as well as medication. As a result of this patients had now been given right to remain in the UK from the home office. Patients expressed thanks to the practice for the support. They advised the correspondence from the practice was very helpful as supporting evidence.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care