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Inspection Summary


Overall summary & rating

Good

Updated 13 September 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Stewart Medical Centre on 1 August 2016. Overall, the practice is rated as good.

Our key findings across all the areas we inspected were as follows:

  • There was a system in place for the reporting and recording of significant events. Learning was applied from events to enhance the delivery of safe care to patients.

  • Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • A programme of clinical audit reviewed patient care and ensured actions were implemented to improve services as a result.
  • The practice planned and co-ordinated patient care with the wider multi-disciplinary team to deliver effective and responsive care to keep vulnerable patients safe.
  • The practice had an effective appraisal system in place and was committed to staff training and development. The practice team had the skills, knowledge and experience to deliver high quality 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 analysed and acted on feedback received from patients.
  • Patients mainly provided positive views on their experience in making an appointment to see a GP or nurse.
  • The practice offered a range of options to consult with a clinician. A GP triaged calls for requests to be seen on the day, and ensured that any patient requiring an urgent appointment was seen. Appointments could be booked in advance and telephone consultations were available. Longer appointments were available for those patients with more complex needs.
  • The practice was maintained to a high standard with good facilities and was well-equipped to treat patients and meet their needs.
  • There was a clear leadership structure in place and the practice had a governance framework which supported the delivery of good quality care. Regular practice meetings occurred, and staff said that GPs and managers were approachable and always had time to talk with them.
  • The practice had submitted a successful funding request to pilot two dementia support workers within primary care. The pilot scheme was to be formally evaluated to assess the outcomes it had achieved for patients and their carers.
  • Information about how to complain was available upon request and was easy to understand. Improvements were made to the quality of care as a result of any complaints received.

We saw the following area of outstanding practice:

  • The practice had developed an expert patient programme. This enabled patients with a new diagnosis to be able to speak with another patient with personal experience of dealing with the same condition.

The areas where the provider should make improvement are:

  • The practice needed to ensure that records clearly documented the follow-up actions taken with children who could be vulnerable, and had not attended a hospital appointment.
  • The practice reviewed patients who had been prescribed high-risk medicines and there was monitoring in place to ensure prescribing remained safe. The system in place needed to be strengthened to ensure that reviews were always undertaken within recommended timescales.
  • Review the documented evidence to support staff induction programmes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 13 September 2016

  • Staff reported all significant events, and learning was applied from incidents to improve safety in the practice.
  • The practice had robust systems in place to ensure they safeguarded vulnerable children and adults from abuse.
  • The practice worked to written recruitment procedures to ensure all staff had the skills and qualifications to perform their roles, and had received appropriate pre-employment checks.
  • Risks to patients and the public had been identified with systems in place to control these. For example, the practice had a designated infection control lead who undertook regular audits.
  • There were effective systems in place to manage medicines and prescriptions kept on site appropriately.
  • There was evidence in place to support that the practice reviewed those patients who had been prescribed high-risk medicines and there was monitoring in place to ensure prescribing remained safe. The system needed to be strengthened to ensure reviews were always undertaken within the recommended timescales as a small number fell slightly outside of these.
  • Actions were taken to review any medicines alerts received by the practice, to ensure patients were kept safe.
  • The practice had robust systems in place to deal with medical emergencies.
  • The practice ensured staffing levels were sufficient at all times to meet their patients’ needs.
  • The practice had developed contingency planning arrangements, supported by a comprehensive and up to date written plan.

Effective

Good

Updated 13 September 2016

  • The practice delivered care in line with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines.

  • The practice had acquired a total achievement of 87% for the Quality and Outcomes Framework (QOF) 2014-15. This was below the CCG average of 98.1%, and the national average of 94.7%. However, the practice had identified a plan to improve their performance and we saw evidence that this was being successful.
  • A programme of clinical audit demonstrated quality improvement, and we saw examples of how audit was being used to enhance safe patient care and treatment.
  • All members of the practice team had received an annual appraisal, which included a review of their training needs. Staff had the skills, knowledge and experience to deliver effective care and treatment. New employees received inductions, although documented evidence of this was not sufficiently robust.

  • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs, in order to deliver care effectively.
  • A daily informal clinical meeting was held to address any problems that had emerged during the morning. This helped to get issues resolved quickly and provided a valuable source of support for clinicians.
  • The practice received regular input from a CCG pharmacist that provided robust support on prescribing issues. From a patient perspective, this helped compliance with prescribed medicines and the practice had high usage of dosette boxes.
  • The practice reviewed all patient deaths on a monthly basis to consider any learning and to share good practice.

Caring

Good

Updated 13 September 2016

  • We observed a patient-centred culture and approach within the practice. Staff treated patients with kindness and respect, and maintained their confidentiality throughout our inspection.
  • Patients we spoke with during the inspection, and feedback received on our comments cards, indicated they were treated with compassion, dignity and respect and felt involved in decisions about their care and treatment.
  • Data from the latest GP survey showed that patients generally rated the practice in line with local and national averages in respect of care.
  • Feedback from community based health care staff and care home staff was positive about the high standards of care provided by the practice team.
  • The practice had identified 1.3% of their list as being carers, which was in line with expected averages. Information was available on the various types of support available to carers. 

Responsive

Good

Updated 13 September 2016

  • Comment cards and patients we spoke with during the inspection provided generally positive experiences about obtaining an appointment with a GP, or being able to speak to someone regarding their concerns. The latest GP patient survey showed that patient satisfaction was generally higher or in line with local and national averages with regards access to GP appointments.
  • There was in-built flexibility within the appointment system including pre-bookable slots; telephone consultations; and ‘on the day’ appointments for those with an urgent need. A GP triaged requests for same day appointments and provided advice or arranged for that patient to be seen by a GP or nurse. Patient feedback regarding the triage service was generally very positive.
  • The practice offered an extended hours’ commuter surgery on one morning each week, and provided one Saturday morning clinic each month.
  • The practice hosted some services on site including ante-natal care, and a weekly Citizens Advice Bureau session. This made it easier for their patients to access services locally.
  • The practice implemented improvements and made changes to the way it delivered services as a consequence of feedback from patients.
  • The premises were well-maintained and clean, and were well-equipped to treat patients to meet their needs. The practice accommodated the needs of patients with disabilities, including access to the building through automatic doors.
  • The practice worked with other local practices to provide primary care services to temporary patients due to the high number of visitors to this popular tourist area within the Peak District National Park.
  • Information about how to complain was available. Learning from complaints was shared with staff to improve the quality of service.
  • If patients at reception wished to talk confidentially, or became distressed, they were offered a private room to ensure their privacy. 

Well-led

Good

Updated 13 September 2016

  • The partners had a strong commitment to delivering high quality care and promoting good outcomes for patients.
  • There was a clear staffing structure in place. GP partners had lead roles providing a source of support and expert advice for their colleagues
  • The partners worked collaboratively other GP practices in their locality, and worked proactively with their CCG.
  • The partners reviewed comparative data provided by their CCG and ensured actions were implemented to address any areas of outlying performance.
  • Staff felt well-supported by management, and the practice held regular staff meetings. An annual ‘away day’ team building event contributed to an effective and motivated workforce.
  • The practice had developed a wide range of policies and procedures to govern activity.
  • The practice proactively sought feedback from patients, which it acted on to improve service delivery. The practice had an active Patient Participation Group (PPG). This group worked well with the practice, and made suggestions to improve services for patients.
  • The practice used innovative measures to shape service delivery, and we saw a number of initiatives that had influenced positively upon patient care. For example, the piloting of dementia support workers within a GP practice setting. 
Checks on specific services

People with long term conditions

Good

Updated 13 September 2016

  • The practice undertook annual reviews for patients on their long-term conditions registers. The recall system had recently been restructured in response to comparatively lower QOF attainment, and this had impacted positively on outcomes.
  • QOF achievement for 2014-15 for conditions including asthma, hypertension and dementia were below the CCG and national averages. However, the practice was able to explain the lower achievement and had developed actions to enhance their performance. We observed practice data (subject to external verification) that demonstrated performance was improving.
  • There was a lead designated GP and/or nurse for all the clinical domains within QOF.
  • The practice had developed an ‘expert patient’ programme to support patients following the diagnosis of a new condition. This enabled patients to talk to someone with personal experience of living with a particular condition, and to discuss any issues or concerns from a non-medical perspective. 

Families, children and young people

Good

Updated 13 September 2016

  • The GPs held a weekly baby clinic on site. Dual appointments were provided for post-natal reviews and eight-week baby checks as a ‘one-stop shop’ for new parents.
  • The midwife held an ante-natal clinic on site every week.
  • Childhood immunisation rates were generally in line with local averages. For example, rates for the vaccinations given to children at five years of age ranged from 93.2% to 98.6% (local average 96.5% to 99.1%). Appointments for vaccinations were extended to 20 minutes to ensure the accuracy of the procedure, and also to allow time for parents to ask any questions.
  • The health visitor attended a meeting with the lead GP for child safeguarding once a month to discuss any concerns. Child protection alerts were used on the clinical system to ensure clinicians were able to actively monitor any concerns. Arrangements to follow up on children who failed to attend for hospital appointments required strengthening.
  • Appointments for children were available outside of school hours.
  • There was a notice board in the waiting area dedicated to younger person’s health. In addition, a practice leaflet was available providing information on services which young people may wish to access confidentially such as healthy eating, drug use, and bullying.
  • Family planning services were provided to fit and remove intrauterine devices (coils) and implants, and advice and support was available for all aspects of contraception.
  • The practice worked within their local community to promote health – for example, representatives had attended a local nursery to discuss health matters.
  • The practice had baby changing facilities, and welcomed mothers who wished to breastfeed on site.

Older people

Good

Updated 13 September 2016

  • The practice had been involved in an enhanced access pilot scheme for those with a deteriorating illness. This gave the practice direct access to the physician for older age patients for telephone advice; and access to an urgent outpatient review, rather than admitting the patient to hospital.
  • The practice team worked closely with a community matron and care co-ordinator to plan and oversee the management of their most vulnerable patients, including those who were at risk of a hospital admission. This was enhanced further by weekly meetings attended by health and care professional staff from the wider health, social and voluntary communities, to plan and co-ordinate care to meet their patients’ needs.
  • Care plans were in place to identify individual patient need, and summary records were shared with relevant services to ensure the patient received the right care at the right time.
  • Longer appointment times could be arranged for those patients with complex care needs, and home visits were available for those unable to attend the surgery.
  • The practice provided care for residents at two local care homes, and fortnightly visits were undertaken to each home by a practice nurse. Any urgent requests for a consultation were undertaken within 24 hours by a GP.
  • The practice shared the medical cover provided to a ward at a local residential unit with another local GP surgery, and visited these patients twice each week.
  • Uptake of the flu vaccination for patients aged over 65 was 71%, which was in line with local (73.9%) and national (70.5%) averages.

Working age people (including those recently retired and students)

Good

Updated 13 September 2016

  • The practice offered on-line booking for appointments and requests for repeat prescriptions. The practice provided electronic prescribing so that patients on repeat medicines could collect them directly from their preferred pharmacy.
  • Extended hours’ GP and nurse consultations were available. Early morning appointments were available one day each week to accommodate the needs of working people. Additionally, appointments to see a GP or the nurse were available on one Saturday morning each month.
  • Telephone consultations were available each day, meaning that patients did not have to travel to the practice unnecessarily.
  • The practice promoted health screening programmes to keep patients safe. Although performance for cervical and breast screening was slightly lower than average figures, the practice was able to explain this and describe how this was being addressed.
  • The practice offered a flexible approach towards health checks and any patient could request to have one undertaken.
  • The practice had attended the local university’s ‘Freshers’ Fair’, to provide advice and support on younger people’s health, and to ensure that students knew how to access local primary care services. 

People experiencing poor mental health (including people with dementia)

Good

Updated 13 September 2016

  • The practice achieved 85.4% for mental health related indicators in QOF, which was 12.7% below the CCG and 7.4% below the national averages. Exception reporting rates for mental health were higher at 22.5% (local 14.5%; national 11.1%) although the practice were able to explain the reasons for this.
  • 91.8% of patients with poor mental health had a documented care plan during 2014-15. This was marginally below the CCG average by 1.4%, and 3.3% higher than the national average, although exception reporting rates were higher.
  • Access to counselling and associated talking therapies was available by GP or self-referral. Patients could attend these services in the local area.
  • The practice lead GP for mental health was also the CCG’s designated clinical lead for mental health.
  • The practice had established strong links with local mental health care teams. A community psychiatric nurse (CPN) attended multi-disciplinary meetings to review and discuss any patients with ongoing mental health needs.
  • Appointments were available on the day for patients experiencing acute mental health difficulties. This was facilitated via the senior clinician triage system.
  • 91% of people diagnosed with dementia had had their care reviewed in a face-to-face meeting in the last 12 months. This was above local and national averages by approximately 7%, with comparable exception reporting rates.

  • The practice staff had received training from the Alzheimer’s Society to become ‘Dementia Friends’. This had involved the PPG who had reviewed patient-facing issues such as improved signage further to the training. Reception rang patients with dementia to remind them of their upcoming appointment.
  • The practice used self-management techniques to improve anxiety management.
  • The practice provided care to 20 patients in local home, 12 of whom were included on the practice dementia register. The practice dealt with individual patient needs as required, but were in the process of working to review future arrangements.
  • The practice worked with local charity projects that promoted well-being and support for people with mental health difficulties. 

People whose circumstances may make them vulnerable

Good

Updated 13 September 2016

  • The practice was mindful that their catchment area incorporated pockets of community deprivation. They had been supportive of a local Sure Start scheme (aimed at giving children the best possible start in life) that had recently closed; however, the practice continued to provide high levels of support to this population in recognition of their health needs.
  • The practice had undertaken an annual health review in the last 12 months for 48.6% of patients with a learning disability However, a manual check of records by the practice team demonstrated this figure was 84%, indicating that there may be an issue with coding.
  • Longer appointments and home visits were available for vulnerable patients, and same day access to a GP was provided for any vulnerable patients with acute needs. The practice encouraged concerned relatives or support workers to contact the practice on the patient’s behalf. Failed attendance was used an opportunity to look into the reasons behind this, and to educate the patient or manage their situation differently.
  • There was a designated lead GP for palliative care. Patients with end-of-life care needs were reviewed either at weekly multi-disciplinary team meetings, or at designated monthly palliative care meetings. These patients had supporting care plans in place. Community based staff informed us that the GPs were caring and highly responsive to these patients, and ensured that any needs were acted upon promptly.
  • The practice supported homeless patients to register at the practice. Residents at a local women’s refuge were encouraged to register with the practice.
  • Staff had received adult safeguarding training and were aware how to report any concerns relating to vulnerable patients. There was a designated lead GP for adult safeguarding.