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The Elms Practice
 The Elms Practice

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

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Contents

Summary of this inspection

Page

Overall summary

2

The five questions we ask and what we found

4

The six population groups and what we found

6

What people who use the service say

9

Areas for improvement

9

Outstanding practice

9

Detailed findings from this inspection

Our inspection team

10

Background to The Elms Surgery

10

Why we carried out this inspection

10

How we carried out this inspection

10

Detailed findings

12

Overall 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

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• 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

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The 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

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• 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

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The 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

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• 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

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• 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

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What 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

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Our 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

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• 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

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Our 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

–––

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employment. 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

–––

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Our 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

–––

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• 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

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Our 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

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• 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

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Our 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

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Our 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

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