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Bath Row Medical Practice, Attwood Green Health Centre Good

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Inspection Summary


Overall summary & rating

Good

Updated 19 July 2018

This practice is rated as Good overall; we carried out an announced comprehensive inspection at Bath Row medical practice as part of our regular inspection programme on the 15 May 2018.

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? –Require Improvement

Are services well-led? - Good

At this inspection we found:

  • The practice had sustained a change to clinical staffing levels which had impacted on appointment availability. In response to patient feedback the provider had implemented telephone appointments, extended hours and emergency doctors to deal with on the day requests, but the practice were still unable to manage demand.
  • The practice had further developed their policy with regards to identifying carers, this had led to a small increase in numbers of carers identified.
  • The practice had an active patient participation group (PPG) who had formed a patient panel and advised the practice on patient engagement.
  • We found that the practice’s performance in the Quality and Outcomes Framework (QOF) was in line with the local and national averages. Exception reporting was high in comparison to local and national averages.
  • We found the practice to be organised and have comprehensive policies and procedures to guide staff. Staff we spoke with described the practice as supportive and a good place to work.

The areas where the provider should make improvements are:

  • Continue to review current processes to improve patient access.
  • Consider ways to improve and encourage patients to attend cancer screening.
  • Proactively identify carers within the practice population to ensure they receive the appropriate support.

Professor Steve Field CBE FRCP FFPH FRCGP
Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 19 July 2018

We rated the practice as good for providing safe services.

Safety systems and processes

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

  • The practice had systems to safeguard children and vulnerable adults from abuse. All staff whose files we viewed had received up-to-date safeguarding and safety training appropriate to their role. GPs, nurses and the management team had received level three training in children’s safeguarding and level two in adult safeguarding whilst the reception staff whose files we viewed had received level one training in safeguarding for both children and adults.
  • Staff we spoke to knew how to identify and report concerns and all staff we spoke to were aware of who the safeguarding lead at the practice was.
  • All non-clinical staff whose files we viewed were trained as chaperones but only those who acted in that role had received a 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.)
  • All clinical staff whose files we viewed had received a DBS check.
  • Staff took steps, including working with other agencies, to protect patients from abuse, neglect, harassment, discrimination and breaches of their dignity and respect. For example, the safeguarding lead worked closely with health visitors.
  • From the staff files we viewed we saw evidence that the practice carried out appropriate staff checks at the time of recruitment and on an ongoing basis.
  • There was an effective system to manage infection prevention and control, including audits and associated action plans.
  • The practice had arrangements for calibration checks, to ensure that facilities and equipment were safe and in good working order.
  • Arrangements for managing waste and clinical specimens kept people safe.

Risks to patients

There were systems to assess, monitor and manage risks to patient safety; however, the practice told us that clinical staffing was not always adequate to accommodate the services provided.

  • Systems were in place for planning and monitoring the number and mix of staff needed to meet patients’ needs, however for clinical staff these were ineffective. The practice told us that clinical staffing levels were not sufficient to deliver services and meet patient demand. The practice demonstrated action taken to reducing risks whilst recruitment of additional clinical staff was considered.
  • There was an effective and comprehensive induction system for new and temporary staff tailored to their role, including a locum pack that was specific to the practice.
  • The practice was equipped to deal with medical emergencies and staff whose files we viewed were trained in emergency procedures. Staff we spoke with explained that they understood their responsibilities to manage emergencies on the premises and to recognise those in need of urgent medical attention. Clinicians demonstrated that they knew how to identify and manage patients with severe infections including sepsis.

Information to deliver safe care and treatment

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

  • The care records we saw showed that information needed to deliver safe care and treatment was available to staff. There was a documented approach to managing test results.
  • The practice had systems for sharing information with staff and other agencies to enable them to deliver safe care and treatment.
  • Clinicians made timely referrals in line with protocols.

Appropriate and safe use of medicines

The practice had systems for the appropriate and safe handling of medicines.

  • The systems for managing and storing medicines, including vaccines, medical gases, emergency medicines and equipment, minimised risks. For example, alarmed and locked medicine cupboards and fridges as well as documented checks of oxygen and medical equipment.
  • We saw that staff prescribed and administered to patients and gave advice on medicines in line with current national guidance. The practice had reviewed its antibiotic prescribing and taken action to support good antimicrobial stewardship in line with local and national guidance, the practice’s antibacterial prescription averages were lower than local and national averages.
  • Patients’ health was monitored in relation to the use of medicines and followed up on, including audits and we saw that patients were involved in regular reviews of their medicines.

Track record on safety

The practice had a good track record on safety.

  • On the day of inspection, the practice were unable to provide evidence that fire and Legionella risk assessments had been undertaken; however, since the inspection we have received evidence to confirm that these had been completed. There were comprehensive risk assessments in relation to other safety issues such as health and safety.
  • The practice had monitored and reviewed activity. This helped it to understand risks and gave a clear, accurate and current picture of safety that led to safety improvements.

Lessons learned and improvements made

The practice learned lessons and made improvements when things went wrong.

  • Staff that we spoke to understood their duty to raise concerns and report incidents and near misses. Leaders and managers supported them when they did so.
  • There were systems for reviewing and investigating when things went wrong. The practice learned and shared lessons, identified themes and took action to improve safety in the practice.
  • The practice acted on and learned from external safety events as well as patient and medicine safety alerts by printing off hard copies and circulating emails and discussing them in team meetings. The practice showed the inspection team how they did this with the latest alert.

Please refer to the Evidence Tables for further information.

Effective

Good

Updated 19 July 2018

We rated the practice as good for providing effective services overall except for the “working age people” population group, which we rated as requires improvement with regards to lower than average cervical screening results.

(Please note: Any Quality Outcomes (QOF) data relates to 2016/17. QOF is a system intended to improve the quality of general practice and reward good practice.)

Effective needs assessment, care and treatment

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

  • Patients’ immediate and ongoing needs were fully assessed. This included their clinical needs and their mental and physical wellbeing. The practice had arranged for a consultant Psychiatrist to attend each month to discuss patients experiencing low mental health as part of a clinical review meeting.
  • We saw no evidence of discrimination when making care and treatment decisions.
  • The practice was able to evidence that they utilised technology to facilitate patient care, this included the clinical system, telephone appointments and online services.
  • Staff whose clinical decisions we saw used appropriate tools to assess the level of pain in patients.
  • Staff advised patients what to do if their condition got worse and where to seek further help and support.

Older people:

  • Older patients who are frail or may be vulnerable received a full assessment of their physical, mental and social needs. The practice used an appropriate tool to identify patients aged 65 and over who were living with moderate or severe frailty. Those identified as being frail had a clinical review including a review of medication.
  • Patients aged over 75 were invited for a health check. If necessary they were referred to other services such as voluntary services and supported by an appropriate care plan.
  • The practice followed up on older patients discharged from hospital. It ensured that their care plans and prescriptions were updated to reflect any extra or changed needs.
  • Staff that we spoke with had appropriate knowledge of treating older people including their psychological, mental and communication needs.
  • The practice worked closely with community matrons and carers at nursing homes.

People with long-term conditions:

  • Patients with long-term conditions had a structured annual review to check their health and medicines needs were being met. For patients with the most complex needs, the GP worked with other health and care professionals to deliver a coordinated package of care, this including holding multi-disciplinary (MDT) meetings.
  • Staff who were responsible for reviews of patients with long term conditions had received specific training.
  • The practice was able to demonstrate how they identified patients with commonly undiagnosed conditions, for example diabetes, chronic obstructive pulmonary disease (COPD), atrial fibrillation and hypertension through an ongoing review process.
  • There was evidence of high exception reporting, however the practice was able to demonstrate a comprehensive policy and process for exception reporting. We reviewed records which demonstrated that patients had been exception reported appropriately.

Families, children and young people:

  • Childhood immunisations were carried out in line with the national childhood vaccination programme. Uptake rates for the vaccines given were in line with the target percentage of 90%.
  • The practice had arrangements to identify and review the treatment of newly pregnant women on long-term medicines. These patients were provided with advice and post-natal support in accordance with best practice guidance.
  • The practice had arrangements for following up failed attendance of children’s appointments in secondary care or for immunisation. These were reported to the practice safeguarding lead, who met regularly with health visitors to discuss any concerns.

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

  • Data provided by Public Health England (PHE) showed the practice’s uptake for cervical screening to be below the national coverage target for the national screening programme.
  • The practices’ uptake for breast and bowel cancer screening was in line the local averages but below national averages.

  • The practice had systems to inform eligible patients of the benefits of the meningitis vaccine, for example before attending university for the first time.
  • Patients whose records we had viewed had access to appropriate health assessments and checks including NHS checks for patients aged 40-74. The practice followed-up on the outcome of health assessments and checks where abnormalities or risk factors were identified.

People whose circumstances make them vulnerable:

  • End of life care was delivered in a coordinated way which took into account the needs of those whose circumstances may make them vulnerable. For example, Gold Standard Framework (GSF) and multi-disciplinary team (MDT) meetings.
  • The practice held a register of patients living in vulnerable circumstances including homeless people, travellers and those with a learning disability. The practice’s clinical system was set up to alert staff of these patients.
  • The practice had a system for vaccinating patients with an underlying medical condition according to the recommended schedule.

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

  • The practice assessed and monitored the physical health of people with mental illness by providing access to health checks and referrals to ‘stop smoking’ services.
  • When patients were assessed to be at risk of suicide or self-harm the practice had arrangements in place to support them. For example, they would consult a Psychiatrist that attended the practice regularly and agree an appropriate approach for care and treatment.
  • The practice specifically considered the physical health needs of patients with poor mental health and those living with dementia.
  • Patients at risk of dementia were identified and offered an assessment to detect possible signs of dementia. When dementia was suspected there was an appropriate referral for diagnosis.
  • The practice offered annual health checks to patients with a learning disability.

Monitoring care and treatment

The practice had a comprehensive programme of quality improvement activity and routinely reviewed the effectiveness and appropriateness of the care provided. Where appropriate, clinicians took part in local and national improvement initiatives such as Clinical Commissioning Group (CCG) local improvement schemes.

  • The practice’s overall exception reporting within QOF was 14% which was above the local and national averages as were a number of other exception reporting indicators. For example, diabetes and cardio-vascular disease (CVD). The practice was aware of these and having looked at a selection of these patients and found that these patients had been appropriately exception reported.
  • The practice used information about care and treatment to make improvements.
  • The practice was actively involved in quality improvement activity. For example, the practice ran audits regarding diabetes patients to identify and treat potential Cardio-Vascular Disease (CVD).

Effective staffing

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

  • Staff we spoke with had appropriate knowledge for their role, for example, to carry out reviews for people with long term conditions, older people and people experiencing poor mental health.
  • Staff whose role included immunisation and taking samples for the cervical screening programme, whose files we viewed had received specific training and could demonstrate how they stayed up to date.
  • The practice provided protected time for training. Up to date records of skills, qualifications and training were maintained. Staff were encouraged and given opportunities to develop. The practice had implemented training for a variety of administration activities and roles to ensure continuity of services in the event of staff absence.
  • The practice provided staff with ongoing support. This included an induction process, appraisals, clinical supervision and support for revalidation. The practice ensured the competence of staff employed in advanced roles by audit of their clinical decision making.
  • There was a clear approach for supporting and managing staff when their performance was poor or variable.

Coordinating care and treatment

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

  • Staff at the practice explained that they were involved in assessing, planning and delivering care and treatment.
  • The practice shared clear and accurate information with relevant professionals when deciding care delivery for people with long term conditions and when coordinating healthcare for care home residents. They shared information and liaised with community services, social services and carers. The practice also communicated with health visitors and community services for children who had relocated into the local area.
  • Patients received coordinated and person-centred care. This included when they moved between services, when they were referred, or after they were discharged from hospital. The practice worked with patients to develop personal care plans that were shared with relevant agencies.
  • The practice ensured that end of life care was delivered in a coordinated way, for example, special care notes and gold standard framework (GSF) meetings, which took into account the needs of different patients, including those who may be vulnerable because of their circumstances.

Helping patients to live healthier lives

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

  • The practice identified patients who may be in need of extra support and directed them to relevant services. For example, dementia charities and national advice services. This also included patients in the last 12 months of their lives, patients at risk of developing a long-term condition and carers.
  • Staff encouraged and supported patients to be involved in monitoring and managing their own health, for example through social prescribing schemes.
  • The practice discussed changes to care or treatment with patients and their carers as necessary.
  • The practice supported national priorities and initiatives to improve the population’s health. For example; referring to stop smoking services.

Consent to care and treatment

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

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

Please refer to the Evidence Tables for further information.

Caring

Good

Updated 19 July 2018

We rated the practice as Good for providing caring services.

Kindness, respect and compassion

Staff treated patients with kindness, respect and compassion.

  • The practice’s performance concerning the way patients felt staff treated them was generally in line with local and national averages, this was supported by the comment cards we received from patients on the day of the inspection.
  • Staff demonstrated an understanding of patients’ personal, cultural, social and religious needs.
  • Patients whose feedback we received explained that the practice gave patients timely support and information in terms of referrals and results.

Involvement in decisions about care and treatment

The national GP patient survey showed mixed responses with regards staff helping them to be involved in decisions about their care and treatment. The practice had commissioned a private survey that showed improved patient satisfaction scores.

The practice were aware of the Accessible Information Standard (a requirement to make sure that patients and their carers can access and understand the information that they are given.)

  • We saw that staff communicated with people in a way that they could understand, for example, staff we spoke with understood how to access communication aids and easy read materials for patients and interpretation services.
  • We saw leaflets at the practice that helped patients find further information and access community and advocacy services. Feedback from the national GP patient survey highlighted that some patients felt that the practice did not always effectively facilitate patients being involved in their care and treatment.
  • The practice had a carers pack and a carers identification policy.
  • The percentage of patients who responded to the National GP patient survey, who stated that they would definitely or probably recommend their GP surgery to someone who has moved into the area was below the local and national averages.

Privacy and dignity

The practice respected patients’ privacy and dignity.

  • Staff that we spoke with knew that if patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs.
  • Staff we spoke with recognised the importance of people’s dignity and respect.

Please refer to the Evidence Tables for further information.

Responsive

Requires improvement

Updated 19 July 2018

We rated the practice and all of the population groups, as requires improvement for providing responsive services due to continued concerns regarding patients accessing care and treatment.

Responding to and meeting people’s needs

The practice organised services to meet patients’ needs but could not always deliver these in line with patient demand. It took account of the needs of patients and their preferences and had implemented changes, but these not had been effective.

  • The practice understood the needs of its population and had made changes to further tailor services in response to those needs.
  • The practice had implemented and action plan and made adjustments in relation to access services however the actions taken had not yet demonstrated improved patient satisfaction.
  • Telephone and web GP consultations were available which supported patients who were unable to attend the practice during normal working hours.
  • The facilities and premises were modern and clean and appropriate for the services delivered.
  • The practice provided effective care, treatment and care coordination for patients who were more vulnerable or who had complex needs or multiple long-term conditions including Gold Standard Framework (GSF) and Multi-Disciplinary Team (MDT) meetings.

Older people:

  • All older patients whose records we viewed had a named GP who supported them in whatever setting they lived, whether it was in their own home, a supported living or residential care.
  • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments. The GPs and practice nurses also accommodated home visits for those who had difficulties getting to the practice.

People with long-term conditions:

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

Families, children and young people:

  • We found there were systems to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency (A&E) attendances. These were also discussed between the health visitor and the practice’s safeguarding lead.
  • All parents or guardians calling with concerns about a child under the age of 18 years of age were offered a same day appointment when necessary.

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

  • The needs of this population group had been identified and the practice had adjusted the services it offered to increase accessibility and flexibility. For example, extended opening hours, increased number of patients who could wait in the telephone queue and appointments at local hubs any time as part of the practice’s federation membership. These however had not yet demonstrated that they had met this population group’s needs.

People whose circumstances make them vulnerable:

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

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

  • Staff we spoke with had a good understanding of how to support patients with mental health needs and those patients living with dementia.
  • The practice held GP led dedicated monthly mental health and dementia clinics. Patients who failed to attend were proactively followed up by a phone call from a GP. The practice arranged for a Psychiatrist to attend every month to discuss patients and review their notes as part of an ongoing clinical review.

Timely access to care and treatment

Patient feedback indicated that they were not always able to access care and treatment from the practice within an acceptable timescale for their needs.

  • The national GP patient survey showed that patient satisfaction with waiting times, delays and cancellations was lower than local and national averages. However, referrals and test results were still given in a timely manner.
  • Patients reported that the appointment system was not able to provide enough appointments to meet their needs.
  • Patients with the most urgent needs had their care and treatment prioritised.
  • The practice had commissioned a private company to conduct a survey on their behalf to gather further patient feedback and help them to understand how they could further improve.
  • The practice had recruited a salaried GP, who is due to start in June 2018, this GP was specifically employed to cover the busier periods experienced by the practice to try to improve patient access to appointments.

Listening and learning from concerns and complaints

The practice took complaints and concerns seriously and responded appropriately to improve the quality of care.

  • Information about how to make a complaint or raise concerns was available in the reception area. We saw that staff treated patients who made complaints compassionately.
  • The complaint policy and procedures were in line with recognised guidance. The practice learned lessons from individual concerns and complaints and also from analysis of trends. It acted as a result to improve the quality of care.

Please refer to the Evidence Tables for further information.

Well-led

Good

Updated 19 July 2018

We rated the practice and all of the population groups as good for providing a well-led service.

Leadership capacity and capability

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

  • Leaders we spoke with were knowledgeable about issues and priorities relating to the quality and future of services. They understood the challenges and were trying various means to address them.
  • Leaders at all levels were visible and approachable. They worked closely with staff and others to make sure they prioritised compassionate and inclusive leadership.
  • The practice had effective processes to develop leadership capacity and skills, including planning for the future leadership of the practice.

Vision and strategy

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

The practice had a vision, set of values, a strategy and supporting business plans to achieve priorities. The practice developed its vision, values and strategy jointly with patients, staff and external partners and staff we spoke with were aware of and understood these and their role in achieving them.

  • The practice could not demonstrate that they always proactively planned its services to meet the needs of the practice population.
  • The practice monitored progress against delivery of the strategy and were aware of identified issues.

Culture

The practice had a culture of sustainable care.

  • The practice focused on the needs of patients and had made adjustments but these had not yet demonstrated a positive impact.
  • Staff we spoke with stated they felt respected, supported and valued and there was a strong emphasis on the safety of staff.
  • Openness, honesty and transparency were demonstrated when responding to incidents and complaints. The provider was aware of and had systems to ensure compliance with the requirements of the duty of candour.

  • Staff we spoke with told us they were able to raise concerns and were encouraged to do so. They had confidence that these would be addressed, we saw that a whistleblowing policy was in place.
  • There were processes for providing all staff with the development they needed. This included appraisal and career development conversations. All staff had received regular annual appraisals in the last year. Staff were supported to meet the requirements of professional revalidation where necessary.
  • All staff were considered valued members of the practice team. Clinical staff were given protected time for professional development and evaluation of their clinical work.
  • Staff we spoke with explained that the practice actively promoted equality and diversity and that they felt they were treated equally. Staff, whose files we reviewed had received equality and diversity training
  • All staff and management that we spoke with explained that there were positive relationships between staff and teams.

Governance arrangements

There were clear responsibilities, roles and systems of accountability within the practice.

  • There were structures, processes and systems in place to support governance and management. These were understood by the staff that we spoke with.
  • The governance and management of partnerships, joint working arrangements and shared services promoted interactive and co-ordinated person-centred care.
  • Staff we spoke with were clear on their roles and accountabilities including in respect of safeguarding and infection prevention and control.
  • Practice leaders had established policies, procedures and activities to ensure safety and assured themselves that they were operating as intended.

Managing risks, issues and performance

There were processes for managing risks, issues and performance within the practice.

  • There was an effective, process to identify, understand, monitor and address current and future risks including risks to patient safety.
  • The practice had processes to manage current and future performance. Performance of employed clinical staff could be demonstrated through audit of their consultations, prescribing and referral decisions. Practice leaders had oversight of national and local safety alerts, incidents, and complaints.
  • Clinical audits had a positive impact on quality of care and outcomes for patients. There was clear evidence of action to change the practice to improve quality.
  • The practice had plans in place and had trained staff for major incidents.

Appropriate and accurate information

The practice acted on appropriate and accurate information.

  • Quality and performance information was reported, monitored and combined with the views of patients to implement adjustments to services. These were discussed in relevant meetings where all staff had sufficient access to the information.
  • The information used to monitor performance and the delivery of quality care was accurate and useful. There were plans to address any identified weaknesses and the practice had already made adjustments, but these had not yet demonstrated a positive impact.
  • The practice used information technology systems to monitor and improve the quality of care.
  • The practice submitted data or notifications to external organisations as required.
  • There were arrangements in line with data security standards for the availability and confidentiality of patient identifiable data, records and data management systems.

Engagement with patients, the public, staff and external partners

The practice involved patients, the public, staff and external partners to support improvement of services.

  • A full and diverse range of patients’, staff and external partners’ views and concerns were encouraged, heard and acted on to shape services and culture. There was an active patient participation group (PPG), who formed a patient panel and had re-written all the practice’s generic correspondence to ensure that it was appropriate for the population.
  • The service was transparent, collaborative and open with stakeholders about performance.

Continuous improvement and innovation

There was evidence of systems and processes for learning, continuous improvement and innovation; however, these had not yet demonstrated a positive impact.

  • There was a focus on continuous learning and improvement.
  • Staff we spoke with knew about improvement methods and had the skills to use them.
  • The practice made use of internal and external reviews of incidents and complaints. Learning was shared and used to try and make improvements.

Please refer to the Evidence Tables for further information.

Checks on specific services

People with long term conditions

Good

Families, children and young people

Good

Working age people (including those recently retired and students)

Requires improvement

People experiencing poor mental health (including people with dementia)

Good

People whose circumstances may make them vulnerable

Good