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North Norfolk Primary Care Limited Good

This service was previously registered at a different address - see old profile

Inspection Summary


Overall summary & rating

Good

Updated 13 July 2021

This service is rated as Good overall. (Previous inspection September 2019 – Requires Improvement)

The key questions are rated as:

  • Are services safe? – Good
  • Are services effective? – Good
  • Are services caring? – Good
  • Are services responsive? – Good
  • Are services well-led? – Good

Following our previous inspection in September 2019, the service was rated Requires Improvement overall and for providing Safe and Well-led services. We rated the provider as Good for providing Effective, Caring and Responsive Services.

The full reports for previous inspections can be found by selecting the ‘all reports’ link for North Norfolk Primary Care Limited on our website at www.cqc.org.uk

Why we carried out this inspection

This inspection was a focused follow-up inspection:

  • We inspected the key questions; are services Safe, Effective and Well-led.
  • Pre-inspection information did not highlight any change in rating for providing Caring and Responsive services. Ratings for these key questions are carried forward from the previous inspection.
  • We followed up on breaches of regulations identified at our previous inspection to ensure the required action had been taken.

How we carried out the inspection

Throughout the pandemic CQC has continued to regulate and respond to risk. However, taking into account the circumstances arising as a result of the pandemic, and in order to reduce risk, we have conducted our inspections differently.

This inspection was carried out in a way which enabled us to spend a minimum amount of time on site. This was with consent from the provider and in line with data protection and information governance requirements.

Our findings

We based our judgement of the quality of care at this service on a combination of:

  • what we found when we inspected
  • information from our ongoing monitoring of data about services and
  • information from the provider, patients, the public and other organisations.

We found that:

  • The service provided care in a way that kept patients safe and protected them from avoidable harm.
  • Patients received effective care and treatment that met their needs.
  • Staff dealt with patients with kindness and respect and involved them in decisions about their care.
  • Patients could access care and treatment in a timely way.
  • The way the service was led and managed promoted the delivery of high-quality, person-centred care.

Dr Rosie Benneyworth BM BS BMedSci MRCGP

Chief Inspector of Primary Medical Services and Integrated Care

Inspection areas

Safe

Good

Updated 13 July 2021

At our last inspection in 2019 we rated the service as Requires Improvement for providing Safe services because:

  • Systems and processes to keep people safe and safeguarded from abuse were not always effective enough to assure the provider that premises were safe to use and that sufficient medicines were available in an emergency.

At this inspection we found the service had taken action to address these concerns and the provider was rated Good for providing safe services.

  • There was a robust system of ensuring the premises used in the improved access service were safe for their intended purpose, that there was appropriate provision of emergency medicines and equipment and that prescription stationery was secure. This system extended to other services including the phlebotomy service.
  • There were regular audits and checks to ensure agreed standards were met at each site.
  • There was good oversight and management of safety systems and processes.

Safety systems and processes

The service had clear systems to keep people safe and safeguarded from abuse.

  • The provider had robust systems in place to ensure the safety and suitability of the sites they operated in. The provider had engaged with site hosts and agreed a service specification. The specification included providing evidence of safety risk assessments and actions such as fire safety, infection prevention and control and health and safety. Also included in the specification were the requirements for sites to ensure good supply of appropriate emergency medicines and equipment in line with national guidelines. The provider carried out regular checks and audits to ensure compliance with the service specification. Where sites were not compliant, actions were put in place for improvements to be made. The provider had arrangements in place to withdraw sites from hosting their service should compliance not be maintained.
  • Staff received safety information from the provider and as appropriate from the site they were working in, as part of their induction and refresher training.
  • The provider had systems to safeguard children and vulnerable adults from abuse. Policies were regularly reviewed and were accessible to all staff. They outlined clearly who to go to for further guidance.
  • The service worked with other agencies including NHS GP practices and care home services to support patients and protect them from neglect and abuse. Staff took steps, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect.
  • All staff received up-to-date safeguarding and safety training appropriate to their role. They knew how to identify and report concerns.
  • Staff who acted as chaperones were trained for the role and had received a Disclosure and Barring Service (DBS) check. (DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable).
  • The provider carried out staff checks at the time of recruitment and on an ongoing basis where appropriate. DBS checks were undertaken where required and there was a system for regular review and updating.
  • There was an effective system to manage infection prevention and control.
  • The provider ensured that equipment was maintained according to manufacturers’ instructions. There was a clear process of tracking equipment to ensure portable appliance testing and equipment calibration was up to date.
  • There were systems for safely managing healthcare waste.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety.

  • There were arrangements for planning and monitoring the number and mix of staff needed. The service worked individually and collectively with each Primary Care Network (PCN, a group of GP practices collaborating to share resources and funding). Services were tailored to the specific needs of patients and practices in the PCN area. There was an effective system in place for dealing with changes in demand.
  • There was an effective induction system for temporary staff tailored to their role.
  • Staff understood their responsibilities to manage emergencies and to recognise those in need of urgent medical attention. They knew how to identify and manage patients with severe infections, for example, sepsis.
  • Patients were prioritised appropriately for care and treatment, in accordance with their clinical need. There were set inclusion and exclusion criteria for each service. These criteria were regularly reviewed with the host GP practices and care home services.
  • Staff told patients when to seek further help. They advised patients what to do if their condition got worse.
  • When there were changes to services or staff the service assessed and monitored the impact on safety.

Information to deliver safe care and treatment

Staff had the information they needed to deliver safe care and treatment to patients.

  • Information needed to deliver safe care and treatment was available to relevant staff in an accessible way. The service had access to patients’ clinical records through the clinical computing system used by practices across North Norfolk practices. There were clinical quality audits to ensure individual care records were written and managed in a way that kept patients safe.
  • Staff working in the care home visiting team were able to access the clinical computer system remotely.
  • The service had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment. This was predominantly through direct access to the clinical records system.
  • Where referrals were indicated, in line with protocols and up to date evidence-based guidance, the patients usual GP was informed.

Appropriate and safe use of medicines

The service had reliable systems for appropriate and safe handling of medicines.

  • The systems and arrangements for ensuring host sites were managing medicines, including medical gases, emergency medicines and equipment, minimised risks.
  • The service ensured prescription stationery was kept securely and monitored its use.
  • Clinicians prescribed medicines to patients in line with service policy, legal requirements and current national guidance. Host sites monitored prescribing and liaised with clinicians directly, and North Norfolk primary care, to review and improve prescribing.
  • Patients’ health was monitored in relation to the use of medicines and followed up on appropriately. Patients were involved in regular reviews of their medicines.

Track record on safety

The service had a good safety record.

  • There were comprehensive risk assessments in relation to safety issues.
  • The service monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture that led to safety improvements.
  • There was a system for receiving and acting on safety alerts.
  • Joint reviews of incidents were carried out with partner organisations where necessary, including host GP practice sites and care service providers.

Lessons learned and improvements made

The service learned and made improvements when things went wrong.

  • There was a system for recording and acting on significant events and incidents. Staff understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were adequate systems for reviewing and investigating when things went wrong. The service learned and shared lessons, identified themes and took action to improve safety in the service. For example, following two needlestick injuries, there was a comprehensive review of policy, procedure, working environments, equipment and training. The review found that there were all reasonable risk mitigations in place and shared information with staff in the phlebotomy service reminding them of proper procedure to follow to minimise risk of injury.

  • The service learned from external safety events and patient safety alerts. The service had an effective mechanism in place to disseminate alerts to all members of the team including sessional and agency staff.
  • The provider took part in end to end reviews with other organisations. Learning was used to make improvements to the service. The service regularly reviewed service delivery with GP practices in PCN groups. Changes were made to the provision of services based on needs assessments carried out locally. For example, the improved access arrangements in one PCN area included provision of a roving health care assistant (HCA), able to carry out long term conditions health checks for housebound patients. This was a key aspect of care the practice were unable to consistently deliver on without this additional support.

Effective

Good

Updated 13 July 2021

We rated the service as good for providing effective services.

Effective needs assessment, care and treatment

The provider had systems to keep clinicians up to date with current evidence-based practice. This supported and enhanced systems in place with the clinicians’ usual place of work. There were systems in place to ensure clinicians assessed needs and delivered care and treatment in line with current legislation, standards and guidance, using clear clinical pathways and protocols.

  • Clinical staff had access to guidelines from the National Institute for Health and Care Excellence (NICE) and used this information to help ensure that people’s needs were met. The provider monitored that these guidelines were followed through regular records reviews.
  • Patients’ needs were fully assessed. This included their clinical needs and their mental and physical wellbeing.
  • Care and treatment was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable. There were systems in place to inform the patients usual GP of any risk factors.

  • We saw no evidence of discrimination when making care and treatment decisions.
  • There were specific inclusion and exclusion criteria set out for each of the services. Where these criteria were not met, the service liaised with host sites and service user practices to understand challenges, improve inclusion and exclusion criteria and ensure the services were utilised effectively.

Monitoring care and treatment

The service had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. The service had a Quality Committee overseeing the quality assurance system and the implementation of the services clinical governance strategy. Clinical audit was undertaken to assess the effectiveness of clinical care and adherence to guidelines or policies. Audits were used to identify where improvements were needed, with improvements measured and monitored as part of the audit cycle. Audits of administrative procedures also took place to ensure they were working effectively.

The service had a regular programme of consultation documentation quality audits for the Enhanced Care Home Team. The audits assessed the quality of record keeping and documentation across eight indicators. The first audit cycle identified an overall compliance with standards of 72.5%. A set of actions was identified and compliance improved in the second audit cycle to 83% overall compliance. Further actions were identified focusing on the areas of non-compliance. These areas saw a significant increase in compliance in the third audit cycle, however this also showed overall compliance fell back to 72%. The service had identified the need for more detailed supervision and targeted training and development needs for staff, including the effective use of clinical computer systems.

The service was meeting its locally agreed contractual arrangements as set by its commissioner and as agreed with each primary care network.

Effective staffing

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

  • All staff were appropriately qualified. The provider had an induction programme for all newly appointed staff, tailored to their role and including bespoke inductions for specific sites they were working at.
  • The provider ensured that all staff worked within their scope of practice and had access to clinical support when required. This included clinical support from host site services as well as the provider.
  • The provider understood the learning needs of staff and provided protected time and training to meet them. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop.
  • Staff were provided with ongoing support. This included one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and support for revalidation. The provider could demonstrate how it ensured the competence of staff employed in advanced roles by audit of their clinical decision making, including non-medical prescribing.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable and the service was able to demonstrate examples of this during our inspection.

Coordinating care and treatment

Staff worked together and worked well with other organisations to deliver effective care and treatment.

  • We saw records that showed that all appropriate staff, including those in different teams, services and organisations, were involved in assessing, planning and delivering care and treatment.
  • Patients received coordinated and person-centred care. Staff communicated promptly with the patient's registered GP so that the GP was aware of the need for further action. Staff also referred patients back to their own GP to ensure continuity of care, where necessary.
  • Patient information was shared appropriately, and the information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way.
  • The service ensured that care was delivered in a coordinated way and took into account the needs of different patients, including those whose circumstances may make them vulnerable.
  • There were clear and effective arrangements for host services and member GP practices to book appointments and care home visits.

Helping patients to live healthier lives

Staff were consistent and proactive in empowering patients and supporting them to manage their own health and maximise their independence.

  • The service identified patients who may be in need of extra support and gave appropriate advice, informing the patients registered GP.
  • Where appropriate, staff gave people advice so they could self-care. Systems were available to facilitate this.
  • Risk factors, where identified, were highlighted to patients and their normal care providers so additional support could be given.
  • There were specific inclusion and exclusion criteria for the services provided. Where patients needs could not be met by the service, staff redirected them to the appropriate service for their needs and worked with member practices and commissioners to review inclusion and exclusion criteria.

Consent to care and treatment

The service 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 provider monitored the process for seeking consent appropriately through clinical documentation audits.

Caring

Updated 13 July 2021

Responsive

Updated 13 July 2021

Well-led

Good

Updated 13 July 2021

At our last inspection in 2019 we rated the service as Requires Improvement for providing Well-led services because:

  • The leadership, governance and monitoring of risks arrangements of the service did not always ensure the delivery of high-quality care.
  • The service could not evidence that all the checks required to employ staff appropriately were in place.
  • The service had not implemented effective systems to ensure appropriate and safe provision of emergency medicines and equipment.
  • The service did not have assurance that the premises from where they delivered services from were safe for their intended purpose. For example, they did not have oversight of up to date fire safety, health and safety or infection prevention and control risk assessments.

At this inspection we found the service had taken action to address these concerns and the provider was rated Good for providing Well-led services.

Leadership capacity and capability

Leaders had the capacity and skills to deliver high-quality, sustainable care.

  • Leaders had the experience, capacity and skills to deliver the service strategy and address risks to it.
  • They were knowledgeable about issues and priorities relating to the quality and future of services. They understood the local challenges in health and social care 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.
  • Senior management was accessible throughout the operational period.
  • The service had effective processes to develop leadership capacity and skills, including planning for the future leadership of the service and effective recruitment to fulfil skills gaps.

Vision and strategy

The service had a clear vision and credible strategy to deliver high quality care and promote good outcomes for patients.

  • There was a clear vision and set of values. The service had a realistic strategy and supporting business plans to assess, monitor and achieve priorities.
  • The service developed its vision, values and strategy jointly with service users, staff and external partners.
  • 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 priorities across the region. The provider planned the service to meet the needs of the local population, tailoring service provision to the differing needs of each primary care network.
  • The provider monitored progress against delivery of the strategy.
  • The provider had systems in place so that staff who worked away from the main base felt engaged in the delivery of the provider’s vision and values.

Culture

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

  • Staff felt respected, supported and valued. They were proud to work for the service.
  • The service had a strong focus on the needs of patients and supporting other health and social care organisations to deliver person-centred care.
  • Leaders and managers acted on behaviour and performance inconsistent with the vision and values.
  • 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 and staff questionnaires we received told us staff 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 needed. This included appraisal and career development conversations. All staff had received appraisals or development conversations in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • Clinical staff were considered valued members of the team. They were given protected time for professional development and evaluation of their clinical work.
  • There was a strong emphasis on the safety and well-being of all staff.
  • The service promoted equality and diversity. Staff had received equality and diversity training. Staff felt they were treated equally.
  • There were positive relationships between staff teams and leaders. Staff were incredibly proud of the teamwork the service had shown throughout the COVID-19 pandemic.

Governance arrangements

There were clear responsibilities, roles and systems of accountability to support good governance and management.

  • 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 interactive and co-ordinated person-centred care.
  • Staff were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Leaders had established proper policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.
  • Good governance arrangements supported the service to quickly, effectively and safely implement new services as required, for example, in responding to the healthcare needs of asylum seekers accommodated in the local area.

Managing risks, issues and performance

There were clear and effective processes for managing risks, issues and performance.

  • There was an effective process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The provider had processes to manage current and future performance of the service. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions.
  • Leaders had oversight of patient safety and medicines alerts, incidents, and complaints.
  • Performance was regularly discussed at senior management and board level. Performance was shared with staff and the local CCG as part of contract monitoring arrangements.
  • Clinical audit had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to resolve concerns and improve quality.
  • The provider had plans in place and had trained staff for major incidents.
  • The provider implemented service developments and changes were made with input from clinicians to understand the impact on the quality of care.

Appropriate and accurate information

The service 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, service users and staff.
  • Quality and sustainability were discussed in relevant meetings where all staff had sufficient access to information.
  • The service 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 service used information technology systems to monitor and improve the quality of care.
  • The service 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 service 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.
  • Staff were able to describe to us the systems in place to give feedback. Staff who worked remotely were engaged and able to provide feedback through daily ‘check-in’ style remote meetings.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There were systems and processes for learning, continuous improvement and innovation.

  • There was a focus on continuous learning and improvement at all levels within the service. The provider had identified a number of key areas for service development and had implemented pilot projects and studies to assess the viability of the developments. For example, the provider had implemented a Rapid Diagnostic Service – Cancer, aimed at reducing the time patients with suspected cancers waited for referrals, investigations and diagnosis. This pilot was planned for 12 months and supported by local commissioners and the member practices in North Norfolk.

  • Staff knew about improvement methods and had the skills to use them. There were systems to support improvement and innovation work.
  • The service 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.

There was a strong culture of innovation evidenced by the number of pilot schemes the provider was involved in. Other pilots and projects included:

  • GP front door, a primary care service in local hospital emergency departments.
  • Community Tele Dermatology Pathway – an online service with pictures of dermatology related complaints and conditions being reviewed by a consultant dermatologist within 24-48 hours with a care and treatment plan and or referral.
  • The service worked with the University of East Anglia to publish findings from a COVID-19 care home resident and staff testing programme. The findings, published early on in the pandemic, were used nationally and internationally to influence policy and decision making around care home testing.
  • The service was highly regarded in the locality and region. The Enhanced Care Home Team were announced as the East regional winner in the excellence in primary care category of the NHS Parliamentary Awards 2020, recognising their work in reducing unplanned hospital admissions from care homes in North Norfolk. The team were shortlisted for the national awards scheduled for July 2021.