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Cambridge Access Surgery Outstanding

Inspection Summary


Overall summary & rating

Outstanding

Updated 5 October 2017

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Cambridge Access Centre on 22 August 2017. Overall the practice is rated as outstanding.

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

  • The practice demonstrated there was strong clinical leadership and cohesive team working with both the practice team and with other services such as drug and alcohol services to deliver health care to their specific population.

  • There was an open and transparent approach to safety and a system in place for reporting and recording significant events.

  • The practice had clearly defined and embedded systems to minimise risks to patient safety. The practice had a risk calendar to monitor when risk assessments were due.

  • Staff were aware of current evidence based guidance. Staff had been specifically trained to undertake the role of treating homeless patients.

  • Results from the practice patient survey showed patients reported they were treated with care and would recommend the practice.

  • There was evidence of the practice providing additional services to patients including receiving mail for those with no fixed abode, offering to charge mobile phones, providing lunch once per month and providing clothing and bedding to the local homeless shelter.

  • The practice had identified 4.8% of their population as carers and were proactive in the management of carers.

  • Information about services and how to complain was available and easy to understand. The practice recognised the population they served were more likely to give verbal feedback rather than written and had a system to record both. Complaints were fully investigated and patients were responded to with an apology and full explanation.

  • For those patients who were not able to make appointments the practice offered a drop in clinic every morning at the practice and also twice weekly at the local shelter.

  • A practice initiative to start a support group for patients with Hepatitis C was being advertised and they had a ‘clean needle’ campaign in place.

  • The practice held a comprehensive central register of policies and procedures which were in place to govern activity.

  • The practice had good facilities and was well equipped to treat patients and meet their needs.

  • 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 patient participation group (PPG) had recently disbanded due to unforeseen circumstances. The practice was actively trying to recruit new members and could evidence they had involved the PPG with patient surveys.

  • The provider was aware of and complied with the requirements of the Duty of Candour.

We saw areas of outstanding practice:

There was an outstanding caring culture within the practice and we saw many examples. Staff treated all the patients as individuals and patients we spoke with confirmed this. Staff had donated items such as clothing and bedding to the local shelter and provided a lunch once a month at the practice for patients. There was always fruit and biscuits available at the practice for patients who wanted them and staff ensured patients enhanced needs were met. Staff knew their population well and would phone the outreach team to check on patients if they had not been to the practice for a period of time. When patients were admitted to hospital, the practice checked they had essential personal belongings. A common mode of transport for patients was by bicycle which had to be left at the front of the building, so the practice provided bike locks to ensure they were kept safe. Patients were allowed to charge their phones at the practice to ensure they could be contacted when necessary. For those patients with dogs, the practice provided water and shelter for them while the patient was seen by a clinician. We received 27 comment cards from patients. All 27 reported caring, professional, approachable staff.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Inspection areas

Safe

Good

Updated 5 October 2017

The practice is rated as good for providing safe services.

  • We found there was an effective system for reporting and recording significant events; lessons were shared with the practice and the other agencies that they worked closely with 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, information, and a written apology. They were told about any actions to improve processes to prevent the same thing happening again. Where appropriate, patients were invited in to discuss the outcomes of significant events.

  • The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe and safeguarded from abuse.

  • There were effective recruitment processes in place and all members of staff had received a Disclosure and Barring Service check (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 practice managed patients who may have substance misuse issues and where appropriate in conjunction with a care plan issued prescriptions for medicines such as methadone. There was evidence of comprehensive training for clinicians undertaking this role and a policy and protocol in place for the prescribing of methadone. The systems and processes for repeat prescribing, including high risk medicines, kept patients safe.

  • There were various risk assessments in place which included a risk assessment for the control of Legionella (Legionella is a term for a particular bacterium which can contaminate water systems in buildings). There was a compliance calendar to ensure risk assessments were carried out in a timely manner within policy.

  • The practice infection control and prevention systems in place to ensure that patients and staff were kept safe from harm were detailed and embedded. For example reception staff cleared and cleaned waiting areas throughout the day.

Effective

Good

Updated 5 October 2017

The practice is rated as good for providing effective services.

  • Data from the Quality and Outcomes Framework showed the practice was an outlier. However, this was reflective of their small list size of 500 registered patients and because of their specific demographic.

  • The practice monitored their performance through a variety of audits relating to prescribing, clinical intervention and compliance. Audits were reflective of the population and included an audit of treatment for chronic alcoholism and diabetes.

  • All members of staff were suitably trained to carry out their roles. All staff had been trained in substance misuse and staff reported training needs were supported by management.

  • There was evidence of appraisals and personal development plans for all staff.

  • Staff worked with other health care professionals to understand and meet the range and complexity of patients’ needs, including the mental health team, psychiatrist and local shelters.

  • End of life care was coordinated with other services involved. Where possible the patient remained under the care of the service during this time.

  • The practice supported patients to attend external appointments such as hospital appointments. The practice were aware of the appointments and contacted the patient prior to the appointment to remind them to attend. If patients were admitted to hospital they phoned the patient to offer support and were aware of any discharges.

  • The practice ensured sharing of information with NHS GP services and general NHS hospital services when necessary and with the consent of the patient. For example, the practice sent or telephoned information of consultations to the patients regular GP if they were registered as a temporary patient.

Caring

Outstanding

Updated 5 October 2017

The practice is rated as outstanding for providing caring services.

  • Data from the practice patient survey showed patients rated the practice highly for several aspects of care.

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

  • The staff allowed patients to charge their mobile phones in the practice and provided a lunch every month for a local drop-in group. They also provided items such as clothes and sleeping bags for the local homeless shelter. They allowed patients to use the practice address for delivery of any mail when they did not have a fixed address.

  • The practice had identified 4.8% of the population as carers. The practice were proactive in supporting these patients and also noted whether patients had a key worker from the local shelters on their notes. Key workers attended weekly multidisciplinary team meetings.

  • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality.

  • Staff had received training in confidentiality, mental health conditions, managing challenging behaviour, conflict resolution and the Mental Capacity Act.

Responsive

Good

Updated 5 October 2017

The practice is rated as good for providing responsive services.

  • Patients told us they found it easy to make an appointment with a GP and that there was continuity of care. Results from the practice survey aligned with these views. The practice also provided a drop in clinic twice per week at the local homeless shelters.

  • Patients we spoke with told us that they found the practice was responsive to their needs and if they were not in the area at the time of requiring health care they would travel back to the practice to seek it.

  • In recognition of a growing prevalence, the practice was working with the local hospital to implement a Hepatitis C clinic for patients to ensure patients with this condition received the support and education to manage their condition.

  • To encourage safe practice the practice had a ‘clean needle’ campaign to target infection rates.

  • The practice ensured the facilities were well equipped and maintained to treat patients and meet their needs.

  • Information about how to complain was available and easy to understand and evidence showed that the practice responded quickly to issues raised. Limited complaints had been made, however the management team proactively gained feedback from patients, including verbal feedback.

  • Translation services were available for patients whose first language was not English. This ensured patients understood their treatment options. The practice also utilised face to face sign language interpretation services for any patients who were deaf.

  • The waiting room had information relating to the needs of the population, including local homeless shelters contact information.

  • Through joint working, the practice had examples of patients who had been supported through a difficult period of their lives and had returned to paid employment. In some cases with agreement the patient had remained registered at the practice giving them the continuity of care to sustain their improved health outcome.

Well-led

Outstanding

Updated 5 October 2017

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

  • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to this. The practice business plan was reviewed on an annual basis.
  • There was a clear leadership structure and staff felt supported by management. The practice demonstrated that there was strong clinical leadership and cohesive team working with both the practice team and with other services such as drug and alcohol services to deliver health care to their specific population.

  • The practice had a number of practice specific policies and procedures to govern activity.

  • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk. The practice had a compliance calendar in place to regularly monitor when audits and risk assessments were due.

  • Administration staff discussed their own working arrangements and ensured rotas were filled. Management reported this increased ownership of their role and improved team work.

  • The provider was aware of and complied with the requirements of the Duty of Candour. The practice encouraged a culture of openness and honesty.

  • Staff told us they had received comprehensive induction and ongoing training programs, this included additional training which specifically met the patient’s needs.

  • The practice proactively sought feedback from staff and patients which it acted on.

  • There was a strong focus on continuous learning, improvement and development of the service at all levels.
Checks on specific services

People with long term conditions

Outstanding

Updated 5 October 2017

The practice is rated as outstanding for the care of people with long-term conditions. Due to the demographics of the population, the practice had limited people with diagnosed long term conditions registered as patients but the practice was active in identifying patients with long term conditions.

  • Performance for diabetes related indicators was 96%, this was 5% above the CCG and England average. The exception reporting rate was 20%, which was higher than the CCG average of 13% and the national average rate of 12%, this was due to the small number of patients with diabetes. The prevalence of diabetes was 2% which was lower than the CCG average of 6% and the national average of 6%.

  • The practice followed up on patients with long-term conditions discharged from hospital and ensured that their care plans were updated to reflect any additional needs.

  • The practice recognised that due to the demographics of the population, patients may not attend appointments for long term follow ups. Therefore, they had implemented systems including contacting the local police outreach team if patients had not been seen for a while, text and phone call reminders and writing appointments down for the patient.

  • All these patients had a named GP. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care.

Families, children and young people

Outstanding

Updated 5 October 2017

The practice is rated as outstanding for the care of families, children and young people. Due to the demographics of the population, the practice had no patients aged under 18 registered with the practice.

  • The practice had safe and effective systems in place for safeguarding children and adults and were aware of the complex situations that patients may be in with families.

  • The practice did not treat patients under 18; if a patient under the age of 18 presented at the practice, there were systems to ensure timely onward referral to appropriate services. The practice would phone practices they referred to, to ensure the young person would receive appropriate treatment.

  • The practice identified at an early stage those patients that required maternity and midwifery services and referred them on as appropriate.

  • Where patients required services including family planning, the practice referred them on appropriately.

  • The practice had completed 68% of cervical smears in the last year compared to the national average of 76%. The practice recognised that due to practice demographics, it may be difficult to get patients to attend appointments for cervical smears. The practice had a system where the practice nurse would go into the community to contact non-attenders and explain the importance of the smear test and book appointments where appropriate.

Older people

Outstanding

Updated 5 October 2017

The practice is rated as outstanding for the care of older people. Due to the demographics of the population, the practice had limited older people registered as patients.

  • Staff were able to recognise the signs of abuse in older patients and knew how to escalate any concerns.

  • The practice offered proactive, personalised care to meet the needs of the older patients in its population.

  • The practice was responsive to the needs of older patients, and offered home visits to the temporary shelters where patients may be staying and urgent appointments for those with enhanced needs.

  • The practice identified at an early stage older patients who may need palliative care as they were approaching the end of life. It involved older patients in planning and making decisions about their care, including their end of life care. The practice also ensured these patients were appropriately referred on for social issues such as housing.

  • The practice followed up on older patients discharged from hospital and ensured that their care plans were updated to reflect any extra needs. They also contacted patients when they had been admitted to hospital to see if they could bring them any essential belongings or contact family.

  • Where older patients had complex needs, the practice shared summary care records with local care services, including the mental health service, community matron and psychiatrist.

  • Older patients were provided with health promotional advice and support to help them to maintain their health and independence for as long as possible, including advice on drug and alcohol dependency.

Working age people (including those recently retired and students)

Outstanding

Updated 5 October 2017

The practice is rated as outstanding for the care of working age people (including those recently retired and students).

  • The practice allowed patients seeking jobs and housing to use the practice as a fixed abode address to send mail to. There was a system in place to ensure these were handled appropriately.

  • The practice had nurses trained in smoking cessation and offered support to those patients who needed it.

  • The practice held drug and alcohol misuse clinics with the inclusion team who were situated in the same building, twice per week. Patients were closely monitored and the practice had good lines of communication with the local pharmacy for those patients who had daily medicine needs.

  • The practice sent text message and phone call reminders to patients who were due an appointment at the practice. They also did this for any other health appointment to encourage attendance by patients. The practice also allowed patients to charge their mobile phones at the practice.

People experiencing poor mental health (including people with dementia)

Outstanding

Updated 5 October 2017

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

  • The practice had very limited numbers of patients with dementia but were aware that patients may be at risk of alcohol induced dementia. The GPs and nurses regularly gave healthy living advice and ran an alcohol detox clinic. The aim was to reduce the occurrence of alcohol-induced dementia.

  • The practice specifically considered the physical health needs of patients with poor mental health and dementia.

  • The practice had a system for monitoring repeat prescribing for patients receiving medicines for mental health needs.

  • The practice prescribed methadone where clinically appropriate. There were very clear guidelines for this which were available on the computer, in paper format, in all clinical rooms and in the reception area. The practice worked very closely with the inclusion team when prescribing methadone to ensure evidence based guidance was followed and for regular case discussion.

  • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health. This included the psychiatrist, inclusion team, mental health team and police outreach team.

  • The practice had information available for patients experiencing poor mental health about how they could access various support groups and voluntary organisations, including the local shelters.

  • Staff interviewed had a good understanding of how to support patients with mental health needs and dementia and were all trained in these areas.

  • Non-clinical staff attended training courses to understand some of the more complex behavioural patterns usually associated with conditions such as schizophrenia.

People whose circumstances may make them vulnerable

Outstanding

Updated 5 October 2017

The practice is rated as outstanding for the care of people whose circumstances may make them vulnerable.

  • The practice had a population of homeless, those at risk of homelessness and those in sheltered accommodation.

  • End of life care was delivered in a coordinated way which took into account these circumstances. The practice ensured any patient that was end of life had appropriate social plans in place.

  • The practice regularly worked with other health care professionals in the case management of vulnerable patients, including the community matron, the local homeless shelters and the church when they held winter meals for patients.

  • The practice had information available for vulnerable patients about how to access various support groups and voluntary organisations, including local shelters.

  • Staff interviewed knew how to recognise signs of abuse in children, young people and adults whose circumstances may make them vulnerable. They were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours.

  • The practice understood homeless patients may not know how to register. They proactively went into the community to encourage registration and improve access to healthcare. A GP and nurse held two weekly drop-in sessions at the local shelter.

  • A common mode of transport for patients was by bicycle which had to be left at the front of the building, so the practice provided bike locks to ensure they were kept safe. The practice had noted an increase in patients suffering domestic violence. Therefore, they had trained staff to deal with this and implemented strategies to ensure these patients could receive care in a discreet manner.