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Primary Care Hub Good Also known as (Rainham Improved Access Hub)

Inspection Summary


Overall summary & rating

Good

Updated 6 November 2019

This service is rated as Good.

This was the first time that this service had been inspected and rated.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Good

Are services well-led? – Good

We carried out an announced comprehensive inspection at Primary Care Hub (Rainham Improved Access Hub) as part of our inspection programme.

The service which is run by Medway Practices Alliance (MPA), provides improved access GP services to patients who are registered with GP practices within the NHS Medway Clinical Commissioning Group (CCG) area. The improved access service gives patients the choice of accessing GP services at a place that is not their own GP practice and at times when their own GP may or may not be open.

Twenty people provided feedback about the service. Nineteen were positive about the service and one was negative. Themes from these comments were that staff were professional, kind, caring and helpful and that the service was impressive, efficient, prompt and thorough. The negative comment related to the location of the hub.

Our key findings were:

  • The service had good systems to manage risk so that safety incidents were less likely to happen. When they did happen, the service learned from them and improved their processes.
  • The service routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.
  • Staff involved and treated people with compassion, kindness, dignity and respect.
  • Patients were able to access care and treatment from the service within an appropriate timescale for their needs.
  • There was a strong focus on continuous learning and improvement at all levels of the organisation.

The areas where the provider should make improvements are:

  • Complete the planned team training on the identification and management of patients with severe infections, for example sepsis.

  • Record the serial numbers of blank prescription forms returned to the safe at the end of the day as well as those distributed to the printers in the morning.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 6 November 2019

We rated Safe as Good because:

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider conducted safety risk assessments. They had appropriate safety policies, which were regularly reviewed and communicated to staff including locums. The policies outlined clearly who to go to for further guidance. Staff received safety information from the service as part of their induction and refresher training. The service had systems to safeguard children and vulnerable adults from abuse.
  • The service worked with other agencies to support patients and protect them from neglect and abuse. Staff took steps to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • All executive, administrative and reception staff were employed by Medway Practices Alliance Limited (MPA) directly. MPA had recruited them appropriately and carried out all the necessary pre-employment checks. Clinical staff were employed through a single locum agency (organised by the Clinical Commissioning Group (CCG)). The locum agency carried out all of the relevant pre-employment checks on the clinicians. Disclosure and Barring Service (DBS) checks were undertaken where required. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).

  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns. Staff who acted as chaperones were trained for the role and had received a DBS check.
  • There was an effective system to manage infection prevention and control as well as systems for safely managing healthcare waste.
  • The provider ensured that facilities and equipment were safe, and that equipment was maintained according to manufacturers’ instructions. All current equipment was under one year old, there were systems to help ensure that it would be maintained and calibrated annually.
  • The premises where the services were provided were rented. We saw that the owners of the premises had carried out appropriate environmental risk assessments. These took into account the profile of people using the service and those who may be accompanying them and helped keep staff and patients safe. This included risk assessments and actions to prevent colonisation with Legionella bacterium. (Legionella is a term for a bacterium which can contaminate water systems in buildings).

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed.
  • There was an effective induction system for agency staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. Staff understood the information readily available to them on how to identify and manage patients with severe infections, for example sepsis, but had not had specific training on the subject. However, records showed that training in the recognition and management of patients with severe infections such as sepsis was due to be delivered by relevantly qualified staff during a team meeting on 26 September 2019.
  • There were suitable medicines and equipment to deal with medical emergencies which were stored appropriately and checked regularly.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.
  • The service had appropriate indemnity arrangements. The contract for improved access services was exclusively an NHS one and the service told us that the clinicians were covered by the Clinical Negligence Scheme for GPs (CNSGP).

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • The service accessed patients’ medical records directly through their IT system. They had access to any individual care records that were already in patients’ medical records and could add to those records where appropriate. They were written and managed in a way that kept patients safe. The records we saw showed that information needed to deliver safe care and treatment was available to relevant staff in an accessible way.
  • The service had systems for sharing information with staff and other agencies to help enable them to deliver safe care and treatment.
  • Clinicians made appropriate and timely referrals in line with protocols and up to date evidence-based guidance.

Safe and appropriate use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for managing medicines minimised risks. The service kept prescription stationery securely and monitored its use. However, although they recorded the serial numbers of blank prescription forms that were placed into the relevant printers each day, they did not record the serial numbers of blank prescription forms that were returned to main storage at the end of the day.

  • The service did not stock or administer vaccines.

  • The service had carried out a medicines audit to help ensure prescribing was in line with best practice guidelines for safe prescribing. Auditing could only be carried out manually because the service’s IT system could not search on patients’ records from remote GP practices. The service had devised a manual system to audit records. The medicines audit was in the management of patients with a sore throat. It was carried out in May/June 2019 and was to be repeated in order to complete the cycle of clinical audit. Recommendations from the audit were circulated to clinicians with guidance on management and the use of the local formulary.

  • The service had also just commenced and were gathering evidence for, a survey of opiate prescribing.

Track record on safety and incidents

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.

  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.

Lessons learned, and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.

  • There were adequate systems for reviewing and investigating when things went wrong. The service learned, shared lessons, identified themes and acted to improve safety in the service. For example, we saw a complaint to MPA from a GP about recording in the medical records of one of their patients. It was raised as a significant event. The issue was discussed and a frequently asked questions paper on making entries in to patients’ computerised medical records produced to help guide hub GPs. There was an increased emphasis on data recording made at induction of new GPs and GPs working in the hubs were informed. An audit of hub GP’s medical records had been recorded and findings disseminated to clinical staff with advice. Similar audits were carried out on a monthly basis.

  • The provider was aware of and complied with the requirements of the Duty of Candour. The provider encouraged a culture of openness and honesty. The service had systems for knowing about notifiable safety incidents. The service had an effective mechanism to disseminate alerts to all members of the team including sessional and agency staff.

When there were unexpected or unintended safety incidents:

  • The service gave affected people reasonable support, truthful information and a verbal and/or written apology.

  • They kept written records of verbal interactions as well as written correspondence if appropriate.

  • The service acted on and learned from external safety events as well as patient and medicine safety alerts.

Effective

Good

Updated 6 November 2019

We rated effective as Good because:

Effective needs assessment, care and treatment

The provider had systems to help keep clinicians up to date with current evidence-based practice. We saw evidence that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance (relevant to their service).

  • The provider assessed needs and delivered care in line with relevant and current evidence-based guidance and standards such as the National Institute for Health and Care Excellence (NICE) best practice guidelines. National and local guidelines were available via documents and links on the service’s shared computer drive.
  • Patients’ immediate and ongoing needs were fully assessed. Where appropriate this included their clinical needs and their mental and physical wellbeing.

  • Clinicians had enough information to make or confirm a diagnosis. If further investigations were organised the results were sent to the patient’s own GP.

  • We saw no evidence of discrimination when making care and treatment decisions.

  • Staff assessed and managed patients’ pain where appropriate.

Monitoring care and treatment

The service was actively involved in quality improvement activity.

  • The service used information about care and treatment to make improvements.
  • The service made improvements through the use of completed audits.
  • Clinical audit had a positive impact on quality of care and outcomes for patients.
  • There was clear evidence of action to resolve concerns and improve quality. For example, an audit of GP consultations was carried out. The audit compared the records from GP consultations with patients with the standards recommended by one of the medical defence organisations and aspects of the records were ranked and comments added. Generally, records were found to be good to excellent. The results of the audit, standards, and tips arising from the audit were circulated to hub GPs via an informative newsletter from the service’s medical director. The audit was repeated monthly. New GPs to the service or those whose records were not meeting expected standards were prioritised. If a clinician was not meeting the expected standards they would have a face to face discussion with the lead clinicians. If a clinician failed to improve, they would not be booked for further clinical sessions.
  • Other examples of monitoring care involved an analysis of referrals from one improved access hub in response to the suggestion that there was a high referral rate from the hubs. The findings did not confirm the suggestion of extremely high referral rates.
  • The service had also carried out the first phase an audit of the management of sore throats with the second phase to take place over the winter. They had also produced a plan for an audit they were about to carry out on the prescribing of opiates (a group of pain-relieving medicine with addictive potential) within the service.
  • The commissioners NHS Medway Clinical Commissioning Group (CCG) carried out regular quality and safety reviews including a visit from their quality and safety officer as well as their prescribing advisor.
  • Practices were encouraged to feed back any concerns to the Medway Practices Alliance Limited (MPA).

The service had a contract with NHS Medway CCG which ran from 01 October 2018 to 31 March 2019 to provide 150 hours per week of improved access GP services for patients in the CCG area. The contract was then extended and revised on 10 September 2019. The service now had to provide 200 hours of (15 minute) appointments per week from 01 April 2019 to 31 March 2020.

Because the contract had been backdated, and there was a slow start to the service, the August 2019 MPA report to the CCG showed that they were in deficit to their contract by 654 hours. They were therefore looking to complete 47,000 hours in total to catch up the backlog (226 to 240 hours per week). We saw that there were plans to manage this by increasing the number of hubs from three to five in the near future. They had also increased the number of GPs at some sessions as well as starting to deliver some nurse sessions. The additional sessions would also help with the pressure on appointments over the coming winter period.

The contract did not require the service to distribute the available hours evenly throughout the year.

  • Utilisation of available appointments (booked appointments) was 100% at the end of August 2019 (target 90%) across all hubs.

  • Did not attends (DNAs) were just under 8% across all hubs.

  • Cancellations were less than 3%.

Friends and Family test results across the improved access hubs averaged out that 97% of respondents would be extremely likely or likely to recommend the service to friends and family for the five months from April to August 2019 inclusive (Target 90%).

A survey of GP practices, taken in April after the first six months of the service, showed that 71% of GP practices were satisfied with the work of the service (target 80%). Not all practices had completed the survey. The service was aiming to improve this figure by engaging further with the surgeries. They had arranged team visits to the surgeries to discuss use of the service and advise further on how to book the appointments. They had held an Annual General Meeting (AGM) and kept practices informed of changes as well as how to use the service with emails and newsletters.

Other issues identified that were to be addressed at these meetings included the inequity of use of the available appointments across the qualifying practices and referral systems.

The service had just been given permission by the local NHS trust to email two week wait referrals directly to secondary care providers rather than having to refer patients via their own GPs practices and so would be collecting data on this for future reports.

Effective staffing

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

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff.
  • Relevant professionals (medical and nursing) were registered with the General Medical Council (GMC)/ Nursing and Midwifery Council (NMC) and were up to date with revalidation.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop. We looked at the training records of three administrative staff members employed by MPA. All had completed the training that the service considered mandatory but had not yet received specific training in the recognition and management of patients with severe infections such as sepsis, although there were posters and prompts describing this available at reception. We saw evidence that the service had arranged training to rectify this at the next team meeting a week after the inspection.
  • MPA monitored whether clinicians had received the appropriate mandatory training and provide on-line training if required.

Coordinating patient care and information sharing

Staff worked and worked well with other organisations, to deliver effective care and treatment.

  • Patient information was shared appropriately (this included when patients were referred to other professional services), and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way. Patient’s GPs were made aware when they had been referred to other services.

  • Patients received coordinated and person-centred care. Staff referred to, and communicated effectively with, other services when appropriate. For example, when making referrals to secondary care. The service was initially limited by their IT systems but had developed a way to allow them to make referrals via patients’ own practice’s administration teams, but without involving additional work for patients’ own GPs. The improved access service kept a log of all referrals that they made.
  • Before providing treatment, doctors at the service ensured they had adequate knowledge of the patient’s health, any relevant test results and their medicines history. If they were unable to access appropriate results, the improved access hub GPs sometimes had to refer the patient back to their own GP. The service tried to avoid this by providing practices in the NHS Medway CCG area with a list of situations and conditions where the patient would be better managed by their own GP rather than making them an appointment with the improved access service.

Caring

Good

Updated 6 November 2019

We rated caring as

Good

because:

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The service sought feedback on the quality of clinical care patients received.

  • Feedback from patients was positive about the way staff treat people.

  • Staff understood patients’ personal, cultural, social and religious needs. They displayed an understanding and non-judgmental attitude to all patients.

  • The service gave patients timely support and information.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment.

  • Telephone interpretation services were available for patients who did not have English as a first language. Information leaflets were available in easy read formats if required, to help patients be involved in decisions about their care.

  • Patients told us through comment cards, that they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them.

  • For patients with learning disabilities or complex social needs family, carers or social workers were appropriately involved.

  • Staff communicated with people in a way that they could understand. For example, communication aids and easy read materials were available.

Privacy and Dignity

The service respected patients’ privacy and dignity.

  • Staff recognised the importance of people’s dignity and respect.

  • Staff knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private area to discuss their needs.

Responsive

Good

Updated 6 November 2019

We rated responsive as Good

because:

Responding to and meeting people’s needs

The service organised and delivered services to meet patients’ needs.

The provider understood the needs of their patients and improved services in response to those needs. For example, they were currently running three improved access hubs in the NHS Medway Clinical Commissioning Group (CCG) area, including this one at Rainham. They understood that some patients found them difficult to access and were in advanced discussions to add two further hubs in the Gillingham and Hoo areas, with a view to adding another two later in the year.

  • The facilities and premises were appropriate for the services delivered.

  • Reasonable adjustments had been made so that people in vulnerable circumstances could access and use services on an equal basis to others. For example, the services were sited in healthy living centres with good wheelchair access including lifts. Patients could make longer appointments if necessary.

Timely access to the service

Patients were able to access care and treatment from the service within an appropriate timescale for their needs.

  • Patients had timely access to initial assessment, test results (if they had been retained in their notes by their own GP), diagnosis and treatment. Some appointments could be booked up to two weeks in advance and some on the day.

  • Waiting times, delays and cancellations were minimal and managed appropriately.

  • Patients reported that the appointment system was easy to use. Patients booked appointments directly via their own GP practice. Cancellations could be made via a dedicated telephone line.

  • Referrals and transfers to other services were undertaken in a timely way

Listening and learning from concerns and complaints

The service took complaints and concerns seriously and responded to them appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available. Staff treated patients who made complaints compassionately.

  • The complaints policy and procedures were in line with recognised guidance. Medway Practices Alliance Limited recorded complaints for all three of their registered locations and reviewed them at the same meetings. This was so that the service as a whole could learn from any issues raised. There had been six complaints that were received across the whole service (three locations) in the last year. We reviewed three complaints and found that they were satisfactorily handled in a timely way.

  • The service informed patients of any further action that may be available to them should they not be satisfied with the response to their complaint.

  • The service learned lessons from individual concerns, complaints and from analysis of trends. It acted as a result to improve the quality of care. For example, a complaint had been made regarding the clinical management of a patient. The complaint had been managed appropriately and thoroughly investigated. The complainant received an apology and full explanation. Findings and lessons learnt were shared with clinical staff and changes made to equipment and processes. Staff involved received further training.

  • The provider was aware of and had systems to help ensure compliance with the requirements of the duty of candour and we saw examples of this.

Well-led

Good

Updated 6 November 2019

We rated well-led as Good

because:

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were addressing them.
  • They had regular board meetings at which operational and strategic issues were discussed. They also had regular meetings with the commissioners, NHS Medway Clinical Commissioning Group (CCG), to discuss their plans.
  • The organisation had been commissioned to provide an improved access service for patients registered at GP practices in the Medway CCG area at short notice and managed to develop and launch the service over a very short period (around six weeks).

  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership. There were weekly meetings at headquarters (HQ) which HQ staff, the Chairman (Clinical Director), Chief Operations Officer and Operations Director attended. The HQ team were encouraged to feedback issues, challenges and concerns to the executive team at these meetings. Members of the leadership team visited the Rainham improved access hub, as well as the other hubs, regularly.

  • The provider had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service. There was a detailed three-year business plan available. Leadership plans were shared with staff.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to achieve priorities.

  • The service shared their vision, values and strategy with external partners (NHS Medway CCG).

  • Staff were aware of and understood the vision, values and strategy and their role in achieving them. The practice held three monthly staff meetings led by members of the leadership team at which staff were informed of future plans, felt comfortable to feedback and were listened to.

  • The service monitored progress against delivery of the strategy.

Culture

The service had a culture of high-quality sustainable care.

  • Staff felt respected, supported and valued. They told us that they were proud to work for the service.

  • The service focused on the needs of patients.

  • Leaders and managers acted on behaviour and performance consistent with the vision and values.

  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to help ensure compliance with the requirements of the duty of candour.

  • Staff told us they could raise concerns and were encouraged to do so. They had confidence that these would be addressed.

  • There were processes for providing all staff with the development they need. This included appraisal and career development conversations. The service had started in October 2018 and dates were booked for full staff annual appraisals in October 2019. Staff had received interim one to one conversations during the year. Staff were supported to meet the requirements of professional revalidation where necessary. All staff were considered valued members of the team. Locum staff were expected to comply with mandatory training before working for the service but were given access to online training and time to complete it where appropriate. Locum staff were kept informed of updates in policy, guidance and findings from significant events and complaints via newsletters and emails which had an audit trail and were read receipt.

  • There was a strong emphasis on the safety and well-being of all staff.

  • The service actively promoted equality and diversity. It identified and addressed the causes of any workforce inequality. Staff had received equality and diversity training. Staff felt they were treated equally.

  • There were positive relationships between staff and teams.

Governance arrangements

There were responsibilities, roles and systems of accountability to support good governance and management.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of the organisation and working arrangements with other stakeholders promoted co-ordinated person-centred care.

  • Staff were clear on their roles and accountabilities

  • Leaders had established proper policies, procedures and activities to help ensure safety and assured themselves that they were operating as intended. All policies and procedures were readily available to all staff on a shared computer drive.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety. A log of risks was retained and reviewed and updated regularly by the Chief Operations Officer and fed in to the board and where appropriate the HQ and hub staff. For example, the service had identified that the IT clinical system did not allow them to do all that they would like to and had therefore identified it as a potential risk. They had chosen it over other systems as it had the over-riding benefits that they could access previous records and record consultations directly in to a patient’s GP medical records. However, once the consultation was closed and the notes uploaded to the patient’s medical records they could not recover them again until they were booked in to a new clinic. This meant that they had to devise a manual system to audit patients’ medical records. Therefore, carrying out audits was a time-consuming process which required support from the patients’ own GP practices. The service had also developed systems of referral that circumnavigated these issues, but they retained IT on the risk register as they sought to further improve their systems. They had shared risk register issues with the commissioning CCG and worked on solutions with them. However, the software that held policies, procedures and guidance on a shared drive was readily accessible to all staff.

  • The service had processes to manage current and future performance. Performance of clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Leaders had oversight of safety alerts, incidents, and complaints.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change services to improve quality.
  • The provider had plans and had trained staff for major incidents.

Appropriate and accurate information

The service acted on appropriate and accurate information.

  • Quality and operational information was used to help ensure and improve performance. Performance information was combined with the views of patients.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service used performance information which was reported and monitored, and management and staff were held to account.

  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses.

  • The service submitted data or notifications to external organisations as required.

  • There were robust arrangements in line with data security standards for the availability, integrity and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The service involved patients, the public, staff and external partners to support high-quality sustainable services.

  • The service encouraged and heard views and concerns from the public, patients, staff and external partners and acted on them to shape services and culture. The public were involved in consultations prior to setting up the service and the hours and locations of the service were determined largely by local need. Patients filled in Friends and Family surveys and a virtual patient participation group was being set up. The service had an open-door policy, staff had input during meetings, one to one discussions and could feedback via their line managers during hub meetings. The Operations Director visited GP surgeries. Newsletters and other communications were sent to primary care networks, practice managers and senior partners and practices had filled in a survey. A report was sent to the commissioners monthly and representatives of the service met with the commissioners three monthly.

  • Staff could describe to us the systems available to them to give feedback. For example, in meetings, face to face and during training. We saw evidence of feedback opportunities for staff and how the findings were fed back to staff. We also saw staff engagement in responding to these findings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement.
  • The service made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements. For example, the service was concerned that they did not have email access to make direct two week wait referrals (for possible cancer diagnoses) having worked with the CCG and local NHS Trust, this service was made available to them.
  • Leaders and managers encouraged staff to be involved in individual and team objectives, processes and performance. Time was made available for additional training where appropriate.
  • There were systems to support improvement and innovation work. Staff were encouraged to innovate, there was a culture of recognising actions going above and beyond what was expected. Staff could be rewarded for innovation.