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Hickings Lane Medical Centre Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 26 October 2016

We carried out an announced comprehensive inspection at Hickings Lane Medical Centre on 25 July 2016. Overall the practice is rated as outstanding.

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. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. Opportunities for learning were maximised.

  • Risks to patients were assessed and well managed.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. There was a very supportive approach to staff development to ensure they had appropriate skills and experience. The practice used clinical audit to improve patient care and drive quality improvement within the practice.

  • The practice participated in the structured apprentice programme for young adults aspiring to work in primary care.

  • The practice had systems in place to seek consent to summary care records from patients reaching their sixteenth birthday.

  • The practice worked effectively with the wider multi-disciplinary team to plan and deliver integrated care that was responsive to the needs of patients.
  • The practice used proactive methods to improve patient outcomes, working with other local providers to share best practice. This included teledermatology and tele-consultations with hospital consultants.
  • The practice proactively reached out to the community and worked constructively with other organisations to promote patient education and a healthy lifestyle.
  • Feedback from stakeholders and patients about their care, and interactions with all practice staff, was consistently and strongly positive. Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • The practice offered extended opening hours between 7.30am and 7pm Monday to Friday, with the exception of Thursday when the practice closed at 6.30pm. 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.
  • 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 a clear vision which had quality and safety as its top priority. The strategy to deliver this vision was regularly reviewed with stakeholders and discussed with staff.
  • There was a strong and proactive leadership structure within the practice, and staff felt well-supported by management.
  • The leadership drove continuous learning and improvement at all levels, and staff were accountable for delivering change.

We saw several areas of outstanding practice:

The emotional and social needs for children and young people were seen as important as their physical needs. For example:

  • As part of a community project, one of the GP partners had worked with local organisations, young people and children to promote anti-bullying. This included a theatrical production aimed to empower young people to explore anti-bullying issues and seek support when needed.

  • The practice team championed the delivery of good quality care and a flexible service to young people residing in secure children’s home. Ofsted had positively recognised the input of the GPs and practice nurses (and other agencies) in the support provided to the children.

  • The practice offered a range of extra services which provided care closer to patients' homes and reduced referrals and / or burden on hospital services. For example, ultrasound scanning for orthopaedic, musculosketal and dermatology conditions and detection of breech presentations in pregnant women. In addition, the daily extended hours enabled improved access to services for patients.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 26 October 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting, recording and investigating significant events. Learning was based on a thorough analysis and shared with staff and external organisations to support wider improvement.

  • The practice had effective systems in place to ensure they safeguarded vulnerable adults and children from abuse. This included collaborative working with the health visitor, midwife and social workers.

  • The arrangements for managing medicines and vaccines kept patients safe. The practice employed a pharmacist to support the clinicians, and as a result positive outcomes were achieved for patients.

  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe. This included the management of infection control practices and the risks related to the premises, environment and equipment.

  • Staff had received appropriate pre-employment checks and sufficient staff with the right? appropriate skills and experience were in place to meet patients’ needs.

  • The practice had plans in place for dealing with emergencies and staff we spoke with understood their individual roles. This included providing basic life support in a medical emergency, and having a business continuity plan in place for major incidents.

Effective

Good

Updated 26 October 2016

The practice is rated as good for providing effective services.

  • The practice had systems in place to ensure all clinicians were kept up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines. We saw evidence to confirm that the practice staff used these guidelines to influence and improve practice and patient outcomes.

  • The practice used evidence-based procedures and technologies to support the delivery of high-quality care. This included use of ultrasound scans to detect breech presentation in later pregnancy and screening of abdominal aortic aneurysm.

  • Published data showed the practice was performing highly when compared to other practices nationally.

  • The practice had an embedded programme in place for undertaking clinical audits with evidence of quality improvement. The practice had achieved three awards for clinical audits related to specific medicines and consent.

  • Staff had the skills, knowledge and experience to carry out their roles effectively. They were supported to deliver effective care and treatment through supervision, appraisal and personal development plans.

  • Multi-disciplinary working with other health care professionals promoted the provision of integrated care for patients with complex health needs, and / or living in vulnerable circumstances. Feedback from external stakeholders was wholly positive.

  • Staff were proactive in supporting residents within the local community to live healthier lives. This included facilitating healthy lifestyle events for different population groups, and focusing on patient education and empowerment, prevention of ill-health and supporting people to improve their health and wellbeing.

Caring

Good

Updated 26 October 2016

The practice is rated as good for providing caring services.

  • Feedback from patients about their care and treatment was consistently positive. Patients told us they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

  • Patients also gave specific examples of when staff addressing the risk of their health condition deteriorating and to ensure their wellbeing.

  • People’s emotional and social needs were seen as important as their physical needs. For example, one of the GP partners had a passion to minimise children and young people being bullied and as a result was proactive in facilitating theatre shows related to the anti-bullying campaign. Over 200 patients had responded to the Age UK ‘Fit for the Future’ project in 2015. This project was aimed at improving the mental health and physical wellbeing of patients aged 65 and over. A congratulations card was also sent to mothers when they had a new baby.

  • Views of external stakeholders were very positive in respect of the high level of care provided by the practice team and was aligned with our observations.

  • A caring and person centred attitude was demonstrated by all staff we spoke to during the inspection.

  • Data from the national GP patient survey showed patients rated the practice in line with the local and national averages for several aspects of care. For example, 85% of respondents said the last GP they spoke to was good at treating them with care and concern compared to the local average of 86% and the national average of 85%.

Responsive

Outstanding

Updated 26 October 2016

The practice is rated as outstanding for providing responsive services.

  • The practice worked closely with other organisations and the local community in planning how services were provided, to ensure that they meet patients’ needs. For example, the practice was scheduled to merge with another local practice by April 2017, which would increase service provision and accommodate the training of medical students and doctors.

  • The practice offered extra services which provided care closer to patients' homes and helped reduce the pressures on hospital services. For example, the practice had purchased a dermatoscope which was used to examine patients with pigmented skin lesions, and images were sent to hospital dermatology consultants.

  • The practice had initiated positive service improvements for its patients that were over and above its contractual obligations.

  • The practice offered extended opening hours between 7.30am and 7pm Monday to Friday with the exception of Thursday when the practice closed at 6.30pm.

  • Patients we spoke to and comment cards received were very positive about people’s experience in obtaining both urgent and routine appointments. This feedback was aligned with most of the national GP survey results.

  • The practice had good facilities and improvements were being made to the premises to ensure they were suitable for all patients to access.

  • 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 26 October 2016

The practice is rated as outstanding for being well-led.

  • 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.

  • There was a clear leadership structure and staff felt supported by management.

  • High standards were promoted and owned by all practice staff and there was strong team working across all roles.

  • Governance and performance management arrangements had been proactively reviewed and took account of current models of best practice. This included policies and procedures, arrangements to address risks and monitor the service provision.

  • There was a high level of satisfaction and constructive engagement amongst the staff team.

  • The practice had a very engaged patient participation group which influenced practice and community developments.

  • The leadership drove continuous learning and improvement at all levels, and staff were accountable for delivering change.

  • The GP partners undertook lead roles outside of the practice which helped enhance the quality of care for patients and influenced decisions about service provision within the local area.
Checks on specific services

People with long term conditions

Good

Updated 26 October 2016

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

  • The practice had facilitated a community healthy lifestyle outreach event in July 2014, which provided information and support for people who had coeliac disease, lactose intolerance and those wanting advice regarding weight management. Following this event, the practice nurse and community dietician held a six week weight management course for the attendees including non-registered patients.

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. The practice team monitored hospital admissions and discharges, and telephoned high-risk patients to assess if any additional help was required.

  • 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 the local community health teams to deliver a multidisciplinary package of care. This included specialist nurses for heart failure, diabetes and palliative care.

  • Joint clinics were undertaken with a diabetic specialist nurse on a monthly basis to facilitate the management of patients with complex needs. This enhanced the skills of the practice nurse and enabled them to initiate insulin at the practice.

  • Uptake rate of vaccinations for long term conditions including flu and pneumococcal vaccinations were relatively high when compared with the local average.

  • Longer appointments and home visits were available when needed.

Families, children and young people

Outstanding

Updated 26 October 2016

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

  • The GPs and practice nurse undertook regular visits to a secure unit for young people aged between 10 and 17 years. The service offered by the GPs and practice nurse was recognised in the care homes’ Ofsted annual report, which rated the provider as outstanding.

  • Pregnant mothers were offered an ultrasound scan in order to help spot breech babies before they were born. This enabled the obstetrician and midwife to discuss with the mother the best and safest form of delivery. Breech presentations occur when the baby is lying feet first with their bottom downwards. Expectant mothers could access a weekly ante-natal clinic held by the community midwife.

  • Childhood development checks and vaccinations were jointly carried out by the GP and practice nurse in line with national guidelines. This included neonatal checks, six week post-natal checks for new mothers and eight week baby checks.

  • The uptake rates for childhood immunisations were high and above the local averages. For example, published data showed vaccination rates for children under two years old ranged from 97% to 100% compared to the local average ranging from 96% to 97.5%.

  • Records reviewed demonstrated positive examples of joint working with midwives, health visitors, school nurses and social worker. This included six-weekly safeguarding meetings to discuss children in need, on protection plans, at risk of deteriorating health needs and their families. All staff had received relevant training in safeguarding children and vulnerable adults.

  • 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.

  • Appointments were available outside of school hours and this included same day appointments for children aged two and under.

  • The premises were suitable for children and baby changing facilities were available.

  • The practice staff and the patient participation had facilitated a community outreach event in March 2014 aimed at families and young people. A total of 21 adults and 18 children attended.  The activities included a mother and baby yoga session, information relating to Sure Start, support services for children with disabilities and breast feeding.

Older people

Good

Updated 26 October 2016

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

  • The practice had facilitated a community outreach event in 2014 aimed at people aged over 65. About 60 people participated in the event and various organisations attended including the citizens advice bureau and a community based dietician.

  • Over 200 patients over the age of 65 had responded to the Age UK ‘Fit for the Future’ project in 2015. Some of the support offered to patients included claiming for attendance allowance, signposting to social groups, the community transport scheme and occupational services.

  • Data reviewed showed clinical outcomes for conditions commonly found in older people were above local and national averages. This included osteoporosis and rheumatoid arthritis.

  • Monthly multi-disciplinary care meetings were held to ensure integrated care for older people with complex health care needs, and those who were frail and elderly. This allowed patients to be cared for in the community and avoid unnecessary hospital admission.

  • Longer appointment times and home visits were available for those unable to attend the surgery; and every patient over the age of 75 years had a named GP.

  • Influenza and shingles vaccinations were offered to older patients in accordance with national guidance.

Working age people (including those recently retired and students)

Outstanding

Updated 26 October 2016

The practice is rated as outstanding for the care of working-age people (including those recently retired and students).

The needs of patients had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care.

  • The practice provided extended opening hours and appointments five days per week and this included appointments to see the GP, practice nurse and healthcare assistant from 7:30am. Feedback from most patients was consistently positive about their experience in obtaining an appointment quickly and at a convenient time for them.

  • A text reminder service was used to remind patients of their pre-booked appointment 24 to 48 hours in advance to help reduce non-attendance for appointments.

  • Telephone consultations were available each day for those patients who had difficulty attending the practice due to work commitments for example.

  • The practice promoted the use of online services to book and cancel GP appointments, order repeat prescriptions and review a summary of their medical records.

  • Students could register as a temporary resident outside of the university term time.

  • A full range of contraceptive services including a coil fitting service and contraceptive implants was offered.

  • Both GPs had additional qualifications in sports medicine and dermatology which was beneficial for patients, in that diagnostic and screening procedures were undertaken within the practice and data reviewed showed patients had quick access to treatment and care where required.

  • The practice promoted health screening programmes that reflected the needs for this age group. This included travel vaccinations and screening for prostate cancer and abdominal aortic aneurysm. Uptake rates for cervical screening for women between the ages of 25 and 64 and NHS health checks for patients aged 40 to 74 were above the local averages.

People experiencing poor mental health (including people with dementia)

Good

Updated 26 October 2016

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

  • The practice worked with multi-disciplinary teams in the case management of people experiencing poor mental health, including those with dementia. This included advance care planning for patients with dementia and collaborative working with the local mental health team, to ensure patients experiencing acute difficulties or a crisis, received urgent intervention to manage their condition.

  • Same day appointments and home visits were offered to patients if needed.

  • A system was 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. This included referring patients to services providing psychological and talking therapies, providing information on various support groups and voluntary organisations, as well as liaising with the community geriatrician about their care.

  • Arrangements were in place to ensure patients taking high risk medicines requiring regular and essential blood monitoring took place in a timely way.

    Published data showed approximately:

  • 93% of patients on the practice’s mental health register had received an annual health check in 2014/15. This was in line with the local average and 5% above the England average.

  • 78% of people diagnosed with dementia had had their care reviewed in a face to face meeting during 2014/15. This was 8% below the local average and 6% below the national average.

People whose circumstances may make them vulnerable

Good

Updated 26 October 2016

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 patients with a learning disability. All of the 24 patients with a learning disability had received an annual review in the last 12 months, and the practice staff had completed learning disabilities awareness training.

  • The practice offered a flexible service to patients who needed to attend appointments with a carer. Appointments were arranged outside of normal clinical times if required.

  • The practice team was aware of the new guidelines regarding accessible information standards, and as a result proactively identified patients who required additional support at the point of registration. These patients were then set up with an alert on the computer system to ensure they were easily identifiable to all staff.

  • The practice provided relevant information and support for carers and patients receiving end of life care. Patients were kept under close review by the practice team in liaison with the wider multi-disciplinary team.

  • All staff had received safeguarding training relevant to their roles, including domestic violence, consent and the Mental Capacity Act 2005. 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.

  • Patients were able to access an interpreter for pre-booked appointments, a chaperone if needed, weekly dosettes, a wheelchair within the premises and information in large print.