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The Mill Medical Practice Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 20 July 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Mill Medical Practice on 12 April 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 assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had been trained to provide them with the skills, knowledge and experience to deliver effective care and treatment.
  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.
  • The practice participated in the local initiative to improve care for the frail elderly and had very positive feedback from the care homes they looked after.
  • Practice nurses ran a clinic for those patients over 75 who did not have any long term conditions. This ensured that this group of patients had proactive care and identified any unmet needs.
  • 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.
  • Patients said they found it easy to make an appointment for an urgent matter, for some patients it was harder to make appointments with a named GP.
  • An urgent surgery was held every day which enabled ill children to be seen quickly. The practice had developed a template for reviewing unwell children following national guidelines on febrile illness. This included a leaflet for parents explaining what to look out for if a child deteriorates.
  • The practice had very good facilities and was well equipped to treat patients and meet their needs.
  • The practice had a strategy to promote high levels of care for patients and ran services which were not remunerated because they felt they provided good patient care. For example the ultrasound clinic.
  • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on.
  • The provider was aware of and complied with the requirements of the duty of candour.

We saw several areas of outstanding practice:

  • The practice provided a wide range of services to improve care for the frail elderly; this included a care coordinator, virtual ward rounds, working with Age UK and the community matron to look after the most vulnerable patients. They provided a very good service for managing elderly patients in the community and the impact of this work was shown in reduced emergency admissions and A&E attendances for over 65 year olds. The practice had the second lowest ambulance conveyance rate per practice in the CCG, with the activity level over a rolling 12 months showing the practice rate to be 93.71 compared to other practices where rates ranged from 88.38 to 198.24. Emergency hospital admissions had reduced by over 4% over the last year and A&E attendance for over 65 year olds had reduced by 6.5% compared to the previous year.
  • The leadership of the practice had introduced and developed clinical systems, and shared these widely, to enhance how patients were managed resulting in improved patient care. For example they had developed an individualised care plan for diabetes and shared this with other practices in the clinical commissioning group (CCG). The care plan listed patients’ results, explained how to interpret the results and listed individualised targets that the patient and GP had agreed in the consultation. In addition the lead GP was running education sessions on this work which had been highlighted as excellent by the clinical systems provider.
  • The practice had increased the number of patients diagnosed and treated for atrial fibrillation by 40% in the last four years through carrying out pulse checks at the annual flu clinics and putting an alert on the clinical system.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 20 July 2016

The practice is rated as good for providing safe services.

  • There was an effective system in place for reporting and recording significant events
  • Lessons were shared to make sure action was taken to improve safety in the practice.
  • When things went wrong patients received reasonable support, truthful information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again.
  • The practice had systems, processes and practices in place to keep patients safe and safeguarded from abuse. At the time of the inspection we found areas where the practice was not following its policies in respect of the frequency of equipment and building checks, these were amended immediately following the inspection and a robust management review process put in place.
  • Risks to patients were assessed and well managed.

Effective

Outstanding

Updated 20 July 2016

The practice is rated as outstanding for providing effective services.

  • Data from the Quality and Outcomes Framework (QOF) showed patient outcomes were better than the national average.
  • Staff assessed needs and delivered care in line with current evidence based guidance.
  • Clinical audits demonstrated quality improvement.
  • Staff had the skills, knowledge and experience to deliver effective care and treatment.
  • There was evidence of appraisals and personal development plans for all staff.
  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs.
  • Childhood immunisation rates for the vaccines given were better than the clinical commissioning group (CCG) averages.
  • The practice had developed an individualised care plan for diabetes which listed patients’ results, explained how to interpret the results and listed individualised targets that the patient and GP had agreed in the consultation. This template has been shared with other practices as an example of good practice.
  • The practice had developed their use of the clinical IT records system to improve diagnosis and draw together good practice and resources for patients. They shared this learning with local practices and the clinical systems provider to spread the use of good practice.
  • The practice ran an annual flu clinic on a Saturday in which over 2000 patients were vaccinated in one day. The uptake of flu vaccine was higher than the CCG average for both at risk patients and those over 65 years old.
  • The practice used proactive anticipatory care plans to provide coordinated care to their frail patients and this had resulted in reduced hospital admissions and ambulance conveyances for the frail elderly.

Caring

Good

Updated 20 July 2016

The practice is rated as good for providing caring services.

  • Data from the national GP patient survey showed patients rated the practice higher than others for all aspects of care. For example 94% of patients said the GP gave them enough time compared to the clinical commissioning group average of 90% and the national average of 87%.
  • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.
  • Information for patients about the services available was easy to understand and accessible.
  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.
  • The practice had a history of always treating patients registered with the practice and had worked with patients with disruptive behaviour rather than ask them to leave the practice list.

Responsive

Good

Updated 20 July 2016

The practice is rated as good for providing responsive services.

  • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified. The practice had been an early adopter of the frailty initiative and worked with the CCG and other local practices to share learning and develop service improvements.
  • The practice participated in the local initiative to improve care for the frail elderly. Recent data from the CCG showed that the practice had made a positive impact and had reduced the number of emergency admissions and A&E attendances for over 65 year olds in the last year. The practice had the second lowest ambulance conveyance rate per practice in the CCG, with the activity level over a rolling 12 months showing the practice rate to be 93.71 compared to other practices where rates ranged from 88.38 to 198.24. Emergency hospital admissions had reduced by over 4% over the last year and A&E attendance for over 65 year olds had reduced by 6.5% compared to the previous year.
  • 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.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Outstanding

Updated 20 July 2016

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

  • The practice had a clear vision to deliver high quality person centred care delivered with compassion, dignity and respect.  The partners drove improvements to the clinical system and other ways of working in the practice to improve the delivery of high quality person centred care.
  • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings.
  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • The provider was aware of and complied with the requirements of the duty of candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for notifiable safety incidents and ensured this information was shared with staff to ensure appropriate action was taken
  • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active.
  • There was a strong focus on continuous learning and improvement at all levels.
Checks on specific services

People with long term conditions

Outstanding

Updated 20 July 2016

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

  • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority.
  • 90% of patients on the diabetes register had a record of a foot examination and classification which was better than the national average of 88%.
  • The practice ran a weekly diabetic clinic with a specialist nurse and GP, supported by visiting dieticians and podiatrists, providing high quality advice and a wide breadth of treatments for diabetic patients. The practice showed us evidence that they had developed an individualised care plan for diabetes and shared this with other practices in the clinical commissioning group (CCG). The care plan listed patients’ results, explained how to interpret the results and listed individualised targets that the patient and GP had agreed in the consultation.
  • The practice had increased the number of patients diagnosed and treated for atrial fibrillation by 40% in the last four years through carrying out pulse checks at the annual flu clinics and putting an alert on the clinical system.
  • The practice had increased vaccination rates for flu, pneumococcal and shingles for patients in at risk groups significantly using targeted invitations.

  • Longer appointments and home visits were available when needed.

  • 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 relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Outstanding

Updated 20 July 2016

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

  • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of A&E attendances. Immunisation rates were relatively high for all standard childhood immunisations.
  • 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.
  • 80% of eligible female patients had a cervical screening test which was the same as the national average of 82%.
  • Appointments were available outside of school hours and the premises were suitable for children and babies.
  • An urgent surgery was held every day which enabled ill children to be seen quickly. The practice had developed a template for reviewing unwell children following national guidelines on febrile illness. This included a leaflet for parents explaining what to look out for if a child deteriorates.
  • We saw positive examples of joint working with midwives and health visitors. The doctors attended a quarterly meeting with the health visitors to discuss families who needed extra support.

Older people

Outstanding

Updated 20 July 2016

The practice is rated as outstanding for the care of older people.

  • The practice offered proactive, personalised care to meet the needs of the older people in its population. They used the local proactive anticipatory care plan for those patients at risk of unplanned hospital admission which provided a framework for the patient, their family, carers and health care professionals to work together to plan care. The care plan allowed care to be delivered in line with the patient’s wishes.
  • The practice participated in the local initiative to improve care for the frail elderly. The lead GP attended forum meetings and shared this information with other practice staff. Data from the clinical commissioning group (CCG) showed that the practice had reduced the number of emergency admissions and A&E attendances for over 65 year olds in the last year. The practice had the second lowest ambulance conveyance rates per practice in the CCG.
  • The practice identified those patients most at risk of hospital admissions. A care coordinator contacted patients after a discharge to offer assistance and support and updated care plans.
  • The lead GP and care coordinator carried out a virtual ward round each week to discuss the most vulnerable patients with the community matron and the Age UK promoting independence coordinator.
  • The practice carried out weekly visits at five care homes for older people and feedback from the homes was very positive.
  • The practice was responsive to the needs of older people, and offered home visits and urgent appointments for those with enhanced needs.
  • Practice nurses ran a clinic for those patients over 75 who did not have any long term conditions. This ensured that this group of patients had proactive care and identified any unmet needs.

Working age people (including those recently retired and students)

Outstanding

Updated 20 July 2016

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

  • The needs of the working age population, those recently retired and students 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 was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group. The nurses ran health checks for 40 – 65 year olds and had carried out checks on 21% of this age group in the last 18 months. The nurses offered lifestyle advice and signposted patients to local resources such as exercise on prescription.

  • The practice offered early morning appointments from 7.30am for blood tests and asthma reviews and evening telephone consultations with GPs.
  • The practice provided implant and intrauterine device fitting contraceptive services. The lead GP for this service trained other GPs and ran local update courses.
  • The practice offered an ultrasound service, run by one of the GPs, giving a local convenient service to patients.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 20 July 2016

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

  • 97% of patients diagnosed with dementia had had their care reviewed in a face to face meeting in the last 12 months, which is better than the national average.
  • 75% of patients experiencing poor mental health had an agreed care plan, which is worse than the national average of 88%. The practice had identified that this was an issue and had developed an alert on the clinical system to set up a review and a protocol for the doctor to follow in the mental health review.
  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. The GPs held quarterly meetings with the local psychiatrist to review patients whose care was shared between primary and secondary care.
  • The practice carried out advance care planning for patients with dementia.
  • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. Local counsellors ran sessions for patients on site, making it convenient and less stressful for patients to access this service.
  • The practice had a system 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.
  • The practice carried out weekly visits at care homes for people with dementia and feedback from the homes was very positive. The GPs arranged meetings with families to discuss care plans and review care. These meetings took place in the evening when needed.

People whose circumstances may make them vulnerable

Outstanding

Updated 20 July 2016

The practice is rated as outstanding 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.
  • The practice carried out twice weekly visits at a care home for people with epilepsy and learning difficulties, and feedback from the home was very positive. The home told us that the administration staff were always willing to help the residents and there was a good relationship with the GPs and nurses making it easy to work with them for the benefit of the 75 residents.
  • When carrying out annual medicals for learning disability patients the practice used a template which covered a physical, psychological and social check. This gave a baseline level which made it easier for other doctors to assess when patients were unwell or distressed. The annual medical at the care home included information gathered from the resident, their family and care staff, as well as the epilepsy specialist nurse. This multidisciplinary approach enabled the best care to be provided to this vulnerable group.
  • The practice regularly worked with other health care professionals in the case management of vulnerable patients.
  • The practice informed vulnerable patients about how to access various support groups and voluntary organisations. An outreach clinic for drug and alcohol support, run by the local mental health trust, was held in the practice weekly giving patients the chance to be seen in a familiar setting.
  • Staff knew how to recognise signs of abuse in vulnerable adults and children. 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.