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The Health Centre Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 14 November 2017

Letter from the Chief Inspector of General Practice

This inspection was an announced focused inspection carried out on 27 September 2017 to follow up on information we received and to confirm the practice had continued to meet legal requirements and to identify additional improvements made since our last inspection.

We carried out an announced comprehensive inspection at The Health Centre on 28 April 2015. At that inspection the overall rating for the practice was Outstanding. The four domains of responsive, caring, effective and well led were rated as outstanding and the safe domain was rated as good. All inspection reports for The Health Centre can be found by selecting the ‘all reports’ link for The Health Centre on our website at www.cqc.org.uk.

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

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.
  • Weekly meetings took place the agenda of which included significant events and incidents. These prioritised risks at the practice and showed agreed actions. For example, following a serious accident on a lifeboat one of the GPs had joined the RNLI and had become the lifeboat doctor.
  • The needs of vulnerable patients had been identified and since our last inspection additional measures had been put in place. For example, additional nurse clinics were held on the small islands.
  • Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
  • 97% of the patients surveyed said they found it easy to make an appointment with a named GP and added 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.
  • Procedures for emergencies were in place. We were told that each of the inhabited islands had a defibrillator and trained ‘first responders’ (people who had completed first aid and emergency response training), who lived on the islands.
  • There was a strong focus on continuous learning and improvement at all levels.
  • The Health Centre provided placements for GP registrars (qualified doctors training to be GPs) and medical students. Feedback from trainees and students demonstrated this was a popular placement.
  • 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 the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 14 November 2017

The practice is rated as good for providing safe services.

  • From the sample of documented examples we reviewed, we found there was an effective system 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 were informed as soon as practicable, 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 clearly defined and embedded systems, processes and practices to minimise risks to patient safety.
  • Procedures for emergencies were in place. When visiting the ‘off islands’ (inhabited Scilly islands smaller than the main island of St Marys) GPs took a doctors bag, which contained medicines and equipment likely to be needed. In an emergency the GPs called the emergency boat, specifically for the islands, which was staffed by paramedics and contained suitable emergency equipment. We were told that each of the inhabited islands had a defibrillator and trained ‘first responders’ (people who had completed first aid and emergency response training), who lived on the islands.
  • Staff demonstrated that they understood their responsibilities and all had received training on safeguarding children and vulnerable adults relevant to their role.
  • The practice had adequate arrangements to respond to emergencies and major incidents.

Effective

Outstanding

Updated 22 October 2015

The practice is rated as outstanding for providing effective services. Supporting data obtained both prior to and during the inspection showed the practice had systems in place to make sure the practice was effectively run. There was a holistic approach to assessing planning and delivering care to patients living in this unique setting, the GP’s and staff worked collaboratively with other healthcare services to support people with complex needs and reduce the need to obtain health care on the mainland. Care and treatment was delivered in line with national best practice guidance and outcomes for patients were consistently better than expected when compared with other practices. Staff employed at the practice had received appropriate support, training and appraisal. GP appraisals and revalidation of professional qualifications had been completed. The practice had extensive health promotion material available within the practice and on the practice website.

Caring

Outstanding

Updated 22 October 2015

The practice is rated as outstanding for providing caring services. Patients said they were treated with compassion, dignity and respect and they were involved in care and treatment decisions. Feedback from patients was substantially positive with the vast majority of patients reporting that all staff gave them the time they needed, that GPs and nurses were good at explaining treatment and tests to them, and all staff including reception staff were very helpful.

Accessible information was provided to help patients understand the care available to them. Every effort was made to respect and value patent’s individual needs and overcome challenges and obstacles to providing their care in an island setting. We also saw that staff treated patients with kindness and respect ensuring confidentiality was maintained.

The GPs worked with the community staff and Living Well, an Age Concern project, to ensure that services were fully integrated and provided within the patient’s own home, often negating the need for hospital care on the mainland.

Responsive

Outstanding

Updated 14 November 2017

The practice is rated as outstanding for providing responsive services.

  • The practice understood its population profile and had used this understanding to meet the needs of its population.
  • The practice took account of the needs and preferences of patients with life-limiting conditions, including patients with a condition other than cancer and patients living with dementia.
  • Since our last inspection the practice had, employed a reablement physiotherapist who worked with other social services to provide a short term package of care designed to support patients to regain their confidence and independence at home following illness or hospital admission.
  • Patients we spoke with 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.
  • 100% of patients said they could get through easily to the practice by phone compared to the national average of 71%.
  • 96% of patients said that the last time they wanted to speak to a GP or nurse they were able to get an appointment compared with the national average of 84%.
  • The practice had good facilities and was well equipped to treat patients and meet their needs.
  • Information about how to complain was available and evidence from the examples reviewed showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders.

Well-led

Outstanding

Updated 14 November 2017

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

  • The practice continued to have a clear vision and strategy to deliver high quality care and promote good outcomes for their permanent and transient patient population. Staff were clear about the vision and their responsibilities in relation to it.
  • There was a clear leadership structure and staff felt supported by management. The practice had policies and procedures to govern activity and held regular governance meetings.
  • An overarching governance framework supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk.
  • Weekly meetings took place the agenda of which included significant events and incidents. This prioritised risks at the practice and showed agreed actions. For example, following a serious accident on a lifeboat one of the GPs had joined the RNLI and had become the lifeboat doctor.
  • Staff had received inductions, annual performance reviews and attended staff meetings and training opportunities.
  • The provider was aware of the requirements of the duty of candour. In the examples we reviewed we saw evidence the practice complied with these requirements.
  • The partners encouraged a culture of openness and honesty. The practice had systems for being aware of notifiable safety incidents and sharing the information with staff and ensuring appropriate action was taken.
  • The practice proactively sought feedback from staff and patients and we saw examples where feedback had been acted on. The practice engaged with the patient participation group.
  • There was a focus on continuous learning and improvement at all levels. Staff training was a priority and was built into staff rotas.
  • GPs who were skilled in specialist areas used their expertise to offer additional services to patients.

Checks on specific services

People with long term conditions

Outstanding

Updated 22 October 2015

The practice is rated as outstanding for providing care to people with long term conditions.

Nursing staff had lead roles in chronic disease management and had dedicated appointments to review patients with diabetes, asthma and/or chronic respiratory disease. Combined appointments were used where patients had multiple long term conditions. All patients had a named GP and a structured annual review to check that their health and medication needs were being met.

For patients unable to visit the practice or for those living on the off islands staff had set up clinics to review their conditions, portable digital equipment such as stethoscopes and ECG machines (used to measure heart rate) were used. The practice had achieved 100% success rate in screening patients for long term conditions.

For those people with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care so that patients experienced a seamless and integrated service. The practice held multidisciplinary team meetings every month to review the needs of all patients with complex long term conditions.

The nurses had developed, for diabetic patients, a fast pass scheme for foot care. By making patients more aware that any blisters, cuts etc. could be potentially serious this scheme allowed patients to be seen as soon as possible. This had resulted in no patients with diabetic foot injuries currently on the islands.

The practice recognised the needs of patients and their difficulty with transport to the mainland for hospital appointments. Blood testing was carried out by the GPs in the hospital on St Mary’s and an optometry room had been developed within the practice. The GPs were undertaking radiography training to take x rays. Visiting consultants at clinics also reduced the need for patients to travel to the mainland.

Longer appointments and home visits were available when needed. Home visits for patients newly discharged from hospital were undertaken jointly with the community nursing team to carry out an assessment and arrange additional support where needed.

Families, children and young people

Outstanding

Updated 22 October 2015

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

Families had a named GP. The GPs attended all women who gave birth on the islands and had undertaken additional training in neonatal support. Staff worked well with the midwife to provide antenatal and postnatal care. Postnatal health checks were provided by a GP. The practice provided baby and child immunisation programmes to ensure babies and children could access a full range of vaccinations and health screening. National data showed that the practice had achieved 100% in immunisations for children up to the age of five years.

The practice held monthly meetings with the Health Visitor to discuss young children to ensure their health needs were being met.

Sexual health clinics were previously located in Penzance but now located within the practice, to protect confidentiality no set times were provided, patients made an appointment convenient for themselves. The practice is a member of the EEFO system for young people. Information relevant to young patients was displayed and health checks and advice on sexual health for men, women and young people included a full range of contraception services and sexual health screening including chlamydia testing and cervical screening.

To overcome confidentiality issues found within a small close knit community separate notes and booking service for clinics was in place. There was a separate direct telephone line to the GPs for young people to speak with a GP.

The GPs training in safeguarding children from abuse was at the required level. Monthly meetings with Social Services, the Police, the school, hospital and Health Visitors took place. The practice nurse was also the school nurse at the island school and a governor with responsibility for the school boarding house, which provided excellent continuity and a familiar friendly face for young patients.

The practice was proactive in getting feedback from patients. The patient participation group encouraged membership across all of the population groups and now included a member who was a parent with a young family.

Parents with children attending the practice confirmed that they were always present during consultations. Staff understood Gillick principles with regard to assessing whether a young person was able to understand and therefore consent to treatment. Parents told us that all of the staff engaged well with their children so that they found it a positive experience when attending the practice for appointments.

Being a small group of islands staff knew the patients, so younger carers would be identified and supported to contact the relevant support services.

Older people

Outstanding

Updated 22 October 2015

The practice is rated as outstanding for providing care to older people.

All patients over 75 years had a named GP but could see a GP of their choice. Health checks and health promotion were offered to this group of patients. The practice worked with the community matron to care for patients within their own homes. Inter-island travel, provided by foot passenger ferries between the St Mary’s and the off islands, was challenging during inclement weather so the GP’s and nurses had set up clinics on the off islands so patients (particularly older people) would not have to travel to St Mary’s. The practice held monthly multi-disciplinary team (MDT) meetings where patients with complex needs, including end of life care, were discussed. Attendees of these meetings included GP’s, the nurse practitioner, district nurses, and health visitors. The practice also had established links with the Macmillan nurses based in Helston. The practice team strived to provide good quality palliative care on the islands and in the community hospital on St Mary’s.

Nationally reported data showed that outcomes for patients exceeded expectations for conditions commonly found in older people. For example, 100% compared with the national average of 81.3% of patients aged 75 or over with a fragility fracture were treated with an appropriate bone-sparing agent, a medicine used to help strengthen bones.

The practice provided medical care to the local residential home. The GP held regular sessions at the home to review patients with non urgent health problems, this time was also used to proactively identify and manage any emerging health issues and undertake medication reviews.

The practice were aware of lone elderly patients who were vulnerable, and would make regular home visits to check on their welfare. A GP also carried out home visits to older patients presenting with more urgent health needs.

Staff from the practice visited the housebound to ensure tests and routine examinations were carried out. For patients who were registered as needing their medicines from the dispensary, the practice pharmacy provided medicines in blister packs for older people with memory problems or had other difficulties. Medicines were delivered to the patient’s home or to a nearby shop for ease of access. Pneumococcal vaccination and shingles vaccinations were provided at the practice for older people on set days as well as during routine appointments. Staff recognised that some patients required additional help when being referred to other agencies and assisted them with this, for example with booking flights or a passage on the ferry to the mainland.

Working age people (including those recently retired and students)

Outstanding

Updated 22 October 2015

The practice is rated as outstanding for providing care to working age people. The practice provided telephone consultations with the GP, or skype consultations, at the patient’s convenience prior to an appointment, and extended surgery hours would accommodate the patient if they needed to be seen. The practice had extended their opening hours and were open on Saturday mornings. Patients could order repeat prescriptions on line.

Overseas travel advice including up-to-date vaccinations was available from the nursing staff within the practice with additional input from the GP’s if required.

Patients over 45 could arrange to have a health check with a nurse. The practice had achieved 89% of health checks for this age group. The practice GPs had also, at the request of local population, undertaken additional training to provide ENG1 tests (this is a test that seafarers require to work at sea); prior to this patients would have needed to travel to the mainland.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 22 October 2015

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

Patients with suspected dementia were being screened for early identification and referred to the memory clinic for diagnostic tests. Data showed the practice was above the national average of 54.3% at 100% in diagnosing people with dementia. Patients had care plans in place, which supported their ongoing changing needs and those of their carers.

The practice had links with the local bus service to transport patients to the practice for the memory clinic. Support and education in dementia had been provided by the practice to the shopkeepers on the islands, to increase their awareness of dementia in order to support carers and protect the dignity of sufferers.

Flexible services and appointments were available, which enabled patients experiencing poor mental health to have longer appointments at quieter times of the day, avoiding times when people might find this stressful. In house mental health medication reviews were conducted to ensure patients received appropriate doses. For example, patients taking particular medicines had regular blood tests to maintain therapeutic levels and ensure safe prescribing.

Staff were skilled in recognising and responding to patients experiencing mental health crisis, providing support to access emergency care and treatment. The practice worked collaboratively with the community mental health team and consultant psychiatrists from the mental health partnership trust based on the mainland. Clinics were held on St Mary’s by the mental health teams.

The practice were currently exploring ways of providing arrangements to provide a place of safety for patients when in crisis, which met the criteria of the Mental Health Act 2005 and would remove the necessity for urgent transfer to the mainland.

People whose circumstances may make them vulnerable

Outstanding

Updated 22 October 2015

The practice is rated as outstanding for people whose circumstances may make them vulnerable

The practice held a register of patients living in vulnerable circumstances including those with a learning disability. It had carried out annual health checks for people with a learning disability and 100% of these patients had received a follow-up. It offered longer appointments for patients who may need more time, such as those with a learning disability and their carers for reviews.

The islands accommodate a large number of seasonal workers, the practice register these people and provide health checks and flu vaccinations. This included alcohol and drug screening. Patients with alcohol addictions were referred to an alcohol service for support and treatment and to the local drug addiction service.

The practice worked closely with the community matron to arrange visits to vulnerable patients to assess and arrange any equipment or other assistance needed by the patient and their carers.

The practice would provide primary care services for homeless patients (of which there were none); staff said they would not turn away a patient if they needed primary care. Patients with language interpretation requirements were known to the practice and staff knew how to access translation services.

Reception staff were able to identify vulnerable patients and offer longer appointment times where needed and sent letters for appointments.

The islands are a popular holiday destination, staff told us that they would see and treat any patients who became unwell whilst on holiday.