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Inspection Summary


Overall summary & rating

Outstanding

Updated 12 November 2015

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Brookvale Practice on 8th September 2015.

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.

  • Risks to patients were assessed and well managed

  • The practice used innovative and proactive methods to improve patient outcomes, for example, through its use of screening services and health promotion.

  • There was a robust system in place to undertake audits of the operation of the practice and improve patient care.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. Information was provided to help patients understand the care available to them.

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

  • The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG).
  • The practice was well equipped to treat patients and meet their needs. Information about how to complain was available and easy to understand
  • The practice had a clear vision which had quality and safety as its top priority. There was a clear leadership structure and staff felt supported by management.

We saw several areas of outstanding practice including:

  • The practice proactively engaged patients to promote their well-being. The practice had run several events to raise patient awareness of health conditions and promote good health. For example, a talk was given to patients about mammography screening to improve mammography uptake. This event was held in the evening to promote attendance. A health promotion evening was held were male patients were invited for a range of health checks such as blood pressure, body mass index (BMI) and glucose monitoring. Information stands were available and a presentation was given by one of the GPs about prostate cancer risk. This event was well attended and helped to identify several patients who required follow up. The Fit for 15 campaign was introduced this year to increase the cardiovascular screening of patients aged 18 and over. In the last 12 months the practice had completed 478 health checks compared with 253 the previous year.

  • The practice had strategies in place to identify long term conditions early and therefore improve patient care. For example, to identify patients at risk of chronic obstructive pulmonary disease (COPD) spirometry was offered to smokers aged 35 and over. This strategy had been in place for a number of years and this work gained recognition with a prize from the International Primary Care Respiratory Group. The practice also took pulse checks at each chronic disease review and at flu clinics and had an ECG on site to identify patients at risk of atrial fibrillation. Data showed that Brookvale Practice had more patients with atrial fibrillation than other practices within the CCG. A one day event was also held were practice staff visited the homes of patients who were overdue a blood pressure check to carry out this health screening and promote patient wellbeing.

  • The practice provided examples of audits to demonstrate that audit and quality improvement were central to the operation of the practice. The practice had been recognised by the RCGP Mersey faculty having won prizes for an audit of diabetes care and an audit of peripheral vascular disease.

  • Home visits were undertaken to housebound patients and patients that were hard to engage. The nursing team dedicated two days per week to home visits which included long term condition reviews and immunisation. The effectiveness of this approach (together with extended hours and publicity) was shown in data demonstrating flu vaccine uptake for 2014. For example, the practice had vaccinated 61.5% of the patient population under 65 and at risk compared to 45.7% and 46.9% at two neighbouring practices with a similar patient population. Quality and Outcomes Framework (QOF) Performance also showed the effectiveness of this approach. For example, performance for diabetes assessment and care was higher than the national averages. For example, the percentage of patients with diabetes who had received foot screening was 94% when compared to the national average of 88%. The percentage of patients who had received a blood pressure reading in the last 12 months was 85% compared to the national average of 78% and the percentage of patients who had received an albumin: creatinine ratio test was 94% compared to the national average of 85%.

  • The practice provided a range of services to demonstrate that it was person centred in its approach to patient care and that it recognised and respected the totality of patients’ needs. The practice had close links with the Halton Carers Association and a representative from the association attended practice meetings such as the avoiding unplanned admissions to hospital and palliative care meetings so they were able to identify any support needed by carers and act promptly. A carer’s register was maintained. Information publicising services for carers was available in the waiting area and on the website. Text messages were sent to carers notifying them of events and useful information. For example, carers had recently been sent a text message about a non-means tested allowance available to them for breaks. Staff told us that if families had suffered bereavement, their usual GP contacted them or sent them a sympathy card. A Christmas present or hamper was provided to older patients with no family. The practice had signed up for the Safe in Town scheme and provided a safe haven for vulnerable people (vulnerable people were able to come to the practice and the person’s carers would be contacted). In 2014 the practice was awarded a grant to develop a community garden at the practice. Patients worked to create the garden which provided exercise and reduced social isolation.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 12 November 2015

The practice is rated as good for providing safe services. Staff understood and fulfilled their responsibilities to raise concerns, and to report incidents and near misses. Lessons were learned and communicated widely to support improvement. Information about safety was recorded, monitored, appropriately reviewed and addressed. Risks to patients were assessed and well managed. We noted that the recruitment practices should be improved by recording an assessment of the physical and mental fitness of staff.

Effective

Outstanding

Updated 12 November 2015

The practice is rated outstanding for providing effective services. The practice proactively engaged patients to promote their well-being. The practice had run several events to raise patient awareness of health conditions and promote good health. For example, a talk was given to patients about mammography screening to improve mammography uptake. This event was held in the evening to promote attendance. A health promotion evening was held were male patients were invited for a range of health checks such as blood pressure, body mass index (BMI) and glucose monitoring. This event was well attended and helped to identify several patients who required follow up. The Fit for 15 campaign was introduced this year to increase the cardiovascular screening of patients aged 18 and over. In the last 12 months the practice had completed 478 health checks compared with 253 the previous year.

The practice had strategies in place to identify long term conditions early and therefore improve patient care. For example, to identify patients at risk of chronic obstructive pulmonary disease (COPD) spirometry was offered to smokers aged 35 and over. This strategy has been in place for a number of years and this work gained recognition with a prize from the International Primary Care Respiratory Group. A project was undertaken to encourage male patients over 65 to request aortic aneurysm screening (the national programme offers this to patients who are 65 years of age, patients older than this have to request this screening). Patients were informed about this testing via practice website, waiting room TV, consultations and mailshots. Patients were invited to the practice to discuss to discuss this screening prior to referral. Results showed that 118 scans had been requested and as a consequence six patients with aortic aneurism and an incidental cancer diagnosis had been identified.

The practice had a very good skill mix which included two nurse clinicians and a nurse practitioner who were able to see a broader range of patients than the practice nurses. In addition the practice had four practice nurses and a health care assistant which allowed for greater capacity for monitoring and reviewing patients’ health. The practice provided examples of audits to demonstrate that audit and quality improvement was central to the operation of the practice. The practice had been recognised by the RCGP Mersey faculty having won prizes for an audit of diabetes care and an audit of peripheral vascular disease.

Patients’ needs were assessed and care was planned and delivered in line with current legislation. Staff referred to guidance from the National Institute for Health and Care Excellence (NICE) and used it routinely. Data showed patient outcomes were at or above national averages. Staff worked with other health care teams and there were systems in place to ensure appropriate information was shared. Staff had received training appropriate to their roles and there was a clear commitment towards staff learning and development.

Caring

Outstanding

Updated 12 November 2015

The practice is rated outstanding for providing caring services. The practice provided a range of services to demonstrate that patients were provided with a caring service. The practice had close links with the Halton Carers Association and a representative from the association attended practice meetings such as the avoiding unplanned admissions to hospital and palliative care meetings so they were able to identify any support needed by carers. A carer’s register was maintained. Information publicising services for carers was available in the waiting area and on the website. Text messages were sent to carers notifying them of events and useful information. For example, carers had recently been sent a text message about a non-means tested allowance available to them for breaks. Staff told us that if families had suffered bereavement, their usual GP contacted them or sent them a sympathy card. A Christmas present or hamper was provided to older patients with no family. The practice had signed up for the Safe in Town scheme and provided a safe haven for vulnerable people (vulnerable people were able to come to the practice and the person’s carers would be contacted). In 2014 the practice was awarded a grant to develop a community garden at the practice. Patients worked to create the garden which provided exercise and reduced social isolation.

Patients’ views gathered at inspection demonstrated they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. We also saw that staff treated patients with kindness and respect, and maintained confidentiality. Staff helped people and those close to them to cope emotionally with their care and treatment.

Responsive

Outstanding

Updated 12 November 2015

The practice is rated outstanding for providing responsive services. Services were planned and delivered to take into account the needs of different patient groups. For example, extended hours services were provided Monday and Tuesday morning and evening and from 09:00 to 13:00 on Saturdays. Home visits were undertaken to housebound patients and patients that were hard to engage. The nursing team dedicated two days per week to home visits which included long term condition reviews and immunisation. The effectiveness of this approach was shown in data demonstrating flu vaccine uptake for 2014 was higher than neighbouring practices with a similar patient population. Quality and Outcomes Framework (QOF) Performance for diabetes assessment and care was higher than the national averages. There were longer appointments available for people with a learning disability and Saturday morning clinics were offered to patients with a learning disability to encourage attendance. One-stop clinics were provided to encourage uptake for health monitoring services related to specific conditions. There were disabled facilities, hearing loop and translation services available. Chairs for bariatric patients were provided in the waiting area. In response to a high number of patients being illiterate alerts were placed on staff computers to indicate assistance may be required. The practice referred patients to Wellbeing Enterprise Services, a social enterprise to support people to achieve happier, healthier and longer lives. Patients could be referred for support with a number of issues, including, debt management, housing, social isolation. A report from this service showed that patients who were referred by the practice benefitted from the interventions provided. For example, by experiencing a reduction in their symptoms of depression and improving their general well-being.

Access to the service was monitored to ensure it met the needs of patients. The practice had a complaints policy which provided staff with clear guidance about how to handle a complaint.

Well-led

Good

Updated 12 November 2015

The practice is rated good for being well-led. It had a clear vision and strategy. Governance arrangements were underpinned by a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity. There were systems in place to monitor and improve quality and identify risk. The practice proactively sought feedback from staff and patients, which it acted on and had an active PPG. Staff had received inductions, regular performance reviews and attended staff meetings and events. The practice was aware of future challenges.

Checks on specific services

People with long term conditions

Outstanding

Updated 12 November 2015

There were aspects of care and treatment that were outstanding that related to all population groups.

The practice held information about the prevalence of specific long term conditions within its patient population such as diabetes, chronic obstructive pulmonary disease (COPD), cardio vascular disease and hypertension. This information was reflected in the services provided, for example, reviews of conditions and treatment, screening programmes and vaccination programmes. The practice had a system in place to make sure no patient missed their regular reviews for long term conditions. Varied appointments were offered to ensure long term conditions were adequately reviewed. For example, home visits were undertaken to housebound patients or those residing in residential care or nursing homes. One-stop clinics were provided to encourage uptake for health monitoring services related to specific conditions. The practice had strategies in place to identify long term conditions early and therefore improve patient care. For example, to identify patients at risk of chronic obstructive pulmonary disease (COPD) spirometry was offered to smokers aged 35 and over. The practice also took pulse checks at each chronic disease review and at flu clinics and had an ECG on site to identify patients at risk of atrial fibrillation.

The practice had identified all patients at risk of unplanned hospital admissions, a care plan had been developed to support them

and a system was in place to follow up unplanned hospital admissions in a timely manner.

Clinical staff

kept up to update in specialist areas which helped them ensure best practice guidance was always being considered.

Multi-disciplinary team and palliative care meetings were held where patient care was reviewed to ensure patients were receiving the support they required. The practice periodically held educational events for patients with long term conditions. For example, A COPD (chronic obstructive pulmonary disease) tea dance was held which provided information from the respiratory team, advice from the health promotion team and other services, such as benefits advice alongside bingo and line-dancing.

Families, children and young people

Outstanding

Updated 12 November 2015

There were aspects of care and treatment that were outstanding that related to all population groups. The practice is rated as good for the care of families, children and young people. The staff were responsive to parents’ concerns about their child’s health and prioritised appointments for children presenting with an acute illness. The extended hours’ service allowed parents to bring children to appointments, avoiding them having to miss school. Staff were knowledgeable about child protection. Staff put alerts onto the patient’s electronic record when safeguarding concerns were raised. Regular liaison took place with the health visitor and they attended the practice meeting every 6 weeks to discuss any safeguarding issues and to review if an appropriate level of GP service had been provided. The practice was in the process of upgrading its baby changing and breast feeding facilities.

Older people

Outstanding

Updated 12 November 2015

There were aspects of care and treatment that were outstanding that related to all population groups.

The practice was knowledgeable about the number and health needs of older patients using the service. They kept up to date registers of patients’ health conditions and information was held to alert staff if a patient was housebound. Home visits were made to housebound patients to carry out reviews of their health.

The

practice worked with other agencies and health providers to provide support and access specialist help when needed. Older patients with complex health needs were reviewed at multi-disciplinary meetings to ensure they were receiving all necessary GP services. The practice had identified older patients who were at risk of unplanned hospital admissions and developed a care plan to support them. The practice worked with the Carers Centre to support patients who had caring responsibilities.

A Christmas present or hamper was provided to older patients with no family.

Working age people (including those recently retired and students)

Outstanding

Updated 12 November 2015

There were aspects of care and treatment that were outstanding that related to all population groups. The practice is rated good for the care of working-age people (including those recently retired and students). The needs of this population group had been identified and the practice had adjusted the services it offered to ensure these were accessible. For example, the practice offered extended access with the practice being open for 12 hours Monday and Tuesday and on Saturday morning 09:00 to 13:00. Immunisation clinics were provided on Saturday mornings to encourage uptake. Events were held at the weekend and in the evenings to encourage patients to access health screening. For example, a recent talk was given to patients about mammography screening and events have also been held to provide information to patients about health checks and health promotion for various long term conditions. A full range of health promotion and screening services were provided that reflected the needs for this age group. On-line services were also provided such as booking, amending and cancelling routine appointments and ordering repeat prescriptions.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 12 November 2015

There were aspects of care and treatment that were outstanding that related to all population groups.

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

GPs worked with specialist services to review care and to ensure patients received the support they needed.

The practice maintained a register of patients who experienced poor mental health. The register supported clinical staff to offer patients experiencing poor mental health, including dementia, an annual health check and a medication review. The practice referred patients to appropriate services such as psychiatry and counselling services.

The practice had information for patients in the waiting areas to inform them of services available for patients with poor mental health. For example, services for patients who may experience depression. Clinical and non-clinical staff had undertaken training in dementia to ensure all were able to appropriately support patients.

People whose circumstances may make them vulnerable

Outstanding

Updated 12 November 2015

There were aspects of care and treatment that were outstanding that related to all population groups.

The practice is rated 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. Annual health checks were carried out for patients with a learning disability. The practice worked closely with social workers from the learning disability team and carers. Saturday morning clinics were offered to patients with a learning disability to encourage attendance. Staff had been trained to recognise signs of abuse in vulnerable adults and children and had been trained in the Deprivation of Liberty Safeguards (DOLS). Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies. The practice had signed up for the Safe in Town scheme and provided a safe haven for vulnerable people (vulnerable people were able to come to the practice and the person’s carers would be contacted). The practice also referred patients to Wellbeing Enterprise Services, a social enterprise to support people to achieve happier, healthier and longer lives. Patients could be referred for support with a number of issues. Including, debt management, housing, social isolation.