This report describes our judgement of the quality of care at this service. It is based on a combination of what we found
when we inspected, information from our ongoing monitoring of data about services and information given to us from
the provider, patients, the public and other organisations.
Ratings
Overall rating for this service
Good –––Are services safe?
Good –––Are services effective?
Good –––Are services caring?
Good –––Are services responsive to people’s needs?
Good –––Are services well-led?
Good –––The Elms Surgery
Quality Report
16 Derby Street
Ormskirk
L39 2BY
Tel: 01695 588710
Website: www.theelmspractice.nhs.uk
Date of inspection visit: 11 February 2016
Date of publication: This is auto-populated when the
report is published
1
The Elms Surgery Quality Report This is auto-populated when the report is publishedContents
Summary of this inspection
PageOverall summary
2The five questions we ask and what we found
4The six population groups and what we found
6What people who use the service say
9Areas for improvement
9Outstanding practice
9Detailed findings from this inspection
Our inspection team
10Background to The Elms Surgery
10Why we carried out this inspection
10How we carried out this inspection
10Detailed findings
12Overall summary
Letter from the Chief Inspector of General
Practice
We carried out an announced comprehensive inspection
at The Elms Surgery, Ormskirk on 11 February 2016.
Overall the practice is rated as good.
Our key findings across all the areas we inspected were as
follows:
• There was an open and transparent approach to safety
and an effective system in place for reporting and
recording significant events.
• Risks to patients were assessed and well managed.
• Staff assessed patients’ needs and delivered care in
line with current evidence based guidance. Staff had
the skills, knowledge and experience to deliver
effective care and treatment.
• Feedback from patients about their care was
consistently and strongly positive. Patients described
the GP practice as excellent; staff were described as
caring and professional.
• Patients said they were treated with compassion,
dignity and respect and they were involved in their
care and decisions about their treatment.
• The practice had a virtual patient participation group.
We were told the practice acted on feedback and took
action when comments and suggestions were made
• Information about services and how to complain was
available and easy to understand.
• The practice had good facilities and was well equipped
to treat patients and meet their needs.
• The practice worked closely with other organisations
and with the local community in planning how
services were provided to ensure that they met
patients’ 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.
Summary of findings
2
The Elms Surgery Quality Report This is auto-populated when the report is published• The provider was aware of and complied with the
requirements of the Duty of Candour.
We saw an area of outstanding practice:
• The practice had well established links with a local
university, providing clinics on a weekly basis which in
addition to access to a GP, included the provision for
counselling and sexual health services. This was in
response to reduced access across the local area.
The areas where the provider should make
improvements are:
• Ensure a more systematic approach to clinical audits
with two cycle audits to demonstrate effective
improvement in care and treatments.
• Ensure that the patients specific directives for
prescribing of vaccinations are signed off for
individual patients by a GP.
• Ensure that annual infection control audits of the
practice are undertaken in order to identify and
manage infection control and prevention risks.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice
Summary of findings
3
The Elms Surgery Quality Report This is auto-populated when the report is publishedThe five questions we ask and what we found
We always ask the following five questions of services.
Are services safe?
The practice is rated as good for providing safe services.
• There was an effective system in place for reporting and
recording significant events
• Lessons were shared to make sure action was taken to improve
safety in the practice.
• When there were unintended or unexpected safety incidents,
patients received support, truthful information, a verbal and
written apology. They were told about any actions to improve
processes to prevent the same thing happening again.
• The practice had clearly defined and embedded systems,
processes and practices in place to keep patients safe and
safeguarded from abuse.
• Risks to patients were assessed and well managed.
Good
–––Are services effective?
The practice is rated as good for providing effective services.
• Data from the Quality and Outcomes Framework showed
patient outcomes were at or above average for the locality and
compared to the national average.
• Staff assessed needs and delivered care in line with current
evidence based guidance.
• Some clinical audits demonstrated quality improvement.
• Staff had the skills, knowledge and experience to deliver
effective care and treatment.
• There was evidence of appraisals and personal development
plans for all staff.
• Staff worked with multidisciplinary teams to understand and
meet the range and complexity of patients’ needs.
Good
–––Are services caring?
The practice is rated as good for providing caring services.
• The practice was comparable for its satisfaction scores on
consultations with GPs and nurses
• Feedback from patients about their care and treatment was
consistently and strongly positive.
• We observed a well-established patient-centred culture.
• Patients said they were treated with compassion, dignity and
respect and they were involved in decisions about their care
and treatment.
Good
–––Summary of findings
4
The Elms Surgery Quality Report This is auto-populated when the report is published• Information for patients about the services available was easy
to understand and accessible.
• We saw staff treated patients with kindness and respect, and
maintained patient and information confidentiality.
Are services responsive to people’s needs?
The practice is rated as good for providing responsive services.
• Practice staff reviewed the needs of its local population and
engaged with the NHS England Area Team and Clinical
Commissioning Group to secure improvements to services
where these were identified. For example the continued
engagement with the local university.
• Some patients said they found it hard to access the practice in
the morning. The practice had responded by ensuring
additional reception staff were on duty to take calls.
• Urgent appointments were available the same day.
• The practice had good facilities and was well equipped to treat
patients and meet their needs.
• Information about how to complain was available and easy to
understand and evidence showed the practice responded
quickly to issues raised. Learning from complaints was shared
with staff and other stakeholders
Good
–––Are services well-led?
The practice is rated as good for being well-led.
• There was a clear leadership structure and staff felt supported
by management. The practice had a number of policies and
procedures to govern activity and held regular governance
meetings.
• 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 provider was aware of and complied with the requirements
of the Duty of Candour. The partners encouraged a culture of
openness and honesty.
• The practice had systems in place for knowing about notifiable
safety incidents and ensured this information was shared with
staff to ensure appropriate action was taken
• The practice proactively sought feedback from staff and
patients, which it acted on. The patient participation group was
active
Good
–––Summary of findings
5
The Elms Surgery Quality Report This is auto-populated when the report is publishedThe six population groups and what we found
We always inspect the quality of care for these six population groups.
Older people
The practice is rated as good for the care of older people.
• The practice offered proactive, personalised care to meet the
needs of the older people in its population.
• The practice was responsive to the needs of older people, and
offered home visits and urgent appointments for those with
enhanced needs.
• Patients had an admission avoidance plan and offered support
and regular reviews.
• The practice also worked with the community teams to reduce
unplanned hospital admissions.
Good
–––People with long term conditions
The practice is rated as good for the care of people with long-term
conditions.
• GPs and nursing staff had lead roles in chronic disease
management and patients at risk of hospital admission were
identified as a priority.
• The Quality and Outcomes Framework (QOF) data showed that
the practice was comparable the local clinical commissioning
group and national averages on clinical indicators, including
diabetes, mental health, including dementia and hypertension
(high blood pressure).
• Longer appointments and home visits were available when
needed.
• All these patients had a named GP and a structured annual
review to check their health and medicines needs were being
met. 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.
• For patients with multiple and complex needs reviews were
undertaken at the same time to avoid multiple visits to the
practice.
• Care plans were in place and were up to date
Good
–––Families, children and young people
The practice is rated as good for the care of families, children and
young people.
Good
–––Summary of findings
6
The Elms Surgery Quality Report This is auto-populated when the report is published• There were systems in place 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
A&E attendances
• The uptake of childhood immunisation was good.Rates for the
vaccinations given to under two year olds was 95% and for five
year olds 94%, comparable to CCG and national averages
• Quality and Outcome Framework (QOF) data showed that the
practice performed slightly better that the national average
with 73.9 % of patients with asthma, on the register, who had an
asthma review undertaken in the preceding 12 months,
• Patients told us that children and young people were treated in
an age-appropriate way and were recognised as individuals,
and we saw evidence to confirm this.
• The practice’s uptake for the cervical screening programme was
77.8 %, which was comparable to the CCG average of 77.1% and
the national average of 76.7%.
• Appointments were available outside of school hours and the
premises were suitable for children and babies.
• We saw positive examples of joint working with midwives,
health visitors and school nurses.
Working age people (including those recently retired and
students)
The practice is rated as good for the care of working-age people
(including those recently retired and students).
• The needs of the working age population, those recently retired
and students had been identified and the practice had adjusted
the services it offered to ensure these were accessible, flexible
and offered continuity of care.
• The practice was proactive in offering online services as well as
a full range of health promotion and screening that reflects the
needs for this age group.
• The practice had well established links with a local university,
providing clinics on a weekly basis which in addition to access
to a GP, included the provision for counselling and sexual
health services.
Good
–––People whose circumstances may make them vulnerable
The practice is rated as good for the care of people whose
circumstances may make them vulnerable.
• The practice held a register of patients living in vulnerable
circumstances including with a learning disability.
Good
–––Summary of findings
7
The Elms Surgery Quality Report This is auto-populated when the report is published• The practice offered longer appointments for patients with a
learning disability.
• The practice regularly worked with multi-disciplinary teams in
the case management of vulnerable people.
• The practice informed vulnerable patients about how to access
various support groups and voluntary organisations.
• Staff knew how to recognise signs of abuse in vulnerable adults
and children. Staff 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.
People experiencing poor mental health (including people
with dementia)
The practice is rated as good for the care of people experiencing
poor mental health (including people with dementia).
• 89.1% of patients diagnosed with dementia had their care
reviewed in a face to face meeting in the last 12 months which
was better than the CCG average 80% and the national average
of 77%.
• The practice regularly worked with multi-disciplinary teams in
the case management of people experiencing poor mental
health, including those with dementia.
• The practice had told patients experiencing poor mental health
about how to access various support groups and voluntary
organisations.
• The practice had a system in place to follow up patients who
had attended accident and emergency where they may have
been experiencing poor mental health.
• Staff had a good understanding of how to support patients with
mental health needs and dementia.
Good
–––Summary of findings
8
The Elms Surgery Quality Report This is auto-populated when the report is publishedWhat people who use the service say
What people who use the practice say
The national GP patient survey results published in
January 2016 indicated the practice was performing
below the local and national averages.
• 63% found it easy to get through to this surgery by
phone compared to a CCG average of 72% and a
national average of 73%.
• 82% were able to get an appointment to see or
speak to someone the last time they tried (CCG
average 86%, national average 85%).
• 73% described the overall experience of their GP
surgery as fairly good or very good (CCG average
86%, national average 85%).
• 62% said they would definitely or probably
recommend their GP surgery to someone who has
just moved to the local area (CCG average 78%,
national average 78%).
As part of our inspection we also asked for CQC comment
cards to be completed by patients prior to our inspection.
We received 83 comment cards which were all except
nine were extremely positive about the standard of care
received. Patients commented on the excellent care and
each GP, nurse, health care assistant and reception staff,
were individually mentioned on many of the cards.
Negative comments were made about trying to get
through to the practice in the morning for same day
appointments; however even these contained positive
comments in regards to the staff attitude, care and
treatment.
We spoke with seven patients during the inspection. All
seven patients without exception said they were happy
with the care they received and thought staff were
approachable, committed and caring.
We also spoke with a member of the virtual patient
participation group (PPG). We were told the practice
acted on feedback and we were given examples when
action was taken as a results of comments and
suggestions made
Areas for improvement
Action the service SHOULD take to improve
The areas where the provider should make
improvements are:
• Ensure a more systematic approach to clinical audits
with two cycle audits to demonstrate effective
improvement in care and treatments.
• Ensure that the patients specific directives for
prescribing of vaccinations are signed off for
individual patients
• Ensure that annual infection control audits of the
practice are undertaken in order to identify and
manage infection control and prevention risks.
Outstanding practice
We saw an area of outstanding practice: • The practice had well established links with a local
university, providing clinics on a weekly basis which in
addition to access to a GP, included the provision for
counselling and sexual health services. This was in
response to reduced access across the local area.
Summary of findings
9
The Elms Surgery Quality Report This is auto-populated when the report is publishedOur inspection team
Our inspection team was led by:
Our inspection team was led by a CQC Lead Inspector
.The team included a GP specialist adviser, a second CQC
inspector and a practice manager specialist adviser.
Background to The Elms
Surgery
The Elms Surgery is situated in the town centre of Ormskirk,
West Lancashire. Primary medical services are provided
under a General Medical Services (GMS) contract with NHS
England and the practice is commissioned by the NHS West
Lancashire Clinical Commissioning Group.
The practice population groups are slightly lower than the
CCG averages. The largest population group within the
practice is the under 20 – 24 age group. 49.3% of patients
have a long standing health condition and 3.4% of all
patients are unemployed which is below the CCG average
Information published by Public Health England rates the
level of deprivation within the practice population group as
nine on a scale of one to ten. Level one represents the
highest levels of deprivation and level 10 the lowest.
The practice has one principal male GP, two full time male
salaried GPs and one part time female salaried GP. The GPs
are supported by a practice manager, assistant manager,
one practice nurse, one healthcare assistant, a medicines
coordinator, eight reception staff and administration staff.
The practice is open between 8.30am and 6.30 Monday to
Friday. Appointments are from 9am to 1pm every morning
and 2pm to 6.30pm daily. The practice has ramp access for
those with a disability and there are public short and long
stay car parks close by.
Out of hours (OOH) service is provided by Owls GP OOH
Services, based in the West Lancashire Health Centre at
Ormskirk Hospital. Patients contacting the practice out of
hours are directed to this service via NHS 111.
Why we carried out this
inspection
We inspected this service as part of our new
comprehensive inspection programme.
We carried out a comprehensive inspection of this service
under Section 60 of the Health and Social Care Act 2008 as
part of our regulatory functions. The inspection was
planned to check whether the provider is meeting the legal
requirements and regulations associated with the Health
and Social Care Act 2008, to look at the overall quality of
the service, and to provide a rating for the service under the
Care Act 2014.
How we carried out this
inspection
Before visiting, we reviewed a range of information we hold
about the practice and asked other organisations to share
what they knew. We carried out an announced visit on 11
February 2016. During our visit we:
• Spoke with a range of staff and patients who used the
service.
The Elms Surgery
Detailed findings
10
The Elms Surgery Quality Report This is auto-populated when the report is published• Observed how patients were being cared for and talked
with carers and/or family members.
• Reviewed comment cards where patients and members
of the public shared their views and experiences of the
service.
To get to the heart of patients’ experiences of care and
treatment, we always ask the following five questions:
• Is it safe?
• Is it effective?
• Is it caring?
• Is it responsive to people’s needs?
• Is it well-led?
We also looked at how well services were provided for
specific groups of people and what good care looked like
for them. The population groups are:
• Older people
• People with long-term conditions
• Families, children and young people
• Working age people (including those recently retired
and students)
• People whose circumstances may make them
vulnerable
• People experiencing poor mental health (including
people with dementia)
Please note that when referring to information throughout
this report, for example any reference to the Quality and
Outcomes Framework data, this relates to the most recent
information available to the CQC at that time.
Detailed findings
11
The Elms Surgery Quality Report This is auto-populated when the report is publishedOur findings
Safe track record and learning
There was an effective system in place for reporting and
recording significant events.
• Staff told us they would inform the practice manager of
any incidents and there was a recording form available
on the practice’s computer system.
• The practice carried out a thorough analysis of the
significant events.
• Weekly team meetings were undertaken and significant
events was a standing item on the meeting agenda.
• We reviewed safety records, incident reports national
patient safety alerts and minutes of meetings where
these were discussed. Lessons were shared to make
sure action was taken to improve safety in the practice.
Staff provided examples of significant events and the
action taken as result of analysis. Examples of significant
events provided included clinical, prescribing,
governance and administration. It was clear the practice
took steps to take appropriate action to minimise or
avoid any reoccurrence.
• When there were unintended or unexpected safety
incidents, patients received reasonable support, truthful
information, a verbal and written apology and were told
about any actions to improve processes to prevent the
same thing happening again
Overview of safety systems and processes
The practice had clearly defined and embedded systems,
processes and practices in place to keep patients safe and
safeguarded from abuse, which included:
• Arrangements were in place to safeguard children and
vulnerable adults from abuse that reflected relevant
legislation and local requirements and policies were
accessible to all staff. The policies clearly outlined who
to contact for further guidance if staff had concerns
about a patient’s welfare. The principal GP was the lead
member of staff for safeguarding and had been trained
to level 3 as required. The GP had not attended many
safeguarding meetings due to restrictions on
availability, however always provided reports where
necessary for other agencies. Staff fully understood their
responsibilities and all had received training relevant to
their role, with regular updates facilitated by the lead
GP.
• A notice in the waiting room advised patients that
chaperones were available if required. All staff who
acted as chaperones were trained for the role and 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 principal GP and practice nurse were the infection
control clinical leads but staff explained that all staff
took responsibility in ensuring the practice minimised
infection control risks. There was an infection control
policy in place and staff had received up to date
training. Although annual infection control audits had
not been routinely undertaken check lists were in place
and the practice maintained appropriate standards of
cleanliness and hygiene. We observed the premises to
be clean and well organised.
• The arrangements for managing medicines, including
emergency drugs and vaccinations, in the practice kept
patients safe (including obtaining, prescribing,
recording, handling, storing and security). The practice
had received funding from the local Clinical
Commissioning Group (CCG) and employed a Medicines
Coordinator. They were responsible for the regular
medicines audits, to ensure prescribing was in line with
best practice guidelines for safe prescribing.
Prescription pads were securely stored and there were
systems in place to monitor their use. The practice nurse
had qualified as an Independent Prescriber and could
therefore prescribe medicines for specific clinical
conditions. Patient Group Directions had been adopted
by the practice to allow the practice nurse to administer
medicines in line with legislation. The practice had a
system for production of Patient Specific Directions to
enable the health care assistant to administer
vaccinations. There was some discrepancy on how
these were authorised by the GP and this was discussed
with the principle GP during the inspection.
• We reviewed six personnel files and found appropriate
recruitment checks had been undertaken prior to
Are services safe?
Good
–––12
The Elms Surgery Quality Report This is auto-populated when the report is publishedemployment. For example, proof of identification,
references, qualifications, registration with the
appropriate professional body and the appropriate
checks through the Disclosure and Barring Service.
• There were failsafe systems in place to ensure results
were received for all samples sent for the cervical
screening programme and the practice followed up
women who were referred as a result of abnormal
results.
Monitoring risks to patients
Risks to patients were assessed and well managed.
• There were procedures in place for monitoring and
managing risks to patient and staff safety. The practice
had up to date fire risk assessments and carried out
regular fire drills. All electrical equipment was checked
to ensure the equipment was safe to use and clinical
equipment was checked to ensure it was working
properly. The practice had a variety of other risk
assessments in place to monitor safety of the premises
such as control of substances hazardous to health and
infection control and legionella (Legionella is a term for
a particular bacterium which can contaminate water
systems in buildings).
• Appropriate arrangements were in place for planning
and monitoring the number of staff and mix of staff
needed to meet patients’ need. A rota system was in
place for all the different staffing groups to ensure that
enough staff were on duty.
Arrangements to deal with emergencies and major
incidents
The practice had adequate arrangements in place to
respond to emergencies and major incidents.
• A Disaster Recovery Plan was in place for major
incidents including power failure or building damage.
This was up to date and accessible both in electronic
and paper copies for staff. The GP and practice manager
also retained copies at home. The plan included
emergency contact numbers for staff.
• There was an instant messaging system on the
computers in all the consultation and treatment rooms
which alerted staff to any emergency.
• All staff received annual basic life support training and
there were emergency medicines available in the
treatment room.
• The practice had a defibrillator available on the
premises and oxygen with adult and children’s masks. A
first aid kit and accident book were available.
• Emergency medicines were easily accessible to staff in a
secure area of the practice and all staff knew of their
location. All the medicines we checked were in date and
fit for use.
Are services safe?
Good
–––13
The Elms Surgery Quality Report This is auto-populated when the report is publishedOur findings
Effective needs assessment
The practice assessed needs and 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 systems in place to keep all clinical
staff up to date. Staff had access to guidelines from NICE
and used this information to deliver care and treatment
that met peoples’ needs.
• The practice monitored that these guidelines were
followed through risk assessments, audits and random
sample checks of patient records.
Management, monitoring and improving outcomes for
people
The practice used the information collected for the Quality
and Outcomes Framework (QOF) and performance against
national screening programmes to monitor outcomes for
patients. (QOF is a system intended to improve the quality
of general practice and reward good practice). The most
recent published results were 99.4% of the total number of
points available (100%), with 8% exception reporting.
(Exception reporting is the removal of patients from QOF
calculations where, for example, the patients are unable to
attend a review meeting or certain medicines cannot be
prescribed because of side effects). This practice was not
an outlier for any QOF (or other national) clinical targets.
Data from showed;
• Performance for diabetes related indicators was better
than the CCG and national average. For example data
for diabetic patients and the HbA1C blood tests showed
76% of patients had received this compared to the CCG
at 74.5% and the national average of 68.4%.
• The percentage of patients with hypertension having
regular blood pressure tests was 95.6%, better CCG and
national average of 88.4% and 86.65 respectively
• Performance for mental health related indicators was
better than the CCG and national average. 94.6 % of
patients with schizophrenia, bipolar affective disorder
and other psychoses had a comprehensive, agreed care
plan recorded in the preceding 12 months which was
above the CCG average of 79.65 and national average of
77.2
• 73.9 % of patients with asthma, on the register had an
asthma review in the preceding 12 months compared to
72.6% in the CCG and national data of 69.7%.
• 89.1% of patients diagnosed with dementia had had
their care reviewed in a face to face meeting in the last
12 months which was better than the CCG average 80%
and the national average of 77%.
Clinical audits were undertaken but were not consistently
documented to demonstrate quality improvement.
• There had been three clinical audits completed in the
last two years, one of these was a medication audit on
Disease Modifying Antirheumatic Drugs (DMARD) where
the improvements made were implemented and
monitored.
The practice works effectively with community services
such as the acute visiting services and Community
Emergency Response Team (CERT) to avoid any unplanned
admissions, particularly for the older patient population.
Admission avoidance care plans were in place and updated
as required.
Effective staffing
Staff had the skills, knowledge and experience to deliver
effective care and treatment.
The GP explained that there had been difficulty in
recruitment in the past and a rota system was in place for
all the different staffing groups to ensure that enough staff
were on duty.
• The practice had an induction programme for all newly
appointed staff. It covered such topics as safeguarding,
infection prevention and control, fire safety, health and
safety and confidentiality.
• The practice could demonstrate how they ensured
role-specific training and updating for relevant staff for
example, for those reviewing patients with long-term
conditions. Staff administering vaccinations and taking
samples for the cervical screening programme had
received specific training.Staff who administered
vaccinations could demonstrate how they stayed up to
date with changes to the immunisation programmes.
Are services effective?
(for example, treatment is effective)
Good
–––14
The Elms Surgery Quality Report This is auto-populated when the report is published• The learning needs of staff were identified through a
system of appraisals and meetings. Staff had access to
appropriate training to meet their learning needs and to
cover the scope of their work. All staff had had an
appraisal within the last 12 months.
• Staff received training that included: safeguarding, fire
procedures, basic life support and information
governance awareness. Staff had access to and made
use of e-learning training modules and in-house
training.
Coordinating patient care and information sharing
The information needed to plan and deliver care and
treatment was available to relevant staff in a timely and
accessible way through the practice’s patient record system
and their intranet system.
• This included care and risk assessments, care plans,
medical records and investigation and test results.
Information such as NHS patient information leaflets
were also available.
• The practice shared relevant information with other
services in a timely way, for example when referring
patients to other services such as secondary care
(hospitals) or the out of hours service.
Staff worked together and with other health and social care
services to understand and meet the range and complexity
of patients’ needs and to assess and plan ongoing care and
treatment. This included when patients moved between
services, including when they were referred, or after they
were discharged from hospital. We saw evidence that
multi-disciplinary team meetings took place, for example
with the palliative care team (Gold Standard Framework
meetings) and that care plans were routinely reviewed and
updated.
Consent to care and treatment
Staff sought patients’ consent to care and treatment in line
with legislation and guidance.
• Staff understood the relevant consent and
decision-making requirements of legislation and
guidance, including the Mental Capacity Act 2005.
When providing care and treatment for children and
young people, staff carried out assessments of capacity
to consent in line with relevant guidance.
• Where a patient’s mental capacity to consent to care or
treatment was unclear the GP or practice nurse
assessed the patient’s capacity and, recorded the
outcome of the assessment.
Supporting patients to live healthier lives
The practice identified patients who may be in need of
extra support.
• These included patients in the last 12 months of their
lives, carers, those at risk of developing a long-term
condition and those requiring advice on their diet,
smoking and alcohol cessation and mental health
issues. Patients were then signposted to the relevant
service.
• A dietician made monthly visits to the practice and
smoking cessation advice was available from a local
support group.
The practice’s uptake for the cervical screening programme
was 77.8 %, which was comparable to the CCG average of
77.1% and the national average of 76.7%. There was a
policy to offer telephone reminders for patients who did
not attend for their cervical screening test. The practice
also encouraged its patients to attend national screening
programmes for bowel and breast cancer screening.
Childhood immunisation rates for the vaccinations given to
under two year olds was 95% and for five year olds 94%,
comparable to CCG and national averages
Patients had access to appropriate health assessments and
checks. These included health checks for new patients and
NHS health checks for people aged 40–74. Appropriate
follow-ups for the outcomes of health assessments and
checks were made, where abnormalities or risk factors
were identified.
Are services effective?
(for example, treatment is effective)
Good
–––15
The Elms Surgery Quality Report This is auto-populated when the report is publishedOur findings
Kindness, dignity, respect and compassion
We observed members of staff were courteous and very
helpful to patients and treated them with dignity and
respect.
• Disposable curtains were provided in consulting rooms
to maintain patients’ privacy and dignity during
examinations, investigations and treatments. These
were last changed January 2016.
• We noted that consultation and treatment room doors
were closed during consultations; conversations taking
place in these rooms could not be overheard.
• Reception staff knew when patients wanted to discuss
sensitive issues or appeared distressed they could offer
them a private room to discuss their needs.
We received 83 patient Care Quality Commission comment
cards. Only nine of these had negative comments mostly in
regards to accessing the practice in the mornings by
telephone. The rest of the comment cards were wholly and
strongly positive about the practice. Every one indicated an
individual staff member, including GPs, nurses and
reception staff, who they described as excellent and were
very positive about the service experienced. Patients said
they felt the practice offered an excellent service and staff
were helpful, caring and treated them with dignity and
respect. Comment cards highlighted that staff responded
compassionately when they needed help and provided
support when required.
We spoke with a member of the virtual patient
participation group. They also told us they were satisfied
with the care provided by the practice and said their dignity
and privacy was respected. Following a period of high
turnover of staff, we were informed that staffing within the
practice was now stable. Staff were said to be very caring.
Results from the national GP patient survey showed
patients felt they were treated with compassion, dignity
and respect. The practice was comparable or slightly below
for its satisfaction scores on consultations with GPs and
nurses[JI1]. For example:
• 86% said the GP was good at listening to them
compared to the CCG average of 86% and national
average of 88%.
• 80% said the GP gave them enough time (CCG average
89%, national average 86%).
• 94% said they had confidence and trust in the last GP
they saw (CCG average 95%, national average 95%)
• 75% said the last GP they spoke to was good at treating
them with care and concern (CCG average 86%, national
average 85%).
• 94% said the last nurse they spoke to was good at
treating them with care and concern (CCG average 93%,
national average 92%).
• 74% said they found the receptionists at the practice
helpful (CCG average 86%, national average 87%)
The practice was aware of the results of the surveys and
had formulated action plans to improve.
Care planning and involvement in decisions about
care and treatment
Patients told us they felt involved in decision making about
the care and treatment they received. They also told us
they felt listened to and supported by staff and had
sufficient time during consultations to make an informed
decision about the choice of treatment available to them.
Patient feedback on the comment cards we received was
also very positive and aligned with these views.
Results from the national GP patient survey showed
patients responded positively to questions about their
involvement in planning and making decisions about their
care and treatment. Results were in line with local and
national averages. For example:
• 85% said the last GP they saw was good at explaining
tests and treatments compared to the CCG average of
86% and national average of 86%.
• 78% said the last GP they saw was good at involving
them in decisions about their care (CCG average 83%,
national average 81%)
• 85% said the last nurse they saw was good at involving
them in decisions about their care (CCG average 85%,
national average 85%)
Staff told us that translation services were available for
patients who did not have English as a first language. We
saw notices in the reception areas informing patients this
service was available.
Are services caring?
Good
–––16
The Elms Surgery Quality Report This is auto-populated when the report is published• Information was available in larger print and braille and
the practice had a hearing loop for patients with hearing
loss.
• Longer appointments times were available for patients
with a learning difficulty and alerts were placed on the
system to help identify these patients. This also
included patients who were blind.
Patient and carer support to cope emotionally with
care and treatment
Notices in the patient waiting room told patients how to
access a number of support groups and organisations.
• The practice’s computer system alerted GPs if a patient
was also a carer. The practice had identified 83 patients
on the practice list as carers. Written information was
available to direct carers to the various avenues of
support available to them. This included an external
agency N- Compass
• The practice had a carer coordinator in place
Staff told us that if families had suffered bereavement, their
usual GP contacted them or sent them a sympathy card.
This call was either followed by a patient consultation at a
flexible time and location to meet the family’s needs and/or
by giving them advice on how to find a support service.
Are services caring?
Good
–––17
The Elms Surgery Quality Report This is auto-populated when the report is publishedOur findings
Responding to and meeting people’s needs
The practice reviewed the needs of its local population and
engaged with the NHS England Area Team and Clinical
Commissioning Group (CCG) to help secure improvements
to services where these were identified.
• Home visits were available for older patients and
patients who would benefit from these. The practice
worked closely with community services to avoid
unplanned admissions to hospital
• Same day appointments were available for children and
those with serious medical conditions.
• Patients were able to receive travel vaccinations
available on the NHS and were referred to other clinics
for vaccines available privately.
• There were longer appointments available for patients
with a learning disability
• There were disabled facilities, a hearing loop and
translation services available.
• The practice had well established links with a local
university, providing clinics on a weekly basis which in
addition to access to a GP, included the provision for
counselling and sexual health services. This was in
response to reduced access across the local area
Access to the service
The practice was open between 8.30am and 6.30 Monday
to Friday. Appointments were from 9am to 1pm every
morning and 2pm to 6.30pm daily. In addition to
pre-bookable appointments that could be booked up to
five days in advance, urgent on the day appointments were
also available for people that needed them. After school
appointments were also available with the practice nurse
until 5pm.
Results from the national GP patient survey showed that
patient’s satisfaction with how they could access care and
treatment was lower than local and national averages.
• 59% of patients were satisfied with the practice’s
opening hours compared to the CCG average of 73%
and national average of 75%.
• 63% patients said they could get through easily to the
surgery by phone (CCG average 72%, national average
73%).
• 42% patients said they always or almost always see or
speak to the GP they prefer (CCG average 67%, national
average 60%).
People told us on the day of the inspection that they were
able to get appointments when they needed them.
However nine completed comment cards reflected the
lower survey results above. The practice had action plans
in place to identify areas were they could improve access
and had increased the number of staff on duty each
morning to take calls.
Listening and learning from concerns and complaints
The practice had an effective system in place for handling
complaints and concerns.
• Its complaints policy and procedures were in line with
recognised guidance and contractual obligations for
GPs in England.
• The practice manager and deputy were the designated
responsible persons who handled complaints in the
practice.
• We saw that information was available to help patients
understand the complaints system
We looked at six complaints received in the last 12 months
and found that these were satisfactorily handled, dealt with
in a timely way, and with openness and transparency when
dealing with the complaint. Lessons were learnt from
concerns and complaints the practice had an ongoing
action plan to implement changes as a result of
complaints.
Are services responsive to people’s needs?
(for example, to feedback?)
Good
–––18
The Elms Surgery Quality Report This is auto-populated when the report is publishedOur findings
Vision and strategy
The practice had a clear vision to deliver high quality care
and promote good outcomes for patients.
• The practice had a mission statement and patient
charter which was displayed in the waiting areas and on
the practice website. Staff knew and understood the
values.
Governance arrangements
The practice had an overarching governance framework
which supported the delivery of the strategy and good
quality care. This outlined the structures and procedures in
place and ensured that:
• There was a clear staffing structure and that staff were
aware of their own roles and responsibilities
• Practice specific policies were implemented and were
available to all staff on shared drive.
• Some audits had been undertaken however, a
programme of continuous clinical and internal audit
was needed to monitor quality and to make
improvements
• There were robust arrangements for identifying,
recording and managing risks, issues and implementing
mitigating actions
Leadership and culture
The partners in the practice had the experience, capacity
and capability to run the practice and ensure high quality
care. They prioritise safe, high quality and compassionate
care. The partners were visible in the practice and staff told
us they were approachable and always took the time to
listen to all members of staff.
The provider was aware of and complied with the
requirements of the Duty of Candour. The partners
encouraged a culture of openness and honesty. The
practice had systems in place for knowing about notifiable
safety incidents.
When there were unexpected or unintended safety
incidents:
• The practice gave affected people reasonable support,
truthful information and a verbal and written apology.
• They kept written records of verbal interactions as well
as written correspondence.
There was a clear leadership structure in place and staff felt
supported by management.
• Staff told us the practice held regular team meetings
and we reviewed minutes of these meetings.
• Staff told us there was an open and family culture within
the practice and they had the opportunity to raise any
issues at team meetings and felt confident in doing so
and felt supported if they did.
• Staff said they felt respected, valued and supported,
particularly by the partners in the practice. All staff were
involved in discussions about how to run and develop
the practice, and the partners encouraged all members
of staff to identify opportunities to improve the service
delivered by the practice.
Seeking and acting on feedback from patients, the
public and staff
The practice encouraged and valued feedback from
patients, the public and staff. It proactively sought patients’
feedback and engaged patients in the delivery of the
service.
• The practice had gathered feedback from patients
through the virtual patient participation group (PPG)
and through surveys and complaints received.
• The practice encouraged patients to complete the NHS
Friends and Family Test and the collated results so far
had been consistently positive.
• There was an active PPG which met regularly, carried
out patient surveys and submitted proposals for
improvements to the practice management team. For
example, when issues about privacy in certain parts of
the practice, radio music was introduced to muffle
sound so that conversations could not be heard. Text
reminders for appointments had also been
implemented as a result of suggestions made to reduce
the number patients who failed to attend for
appointments.
• Staff told us they would not hesitate to give feedback
and discuss any concerns or issues with colleagues and
management either at practice meetings or whenever it
was required. Staff told us they felt involved and
engaged to improve how the practice was run.
Are services well-led?
(for example, are they well-managed and do senior leaders listen, learn
and take appropriate action)
Good
–––19
The Elms Surgery Quality Report This is auto-populated when the report is published