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Southdene Medical Centre Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 28 February 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Southdene Medical Centre on 24 November 2016. Overall the practice is rated as outstanding.

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

Patients were protected by a strong comprehensive safety system and there was a focus on openness, transparency and learning when things went wrong. The practice had a strong system in place for recording, monitoring and learning from significant events, accidents, complaints and reporting.

  • The practice used innovative and proactive methods to improve patient outcomes. The practice had a high rate of clinical audit for their size.

  • Outcomes for patients who use similar services were consistently better than expected when compared with similar services. Data showed that the practice was performing highly when compared to practices nationally and in the Clinical Commissioning Group. The latest publically available data from 2015/16 showed the practice had achieved the maximum points available to them for 2015/16 (100%), with a clinical exception rate of 8.2%. This was above the England average of 95.3%, and their clinical exception rate was below the England average of 9.8%.

  • The practice used creative approaches to care and treatment and placed a strong emphasis on patient education. Staff were consistent and proactive in supporting patients to live healthier lives through a targeted approach to health promotion. Information was provided to patients to help them understand the care and treatment available.

  • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment.

  • The practice reviewed the needs of their local population and engaged with the NHS England Area Team and clinical commissioning group (CCG) to meet the needs of the individual patients to ensure flexibility, choice and continuity of care.

  • 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.

  • Patients could access appointments and services in a way that suited them. They said they were able to get an appointment with a GP when they needed one, with urgent appointments available the same day.

  • The leadership, governance and culture were used to drive and improve the delivery of high-quality person-centred care. The practice had a clear vision which had quality and safety as its top priority.

  • There was a clear leadership structure in place and staff felt supported by management. The practice sought feedback from staff and patients, which they acted on.

  • Staff throughout the practice worked well together as a team.

We two areas of outstanding practice which were:

  • The practice had all-encompassing systems and processes in place to ensure that patients received high quality care and treatment. These included learning from significant events, triggering clinical audits and then changes in clinical practice which improved patient care. For example, One of the GP partners kept a folder of NICE guidance updates which they reviewed at clinical meetings to ensure they were followed and actioned. They took action as appropriate with regards to existing patients and updated templates and guidelines and protocols the practice had in place. The practice had structured tiered templates on the practice intranet system to obtain information on medical conditions to improve patient care.
  • The practice placed a strong emphasis on patient education. In addition to the usual education provided to patients during regular appointments they arranged an education programme with diabetic patients with a local renal consultant in May 2016. The practice monitored the personal diabetes control of the patients who attended this session and found that 38% of patients who attended (eight) lost weight and improved the control of their diabetes.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Outstanding

Updated 28 February 2017

The practice is rated as outstanding for providing safe services.

Patients were protected by a strong comprehensive safety system and there was a focus on openness, transparency and learning when things went wrong. The practice had a strong system in place for recording, monitoring and learning from significant events, accidents, complaints and reporting. Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. There was a genuine open culture in which all safety concerns were valued. The practice used opportunities to learn from internal and external incidents, to support improvement.

There were strong arrangements in place to safeguard adults and children from abuse that reflected relevant legislation and local requirements. For example, they regularly generated a report of children who missed appointments and of children who had injured themselves and attended the A & E department or out of hour’s service, these would be reviewed to identify trends and warnings signs which led to further action. The safeguarding lead for the practice was a locality lead and had received a higher level of safeguarding training than other practice leads.

Risk management was well embedded and recognised as the responsibility of all staff. The practice was clean and hygienic and good infection control arrangements were in place. The arrangements for managing medicines, including emergency drugs and vaccinations, in the practice kept patients safe.

Staff recruitment and induction policies were in operation and staff had received Disclosure and Barring Service (DBS) checks where appropriate. Chaperones were available if required and staff who acted as chaperones had undertaken appropriate training.

Effective

Outstanding

Updated 28 February 2017

The practice is rated as outstanding for providing effective services.

The practice had an effective system in place to ensure that all clinicians were up to date with both National Institute for Health and Care Excellence (NICE) guidelines and other locally agreed guidelines.

Outcomes for patients who use similar services were consistently better than expected when compared with similar services. Data from the Quality and Outcomes Framework (QOF) showed that the practice was performing highly when compared to practices nationally and in the clinical commissioning group. The latest publically available data from 2015/16 showed the practice had achieved the maximum points available to them for 2015/16 (100%), with a clinical exception rate of 8.2%. This was above the England average of 95.3% and the local clinical commissioning group (CCG) average of 97.5%. Their clinical exception rate was below the England average of 9.8%.

There was a system in place for clinical audit and the practice had a high rate of audit for their size. The practice had carried out nine, two cycle audits in the last twelve months.

The practice had been recognised locally over the years as having a good track record for the prescribing of medication. They were the second lowest prescribers of antibiotics in the locality out of 39 practices.

There was continuing development of staff skills, staff received appropriate training for their roles and appraisals and supervisions were carried out for all staff. The nurse practitioner had been supported to train for this role.

The practice’s uptake for the cervical screening programme was 90%, which was above the national average of 82%. They told us it had been at a consistently high level since 2007 and it was the highest in the locality. In the past the practice had been asked by the local NHS cervical screening supporting office to give best practice advice to practices with lower screening uptake.

The practice placed a strong emphasis on patient education. In addition to the usual education provided to patients during regular appointments they arranged an education programme with diabetic patients with a local renal consultant in May 2016.

Caring

Good

Updated 28 February 2017

The practice is rated as good for providing caring services.

Feedback from patients and those who completed CQC comment cards were overwhelmingly positive. Patients and staff gave us examples of where the practice had gone the ‘extra mile’. Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment.

Data from the National GP Patient Survey showed scores from patients were variable compared to local and national averages. For example, 100% said they had confidence and trust in the last nurse they saw compared to the CCG average of 98% and the national average of 97%.

There were 47 patients registered as a carer which was 2% of the practice population. Written information was available for carers to ensure they understood the various avenues of support available to them. The practice had close links with the local carers’ organisation.

The practice sent bereavement cards and a pack to family members on the death of a patient. Due to the size of the practice and the longevity of the GPs and practice staff they felt they were able to offer individualised care to patients as they knew their medical and social histories very well.

Responsive

Good

Updated 28 February 2017

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 to meet the needs of the individual patients to ensure flexibility, choice and continuity of care.

Patients could access appointments and services in a way that suited them. Patients said they found it easy to make an appointment with a GP and there was continuity of care, with urgent appointments available the same day. The practice had very good access to appointments for patients. For example, results from the National GP Patient Survey showed that 96% of patients said they could get through easily to the surgery by phone compared to the local CCG average of 79% and national average of 73%.

The practice had developed services to understand the needs of different groups of patients. For example, patients with long term conditions were monitored very closely by the practice nurses, overseen by the GPs. The nurses had received training in many aspects of chronic disease management. The practice were keen to promote self-care to the patients to manage their conditions. Holistic appointments were available for patients where more than one condition could be reviewed and the reception staff had templates to ensure they booked an appointment long enough to suit patient need.

The practice building was purpose built and the design of the building was intended to give the practice a friendly feel rather than looking like a clinical building. They had recently extended it to include a room at reception for patients to be seen in private if necessary or for the room to be used for breast feeding. Disabled access was improved with new flooring and the lowering of the height of the reception desk.

Information about how to complain was available and easy to understand.

Well-led

Outstanding

Updated 28 February 2017

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

The leadership, governance and culture were used to drive and improve the delivery of high-quality person centred care. The practice had a clear vision with quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff. They had a business plan in place with goals and objectives. This set out the arrangements for monitoring, and provided the evidence of how the practice demonstrated improved outcomes. High standards were promoted and owned by all practice staff and teams worked together across all roles.

Governance and performance management arrangements were continually reviewed and reflected best practice. The practice had a governance framework in place which supported the delivery of the business plan and good quality care. Data such as the Quality and Outcomes Framework (QOF) performance supported this.

There was constructive engagement with staff and a high level of staff satisfaction. For example, the nursing team told us that when the refurbishment of the practice was planned their wishes were taken into account regarding storage facilities. The practice had gathered views from the patient participation group (PPG) and had used them to improve the services provided.

The practice had a culture of continuous improvement. The leadership drove continuous improvement and staff were accountable for delivering change. They had systems and processes in place to improve clinical care and these were continually developing.

Checks on specific services

People with long term conditions

Outstanding

Updated 28 February 2017

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

Nationally reported QOF data (2015/16) showed the practice had achieved good outcomes in relation to the conditions commonly associated with this population group. The practice had received maximum points for all 19 clinical domain indicator groups, which included asthma, heart failure, diabetes and chronic obstructive pulmonary disease (COPD) related indicators.

The practice had a register of patient with long term conditions which they were proactive in their monitoring of for annual call and recall appointments for health checks by the nurses. Annual medication reviews were carried out by the practice nurses but reviewed by the GPs. Holistic appointments were available where patients could be reviewed for multiple long term conditions at their appointment, this meant they could be seen in relation to several different long-term conditions at the same time, saving time for the patient. Extended opening hours and home visits were available when needed.

Both of the nurses at the practice received training in many aspects of chronic disease management. This included the MERIT (Meeting, educational requirements, improving treatment) diabetes management programme, which the nurses and GPs attended. Following mentored clinics, the practice has been initiating insulin therapy in patients with type two diabetes, (19 patients since 2012). The practice team had ongoing annual diabetes training to keep up to date with changes. This decision was made after the patients expressed the wish to have their diabetes care delivered within the practice. Since this training referrals of patients with type two diabetes has reduced significantly. The practice offered open access to patients with diabetes receiving insulin via the telephone. Staff were trained in electrocardiogram (ECG) interpretation.

The nurses had received training in tissue viability and were competent in Doppler assessment and ankle brachial pressure index (ABPI) prior to applying compression dressings for patients. This service meant that referrals to secondary care were avoided and it allowed the patients to be seen in the community with familiar staff close to home.

Nurses had been caring for patients with leg ulcers since 2008. Appointments were offered to patients according to patient need, this may have been daily when ulcers are more active and less often throughout the healing process.

A practice audit showed that 14 patients had attended the practice for leg ulcer treatment in the surgery. One patient was seen over a six year period due to complex problems, backed up by advice from secondary care. Twelve patients had been seen with ulcers which had subsequently healed and care was completed. One patient had treatment ongoing.

The practice arranged an education programme with diabetic patients with a local renal consultant in May 2016. They talked to patients and their relatives. They explained about the treatments for diabetes and explained the possible complications of uncontrolled diabetes. The practice were monitoring if the personal diabetes control of the patients who attended would tighten following the presentation. The practice received positive feedback from those who attended who said it was beneficial to their understanding of their condition. There were plans for the coming year to have similar presentations regarding heart disease and respiratory problems including chronic obstructive pulmonary disease (COPD).

Families, children and young people

Outstanding

Updated 28 February 2017

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

There were strong systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk. The practice regularly generated a report of children who missed appointments and of children who had injured themselves and attended the A & E department or out of hours service. These would be reviewed to identify trends and warnings signs which led to further action by the safeguarding lead for the practice. There were safeguarding meetings at the practice every three months.

Childhood immunisation rates for the vaccinations given were above CCG/national averages. For example, childhood immunisation rates for the vaccinations given to under twelve months were 100%, compared to CCG averages of 98%. For five year olds from 97% to 100%, compared to CCG averages of 97% to 99%. The practice told us their child immunisation programme had been above 90% since 2009. The practice had a robust call and re-call system and would contact the family if necessary. There was a flexible appointment system for child immunisations.

The practice’s uptake for the cervical screening programme was 90%, which was above the national average of 82%. They told us it had been at a consistently high level since 2007 and it was the highest in the locality. In the past the practice had been asked by the local NHS cervical screening supporting office to give best practice advice to practices with lower screening uptake. The practice said they believed the high uptake was due to their diligent call and re-call system. Administration staff would telephone patients and persist to encourage them to attend an appointment. The GP would personally contact patients to discuss the benefits of screening.

Appointments were available outside of school hours and the premises were suitable for children and babies. The practice had recently been updated to include a private room at reception which could be used for breast feeding.

Older people

Outstanding

Updated 28 February 2017

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

Nationally reported Quality and Outcomes Framework (QOF) data (2015/16) showed the practice had achieved good outcomes in relation to the conditions commonly associated with this population group. For example, performance for atrial fibrillation related indicators were above the national average (100% compared to 96% nationally). The practice offered proactive, personalised care to meet the needs of the older people in its population.

The practice subscribed to a hospital admission avoidance direct enhanced service. There were care plans in place for at least the most vulnerable 2% of the practice population. There was a vulnerable adult’s wrap around service provided by the CCG. This was provided by a nurse practitioner who visited the practice daily and would visit patients, mostly frail and elderly and those in care homes who the practice had concerns about.

All patients over the age of 75 had a named GP. The practice offered home visits. Prescriptions could be sent to any local pharmacy electronically. The practice had palliative care meetings every month where the practice shared information with palliative care nurses and district nurses ensuring they could provide holistic care to their patients.

Working age people (including those recently retired and students)

Outstanding

Updated 28 February 2017

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 which included appointment booking, test results and ordering repeat prescriptions. There was a full range of health promotion and screening that reflected the needs for this age group.

Flexible appointments, including telephone appointments, were available as well as extended opening hours.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 28 February 2017

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

The practice regularly worked with multi-disciplinary teams in the case management of people experiencing poor mental health. The community psychiatric nurse visited the practice once a week to provide care for patients.

The practice maintained a register of patients experiencing poor mental health and recalled them for at least an annual review. There were care plans in place for those with severe mental health conditions.

Patients with dementia were reviewed annually and offered a care plan in relation to their condition. Patients were told how to access various support groups and voluntary organisations. Performance for mental health related indicators was better than national average. For example, performance for dementia indicators was above the national average (100% compared to 92.8% nationally).

People whose circumstances may make them vulnerable

Outstanding

Updated 28 February 2017

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. This included patients with a learning disability. Emergency contacts for patients were included in this register. This was particularly helpful with a patient with learning disabilities who needed emergency care in the surgery and admission to secondary care. This allowed the named contact from social services to be easily contacted.

The practice offered annual health checks and had an 86% attendance rate for this patient group. If the patient required a home visit the GP and nurse practitioner would visit the patient.

The practice regularly worked with multi-disciplinary teams in the case management of vulnerable people. They told vulnerable patients about how to access various support groups and voluntary organisations. 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. The practice’s computer system alerted GPs if a patient was a carer. There were 47 patients registered as a carer which was 2% of the practice population. Written information was available for carers to ensure they understood the various avenues of support available to them. The practice had close links with the local carers’ organisation.