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Goyt Valley Medical & Dental Practice Outstanding

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Inspection Summary


Overall summary & rating

Outstanding

Updated 9 November 2016

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Goyt Valley Medical Practice on 20 September 2016. Overall, the practice is rated as outstanding.

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

  • Patients overwhelmingly told us they received excellent care and were treated with compassion, dignity and respect. They also said they were involved in their care and decisions about their treatment. This was corroborated bythe outcomes of the latest national GP patient survey, friends and family test results, and CQC comment cards.
  • There was an effective 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.
  • Clinicians kept themselves updated on new and revised guidance and discussed this at clinical meetings. Staff assessed patients’ needs and delivered care in line with current evidence based guidance.
  • Feedback from patients we spoke with on the day, and from CQC comment cards, demonstrated that people had excellent access to GP appointments.
  • We saw evidence of an active programme of clinical audit that reviewed care and ensured actions were implemented to enhance outcomes for patients.
  • The practice planned and co-ordinated patient care with the wider health and social care multi-disciplinary team to deliver effective and responsive care and keep vulnerable patients safe. Regular meetings took place to discuss and review patients’ needs.
  • The practice had an appraisal system in place and supported staff training and development. The practice team had the skills, knowledge and experience to deliver high quality care and treatment.
  • Longer appointments were available for those patients with more complex needs, and there was greater flexibility in offering appointments for vulnerable patients such as those with a learning disability.
  • The practice had good facilities and was well-equipped to treat patients and meet their needs. The premises were accessible for patients with impaired mobility.
  • 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 they felt valued and that GPs and managers were approachable and always had time to talk with them.
  • The partnership had a clear vision for the future of the service, and were engaged with their Clinical Commissioning Group (CCG) in order to progress this.
  • The practice had an open and transparent approach when dealing with complaints. Information about how to complain was available, and improvements were made to the quality of care as a result of any complaints received.
  • The practice patient participation group (PPG) was active and helped to champion the patient voice to influence developments within the practice.

We saw the following areas of outstanding practice:

  • The nurse practitioners provided on-the-day assessment and care for patients presenting with new and acute conditions, and minor illnesses. They undertook home visits and one provided regular input at a local care home for patients with dementia. This alleviated pressure on GPs allowing them more time for complex consultations and produced positive outcomes for patients. For example, input to the care home demonstrated effectiveness through the reduction in contacts with the out of hours’ service and hospital admissions. Over a 12 month period, hospital admissions fell from 67 to 43, and contact with the out of hours’ service reduced from 23 to 17 patients. There was also a decrease in falls at the home from 56 between January to March 2014, to 24 in the corresponding period the following year.
  • The practice directly employed a mental health support worker. Data for emergency admissions for mental health over a three year period showed low figures for the practice. These were the lowest within their locality and one of the lowest within their CCG. The practice were able to provide evidence that over the last two years, only four of 22 patients at high risk of hospitalisation had been admitted, with two of the admissions being outside of the practice’s direct control.
  • The practice demonstrated a responsive approach by taking account of the needs of their local population, and not just their registered patients. This enabled services to be delivered closer to patient’s homes.

The areas where the provider should make improvement are:

  • Review the need to take emergency medicines on home visits, or consider a risk assessment to be completed for this.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 9 November 2016

  • Staff were supported to report significant events in a supportive environment. Learning was applied from incidents to improve safety in the practice.
  • The practice had effective 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.
  • There were systems in place to manage medicines on site appropriately.
  • Patients on high-risk medicines were monitored on a regular basis.
  • Actions were taken to review any medicines alerts received by the practice, to ensure patients were kept safe.
  • The practice had systems in place to deal with medical emergencies within the surgery. However, emergency medicines were not taken on home visits and there was no risk assessment in place to cover this.
  • Risks to patients and the public were well managed. The practice received support for health and safety matters from an external contractor, and there was a comprehensive and proactive approach to risk assessment.
  • The practice had developed contingency planning arrangements supported by an up to date written plan that was regularly updated. 

Effective

Outstanding

Updated 9 November 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 99.1% for the Quality and Outcomes Framework (QOF) 2014-15. This was slightly above the CCG average of 98.1%, and above the national average of 94.7%.
  • Regular clinical meetings took place to discuss issues such as new guidance. Learning lunches provided an environment of ongoing learning and clinical staff development within the practice.
  • The practice had proactively reviewed their skill mix to meet the demands of patients and access to care. This included directly appointing two nurse practitioners whose roles had been developed to provide first-contact patient care and home visits. The practice employed a mental health support worker, and had recently joined a pilot scheme to place a prescribing community pharmacist within the practice team. We saw examples of how all of these roles had impacted positively upon patient care and outcomes.
  • The practice maintained comprehensive documentation to demonstrate their compliance with standards. For example, minutes from meetings were clear and concise and provided a source of reference for other staff to review outcomes from the discussions held.
  • The practice worked collaboratively with the wider health and social community to plan and co-ordinate care to meet their patients’ needs at regular multi-disciplinary team meetings.
  • Staff had the skills and experience to deliver effective care and treatment. New employees received inductions, and all members of the practice team had received an appraisal in the last year, which included a review of their training needs.
  • We saw examples of how clinical audit was being used to drive quality and enhance safe patient care and treatment. 

Caring

Good

Updated 9 November 2016

  • We observed a patient-centred culture and approach within the practice. Staff treated patients respectfully and with kindness.
  • Data from the latest GP survey in July 2016 showed that patients rated the practice higher than local and national averages in respect of the care they received.
  • Patients we spoke with during the inspection, and feedback received on our comments cards, indicated that they felt treated with compassion and dignity, and were given sufficient time during consultations. Patients said they were involved in decisions about their care and treatment.
  • Feedback received from managers at the care home and the community nursing team was very positive about the high standards of care provided by the practice team.
  • The practice was in the process of reviewing their carers register for accuracy. Following this, they intended to review their support for carers, such as the provision of an annual health review. Information was available on the various types of support available to carers.
  • As a small semi-rural practice, the team knew their patients very well. This aided them in providing personalised care and ensured greater continuity for patients.
  • We were provided with examples of individual patient stories which reflected the caring approach of the practice team. This included a patient who had been supported to die an appropriate and dignified death within a care home, rather than being admitted into the hospital.

Responsive

Outstanding

Updated 9 November 2016

  • Comment cards and patients we spoke with during the inspection provided mainly positive experiences regarding obtaining an appointment with a GP. The latest GP survey showed that patient satisfaction was above local and national averages with regards access to GP appointments.
  • The practice had developed the nurse practitioner role to enable them to see patients as the primary contact for any new condition or minor illness. The nurse practitioners operated a triage system when all the appointments had been booked for the day, and would advise patients or arrange to see them either in the surgery or at home. This created good patient access and provided capacity for GPs to see patients with more complex needs.
  • Patients could book appointments and order repeat prescriptions on line. The practice participated in the electronic prescription scheme, so that patients could collect their medicines from their preferred pharmacy without having to collect the prescription from the practice.
  • The practice hosted some services on site including counselling and a weekly clinic provided by the midwife. 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 tidy and clean and well-equipped to treat patients and meet their needs. The practice accommodated the needs of patients with disabilities, including access to the building through automatic doors.
  • The practice reviewed any complaints they received and dealt with these in a sensitive and timely manner. Information about how to make a complaint was available for patients. Learning from complaints was used to improve the quality of service.
  • If patients at reception wished to talk confidentially, or became distressed, they could be offered a more private area to ensure their privacy. 

Well-led

Outstanding

Updated 9 November 2016

  • The partners were committed and passionate to delivering high quality care and promoting good outcomes for their patients.
  • The partners and management closely reviewed the service and strove to adapt to new demands to best meet their patients’ needs. This included the development of a practice team comprised of different disciplines, and enhanced nurse practitioner roles to deliver high quality and responsive care for patients.
  • There was a clear staffing structure in place. GPs and nurses had lead roles providing a source of support and expert advice for their colleagues.
  • The practice had developed a range of policies and procedures to govern activity.

  • The partners worked collaboratively with other GP practices in their locality, and with their CCG. Due to its location on the edge of the High Peak, hospital services were often quite remote for patients. The partners had instigated an independent provider service which relocated some NHS out-patient services into the community, making these more accessible for local residents. This approach was supportive of the local CCG strategy for 21st century patient care.

  • 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.
  • The practice had sought feedback from patients, and acted on this to improve service delivery.
  • There was an active Patient Participation Group (PPG) which acted as a critical friend to positively influence patient care and delivery. The practice worked well with their PPG and we saw evidence of how the PPG had contributed towards the achievement of good outcomes for patients. 
Checks on specific services

People with long term conditions

Outstanding

Updated 9 November 2016

The practice is rated as outstanding for providing responsive and well-led services. The impact of this affected the quality of services provided to all patient groups and this led to an outstanding rating for all population groups.

  • The practice undertook annual reviews for patients on their long-term conditions registers, including a review of their prescribed medicines.
  • QOF achievements for clinical indicators were generally in line with CCG averages, and above national averages. For example, the practice achieved 96.8% for diabetes related indicators, in comparison to local and national averages of 96.7% and 89.2% respectively.
  • A GP with a special interest in diabetes attended the practice each month to review patients with complex needs. In addition, a specialist diabetes nurse attended the practice bi- monthly to undertake a joint clinic with the practice nurse to assist with the management of other complex patients with diabetes. This process had helped to upskill the practice’s nursing team in treating patients with diabetes. Performance data demonstrated the effectiveness of care including lower referrals to secondary care.
  • The practice funded a specialist respiratory nurse to provide two days of clinical input each month. This nurse saw complex patients with breathing problems with the practice nurse. This provided additional expertise as well as providing a training development opportunity for the nursing team.
  • The recall system was co-ordinated by the administration team, and we saw data that showed that patients received regular reviews of their condition including their prescribed medicines.
  • Patients with multiple conditions were usually reviewed in one appointment to avoid them having to make several visits to the practice.
  • There was a lead designated GP or nurse for the clinical domains within QOF.

Families, children and young people

Outstanding

Updated 9 November 2016

The practice is rated as outstanding for providing responsive and well-led services. The impact of this affected the quality of services provided to all patient groups and this led to an outstanding rating for all population groups.

  • Same day rapid access was provided for babies or children who were ill.
  • The midwife held a weekly ante-natal clinic and saw new mothers for a post-natal review at the practice.
  • Childhood immunisation rates were in line with local averages. Rates for the vaccinations given to children up to five years of age ranged from 94.1% to 100% (local averages 95.2% to 99.1%).
  • The practice had an identified lead GP for child safeguarding. The health visitor attended the practice multi-disciplinary team meetings on a monthly basis to review and discuss any child safeguarding concerns. Child protection alerts were used on the clinical system to ensure clinicians were able to actively monitor any concerns.
  • Family planning services were provided on site. A clinic was held weekly between 5-6pm to enable better access for patients.
  • The practice had baby changing facilities, and a small play area was available for children. The practice welcomed mothers who wished to breastfeed on site, and offered a private room to facilitate this if requested.

Older people

Outstanding

Updated 9 November 2016

The practice is rated as outstanding for providing responsive and well-led services. The impact of this affected the quality of services provided to all patient groups and this led to an outstanding rating for all population groups.

  • The practice directly employed their own care co-ordinator to facilitate the planning of care for patients being discharged from hospital, or to provide support to help patients remain in their own home.

  • The needs of older people with more complex needs were reviewed via weekly care co-ordinator meetings and a monthly multi-disciplinary team meeting.
  • Patients requiring support from clinical services such as physiotherapy were referred through a single point of access to ensure they received the individual care they needed.
  • Longer appointment times could be arranged for patients with complex care needs at the request of the GP, or if reception staff knew patients might require additional time, they were booked in towards the end of the consulting session. Home visits were provided for those unable to attend the surgery.
  • Due to the semi-rural location of the practice, transport links could be problematic for some patients. However, access to a local voluntary transport scheme provided patients with an opportunity to get to and from the practice more easily. Patients had to pay for fuel costs only.
  • Uptake of the flu vaccination for patients aged over 65 was 72.8%, which was in line with local (73.9%) and national (70.5%) averages. 

Working age people (including those recently retired and students)

Outstanding

Updated 9 November 2016

The practice is rated as outstanding for providing responsive and well-led services. The impact of this affected the quality of services provided to all patient groups and this led to an outstanding rating for all population groups.

  • The practice had identified that a large proportion of their patients were commuters, and designed access to accommodate this. This was facilitated by a system of triage, extended hours sessions, and telephone consultations. For example, the practice offered extended hours consultations each Tuesday evening to enable improved access for working patients.
  • 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.
  • The practice promoted health screening programmes to keep patients safe. NHS health checks were available.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 9 November 2016

The practice is rated as outstanding for providing responsive and well-led services. The impact of this affected the quality of services provided to all patient groups and this led to an outstanding rating for all population groups.

  • The practice directly employed a mental health support worker to provide social and mental health care and support for patients with poor mental health, including patients in their own home and within a local care home. The support worker could accompany patients to attend appointments to reduce their anxiety, and help with tasks such as completing forms to enable them to receive support for their condition. Data demonstrated the practice had the lowest rate of emergency admissions for mental health in the locality, and amongst the lowest across the CCG area.
  • A nurse practitioner visited a care home specialising in dementia care twice each week. This care was supported up by named GPs, the mental health support worker, and the practice pharmacist. We were provided with examples of excellent patient care such as supporting patients and staff to enable a patient to have a dignified death within their care home setting. The impact of the nurse’s input was supported by data showing reduced hospital admissions and access to out of hours care.
  • The practice achieved 97.7% for mental health related indicators in QOF, which was 0.4% below the CCG and 4.9% above the national averages. Exception reporting rates for mental health related indicators were generally slightly higher than local and national rates.
  • 89.1% of patients with severe and enduring mental health problems had a comprehensive care plan documented in the preceding 12 months according to 2014-15 QOF data. This was slightly below the CCG average and marginally above the national average of 88.5%.
  • There was access to counselling and associated talking therapies’ services on site for one-and-a-half days each week. Patients could self-refer to this service as well as being referred by the GP.
  • A psychiatrist saw complex mental health patients at the practice once a month. A community psychiatric nurse also attended these sessions.
  • The practice worked with local community mental health teams and representatives regularly attended the multi-disciplinary team meetings.
  • 74% of people diagnosed with dementia had had their care reviewed in a face-to-face meeting in the last 12 months. This was below local and national averages by approximately 10%. Exception reporting rates were lower at 5.6%, compared to the local and national averages of 8.8% and 8.3% respectively.
  • Staff had received dementia awareness training from the Alzheimer’s Society at a team meeting. The practice had plans to develop dementia friends training in the future. 

People whose circumstances may make them vulnerable

Outstanding

Updated 9 November 2016

The practice is rated as outstanding for providing responsive and well-led services. The impact of this affected the quality of services provided to all patient groups and this led to an outstanding rating for all population groups.

  • Patients with end-of-life care needs were reviewed at monthly multi-disciplinary team meetings. The practice worked closely with the district nursing team to deliver responsive and caring treatment and support to patients and their families.
  • The practice proactively referred patients to the ‘Wrap-around Care Project’. This provided a point of first contact to access the voluntary sector within the locality. Services available included befriending, transport and shopping with the aim of keeping people independent in their own homes, or to regain confidence following a hospital discharge. The practice kept these patients under regular review to ensure their needs were being met.
  • 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.
  • The practice had undertaken an annual health review in the last 12 months for 50% of patients with a learning disability. The practice used symbols and pictures within letters to enable better understanding for patients with a learning disability.
  • Travellers who resided on boats and barges at a nearby canal were able to register with the practice to ensure they had access to health care services.