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Inspection Summary


Overall summary & rating

Good

Updated 31 October 2019

We carried out an announced comprehensive inspection at GP Direct on 9 August 2018. The overall rating for the practice was good with a rating of requires improvement in the Safe key question The full comprehensive reports on the August 2018 inspection can be found by selecting the ‘all reports’ link for GP Direct on our website at cqc.org.uk.

At the last inspection in August 2018, we rated the practice as requires improvement for providing safe services because:

  • There was no clear system to monitor the stock levels and expiration of vaccines at the practice.
  • There was no clear system to monitor blank prescription forms.

We also found areas where the provider should make improvements:

  • Take action to ensure all the actions arising from risk assessments are recorded.
  • Take action to carry out NHS health checks for patients aged 40-74.
  • Improve the recording of complaint responses to ensure the ombudsman details are always included.

This inspection was an announced focused follow up inspection carried out on 30 September 2019, to confirm the practice had carried out their plan to meet the legal requirements in relation to the breaches in regulation that we identified in our previous inspection on 9 August 2018. This report covers our findings in relation to those requirements and additional improvements made since our last inspection.

Overall the practice is now rated as Good for providing safe services and continues to be rated Good overall.

Our key findings were as follows:

  • The practice had a clear system to monitor the stock levels and expiration of vaccines at the practice.
  • The practice had a clear system to monitor blank prescriptions.
  • Actions arising from fire, health and safety risk assessments were now completed and signed.
  • The practice had carried out 88 NHS health checks since the last inspection; however, this was affected by staffing changes which led to fewer health checks completed.
  • The practice ensured ombudsman details were included in all complaints.

Whilst we found no breaches of regulations, the provider should:

  • Continue to monitor and improve health checks for patients aged 40-74.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Effective

Good

Updated 19 October 2018

We rated the practice and all of the population groups as good for providing effective services overall

Effective needs assessment, care and treatment

The practice had systems to keep clinicians up to date with current evidence-based practice. We saw that clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance supported by clear clinical pathways and protocols.

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • The practice used technology and equipment to improve treatment and support patients’ independence. For example, they utilised their Emis system to highlight patients at risk of chronic kidney disease or those that may benefit from statin therapy.  
  • The nurse case manager used the Emis mobile system during her home visits and had use of her own iPad when carrying out home visits.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • The nurse case manager’s role enabled her to support housebound patients with complex long-term conditions to reduce avoidable admissions to hospital using an integrated care approach.
  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff had appropriate knowledge of treating older people including their psychological, mental and communication needs.

People with long-term conditions:

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP and nursing case manager worked with other health and care professionals to deliver a coordinated package of care.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • GPs followed up patients who had received treatment in hospital or through out of hours services for an acute exacerbation of asthma.
  • Adults with newly diagnosed cardiovascular disease were offered statins for secondary prevention and patients with atrial fibrillation were assessed for stroke risk and treated as appropriate.
  • People with suspected hypertension were offered ambulatory blood pressure monitoring. The nursing case manager had a portable spirometry machine and nebuliser for home visits.
  • The practice could demonstrate how it identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension). The diabetic specialist nurse and dietitian held regular clinics at the practice.
  • The practice’s performance on quality indicators for long term conditions was in line with local and national averages.
  • The practice took part in a six-GP practice diabetes pilot programme that looked at innovative ways of helping patients manage their diabetes. Results from the pilot showed that the programme helped patients to reduce their weight, average blood sugar levels and improve their diet.

Families, children and young people:

  • Childhood immunisation uptake rates were mostly in line with the target percentage of 90% or above, with two indicators at 89%. The results show the practice was marginally below the 90% target. There was a robust recall system in place which included text message invites.
  • The practice had arrangements for following up failed attendance of children’s appointments following an appointment in secondary care or for immunisation.
  • The practice had a midwifery service at the practice and carried out antenatal and postnatal clinics. Their postnatal reviews included a mental health assessment to identify those at risk of postnatal depression.
  • The practice carried out intrauterine device (IUD) fittings for their local family planning clinic, a spill over service that ensured patients were seen in a timely manner.

Working age people (including those recently retired and students):

  • The practice’s uptake for cervical screening for 2016/17 was 58%, which was below the 80% coverage target for the national screening programme. The latest figures provided by the practice for August 2018 show that cervical screening uptake had improved to 70%. The practice had an action plan to continue to promote uptake via all communication methods such as their journal or text messages. They also took action to ensure proactive bookings were made by all clinicians and also ensured better documentation of disclaimers for those who refused.
  • The practice’s uptake for breast and bowel cancer screening was in line with the national average. The practice told us that patients received regular invites including text message invites.
  • The practice had systems to inform eligible patients to have the meningitis vaccine, for example before attending university for the first time.
  • The practice did not carry out routine NHS checks for patients aged 40-74, except for new patients or those on long-term medication. They told us that this was due to a decommissioning of the service two years ago. However, they told us that staff had been trained to carry out these checks in the near future. They took part in other disease screening programmes that included pre-diabetic screening and screening for cardiovascular disease. There was appropriate follow-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable.
  • The enhanced case manager had started to carry out home visits for all housebound patients with learning disability, to assess safety their home environment and act on any identified social issues.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

People experiencing poor mental health (including people with dementia):

  • The practice assessed and monitored the physical health of people with mental illness, severe mental illness and personality disorder by providing access to health checks, interventions for physical activity, obesity, diabetes, heart disease, cancer and access to ‘stop smoking’ services. There was a system for following up patients who failed to attend for administration of long term medication.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to help them to remain safe.
  • Staff were trained to be 'Dementia Friends', a national initiative to learn more about dementia and the ways they could provide support for patients with dementia.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis and patients with dementia were invited to care planning appointments.
  • The practice created a comprehensive template for dementia reviews to be conducted at home, which looked at specific issues such as fire risks at home. This template was shared with other local practices.
  • The practice offered annual health checks to patients with a learning disability.
  • The practices performance on quality indicators for mental health were in line with local and national averages.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives.

  • The most recent published QOF results showed the practice had achieved 98% of the total number of points available, which was above the CCG average of 96% and the national average of 97%.
  • The overall exception rate was 7%, compared to the CCG average of 5% and the national average of 6%. (Exception reporting is the removal of patients from QOF calculations where, for example, the patients decline or do not respond to invitations to attend a review of their condition or when a medicine is not appropriate). Exception reporting rates for cardiovascular disease, primary disease prevention were above local and national averages. For example, exception-reporting rates for cardiovascular disease was 33%, compared to the CCG average of 17% and the national average of 24%. We saw evidence that the practice carried out exception reporting as per national guidelines. The exception reporting for this clinical indicator shows that only three patients were exception reported after the practice had taken appropriate steps to invite the patients for an appointment. Of the patients exception reported, one patient had declined an appointment and two other patients were not suitable due to statin contraindications. 
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. Where appropriate, clinicians took part in local and national improvement initiatives, including patient research. They were involved in clinical research for the last nine years and designated as the sole research hub in Harrow.

Effective staffing

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

  • Staff had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people requiring contraceptive reviews.
  • Staff whose role included immunisation and taking samples for the cervical screening programme had received specific training and could demonstrate how they stayed up to date.
  • The practice understood the learning needs of staff and provided protected time and training to meet them. Staff at all levels of the organisation had access to a suite of bespoke training materials to cover the scope of their work and meet their learning needs.
  • Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • The practice provided staff with ongoing support. There was an induction programme for new staff. This included one to one meetings, appraisals, coaching and mentoring, clinical supervision and revalidation.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

Staff worked together and with other health and social care professionals to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams and organisations, were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when discussing care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information with, and liaised, with community services, social services and carers for housebound patients and with health visitors and community services for children who have relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

Staff were consistent and proactive in helping patients to live healthier lives.

  • The practice lead GP set up a Sunday morning walking group in the local park in July 2016, which encouraged patients to exercise. The walking group was open to all Harrow residents and had an attendance rate of approximately 30 patients and was usually followed by a short medical related talk from the lead GP or local hospital consultants.
  • The practice identified patients who may be in need of extra support and directed them to relevant services. This included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • Staff discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health, for example, stop smoking campaigns, tackling obesity.

Consent to care and treatment

The practice obtained consent to care and treatment in line with legislation and guidance.

  • Clinicians understood the requirements of legislation and guidance when considering consent and decision making.
  • Clinicians supported patients to make decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision.
  • The practice monitored the process for seeking consent appropriately.

Please refer to the evidence tables for further information.

Caring

Good

Updated 19 October 2018

We rated the practice as good for caring.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • Feedback from patients was positive about the way staff treat people.
  • Staff understood patients’ personal, cultural, social and religious needs.
  • The practice gave patients timely support and information.
  • The practices GP patient survey results were above local and national averages for questions relating to kindness, respect and compassion. The practice was a positive outlier for questions relating to confidence and trust in the GP. For example, 99% of patients had confidence and trust in the last GP they saw, which was above the local average of 95% and the national average of 96%.

Involvement in decisions about care and treatment

Staff helped patients to be involved in decisions about care and treatment. They were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given).

  • Staff communicated with people in a way that they could understand, for example, communication aids and easy read materials were available.
  • Staff helped patients and their carers find further information and access community and advocacy services. They helped them ask questions about their care and treatment.
  • The practice proactively identified carers and supported them.
  • The practices GP patient survey results were in line with local and national averages for questions relating to involvement in decisions about care and treatment.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • When patients wanted to discuss sensitive issues, or appeared distressed reception staff offered them a private room to discuss their needs.
  • Staff recognised the importance of people’s dignity and respect. They challenged behaviour that fell short of this.

Please refer to the evidence tables for further information.

Responsive

Good

Updated 19 October 2018

We rated the practice, and all of the population groups, as good for providing responsive services.

Responding to and meeting people’s needs

The practice organised and delivered services to meet patients’ needs. It took account of patient needs and preferences.

  • The practice understood the needs of its population and tailored services in response to those needs.
  • Telephone consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The practice had modern, purpose built facilities which had recently undergone extensive improvement and refurbishment. The new premises were well equipped to treat patients and meet their needs. The practice involved their younger and older patients in the grand re-opening of the practice premises.
  • The practice made reasonable adjustments when patients found it hard to access services.
  • The practice provided effective care coordination for patients who are more vulnerable or who have complex needs. They supported them to access services both within and outside the practice.
  • Care and treatment for patients with multiple long-term conditions and patients approaching the end of life was coordinated with other services.

Older people:

  • All patients had a named GP who supported them in whatever setting they lived, whether it was at home or in a care home or supported living scheme.
  • The practice was responsive to the needs of older patients, and offered longer appointments, home visits and urgent appointments for those with enhanced needs.
  • The enhanced case manager accommodated home visits for those who had difficulties getting to the practice due to limited local public transport availability.
  • There was lift access in the practice for those with poor mobility.

People with long-term conditions:

  • Patients with a long-term condition received an annual review to check their health and medicines needs were being appropriately met. Multiple conditions were reviewed at one appointment, and consultation times were flexible to meet each patient’s specific needs.
  • The practice held regular meetings with the local district nursing team and the palliative care nurses to discuss and manage the needs of patients with complex medical issues.

Families, children and young people:

  • We found there were systems 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 accident and emergency (A&E) attendances. Records we looked at confirmed this.
  • All parents or guardians calling with concerns about a child under the age of 18 were offered a same day appointment when necessary.
  • The practice had a designated private breastfeeding area in the practice, complete with relaxation music for both mother and baby.
  • There was a children’s play area and children’s TV in the waiting room.
  • The practice carried out intrauterine device (IUD) fittings for their local family planning clinic, a spill over service that ensured patients were seen in a timely manner, with access to the practice bypass number. Feedback from all 24 patients who had used this service showed that 100% of these patients would recommend this to friends and family.

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, flexible and offered continuity of care. For example, extended opening hours and Saturday appointments.
  • Patients had access to a wide variety of technological application systems (apps) and communication channels such as the TV information screen, the GP direct journal and the practice website.

People whose circumstances make them vulnerable:

  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability.
  • People in vulnerable circumstances were easily able to register with the practice, including those with no fixed abode. Patients with no fixed abode could use the practice address for their correspondence.

People experiencing poor mental health (including people with dementia):

  • Staff interviewed had a good understanding of how to support patients with mental health needs and they were trained to be 'Dementia Friends', a national initiative to learn more about dementia and the ways they could provide support for patients with dementia.
  • The enhanced nurse carried out home visits for patients with dementia. This was to offer support and coordinate their care with other health and social care providers.
  • Patients with mental health conditions were offered longer appointments. Patients who failed to attend were proactively followed up by a phone call from a GP.
  • Patients with dementia were visited at home by the enhanced case manager, to offer support and to coordinate their care with other health and social care providers.

Timely access to care and treatment

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

  • Patients had timely access to initial assessment, test results, diagnosis and treatment.
  • Waiting times, delays and cancellations were minimal and managed appropriately.
  • Patients with the most urgent needs had their care and treatment prioritised. Same day appointments were available, as well as nurse face to face and telephone appointments available at both sites.
  • Clinical pharmacist appointments were available every day, with a choice of face to face or telephone appointments.
  • Patients reported that the appointment system was easy to use. There were two automated self-check in systems at the practice to minimise delays.
  • The practices GP patient survey results were in line with local and national averages for questions relating to access to care and treatment.

Listening and learning from concerns and complaints

The practice 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; however, some complaint responses did not provide ombudsman details, should a patient wish to escalate their complaint. Staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the evidence tables for further information.

Well-led

Good

Updated 19 October 2018

We rated the practice as good for providing a well-led service.

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.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

The practice had a clear vision and credible strategy to deliver high quality, sustainable care.

  • There was a clear vision and set of values. The practice had a realistic strategy and supporting business plans to achieve priorities.
  • Staff were aware of and understood the vision, values and strategy and their role in achieving them.
  • The strategy was in line with health and social care priorities across the region. The practice planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy.

Culture

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

  • Staff stated they felt respected, supported and valued. They were proud to work in the practice.
  • The practice had a strong focus on the needs of patients.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values and we saw examples of this.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.
  • Staff we spoke with told us they were able to 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. All staff received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The practice actively promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff and teams.

Governance arrangements

The practice had a governance framework; however, monitoring of specific areas required improvement.

  • Structures, processes and systems to support good governance and management were clearly set out, understood and effective. The governance and management of partnerships, joint working arrangements and shared services promoted co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Practice leaders had established policies, procedures and activities to ensure safety. However, these required monitoring to assure themselves that they were operating as intended. This was in relation to the medicines management and risk assessments.

Managing risks, issues and performance

Processes for managing risks, issues and performance were established, although some required effective monitoring

  • There was an effective, process to identify, understand and address current and future risks including risks to patient safety. However, some monitoring was required to ensure that these were established in all areas. For example, monitoring was required to ensure that all recommended actions from the risk assessments had been carried out and clearly recorded on the action plans. Effective monitoring of blank prescriptions and vaccine stocks was also required to minimise risk to patient safety.
  • The practice had processes to manage current and future performance. Practice 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 practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.
  • The practice considered and understood the impact on the quality of care of service changes or developments.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and operational information was used to 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; except for safeguarding, which was not always discussed at whole practice meetings.
  • Although there was evidence of meeting minutes, these were not robust and did not always clearly record what was discussed.
  • The practice 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. The practice needed to ensure that they were plans to address any identified weaknesses, in relation to cardiovascular primary prevention exception reporting rates.
  • The practice 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 practice involved patients, the public, staff and external partners to support high-quality sustainable services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation.

  • There was a strong focus on continuous learning and development. Their participation in the diabetes pilot programme saw patients reduce their weight, average blood sugar levels and improve their diet.
  • The practice was very engaged at the forefront of technological development, which aimed to improve the patient journey.
  • Staff knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to make improvements.
  • Leaders and managers encouraged staff to take time out to review individual and team objectives, processes and performance.

Please refer to the evidence tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Older people

Good

Working age people (including those recently retired and students)

Good

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good