Care Quality Commission€¦ · Care Quality Commission Inspection Evidence Table St Johns Surgery (1-567953435) Inspection date: 22 October 2018 Date of data download: 04 September

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Care Quality Commission

Inspection Evidence Table

St Johns Surgery (1-567953435)

Inspection date: 22 October 2018

Date of data download: 04 September 2018

Please note: Any Quality Outcomes Framework (QOF) data relates to 2016/17.

Safe

Safety systems and processes

Safeguarding Y/N

There was a lead member of staff for safeguarding processes and procedures. Yes

Safety and safeguarding systems, processes and practices were developed, implemented and communicated to staff.

Yes

Policies were in place covering adult and child safeguarding. Yes

Policies were updated and reviewed and accessible to all staff. Yes

Partners and staff were trained to appropriate levels for their role (for example level three for GPs, including locum GPs)

Yes

Information about patients at risk was shared with other agencies in a timely way. Yes

Systems were in place to highlight vulnerable patients on record. There was a risk register of specific patients

Yes

Disclosure and Barring Service checks were undertaken where required Yes

Explanation of any ‘No’ answers:

2

Recruitment Systems Y/N

Recruitment checks were carried out in accordance with regulations (including for agency staff and locums).

Yes

Staff vaccination was maintained in line with current Public Health England (PHE) guidance and if relevant to role.

Yes

Systems were in place to ensure the registration of clinical staff (including nurses and pharmacists) was checked and regularly monitored.

Yes

Staff who require medical indemnity insurance had it in place Yes

Explanation of any answers:

3

Safety Records Y/N

There was a record of portable appliance testing or visual inspection by a competent person

Date of last inspection/Test: 7 April 2018 for St Johns Surgery and 29 March 2018 for the branch surgery.

Yes

There was a record of equipment calibration

Date of last calibration: 20 April 2018 for St Johns Surgery and 27 April for the branch surgery.

Yes

Risk assessments were in place for any storage of hazardous substances e.g. liquid nitrogen, storage of chemicals

Yes

Fire procedure in place Yes

Fire extinguisher checks Yes

Fire drills and logs Yes

Fire alarm checks Yes

Fire training for staff Yes

Fire marshals Yes

Fire risk assessment

Date of completion: 7 October 2016 Yes

Actions were identified and completed.

When the fire evacuation of the building was carried out it was noted that no-one reported to the firemen that the other tenants were safe (there was a nursery in the same building as the practice). This was rectified following the inspection.

Following the incident at Grenfell Tower the practice has undertaken additional safety checks of the building together with BHI parkside who undertake the maintenance of the building. One of the things identified was that when contractors who came into the building to drill a hole in the wall fire smoke could potentially pass through the building if a fire occurred. This was being addressed as a building wise initiative.

Yes

Additional observations:

Health and safety

Premises/security risk assessment?

Date of last assessment: October 2016

Legionella Risk Assessment: 3 July 2018

Yes

4

Health and safety risk assessment and actions

Date of last assessment: October 2018 – no further action was required as everything was in order.

Additional comments:

5

Infection control Y/N

Risk assessment and policy in place

Date of last infection control audit: 27 September 2018

The practice acted on any issues identified

A number of issues were identified which the practice has acted on:

- Ensuring that sharps bins were correctly sized, labelled and used correctly.

- De-cluttering desks and work surfaces before the end of the day so that the cleaners could clean desks and work surfaces.

Yes

The arrangements for managing waste and clinical specimens kept people safe? Yes

Explanation of any answers: External company – NHS England have the contract for infection prevention and control.

6

Risks to patients

Question Y/N

There was an effective approach to managing staff absences and busy periods. Yes

Comprehensive risk assessments were carried out for patients. Yes

Risk management plans were developed in line with national guidance. Yes

Staff knew how to respond to emergency situations. Yes

Receptionists were aware of actions to take if they encountered a deteriorating or acutely unwell patient and had been given guidance on identifying such patients.

Yes

In addition, there was a process in the practice for urgent clinician review of such patients. Yes

The practice had equipment available to enable assessment of patients with presumed sepsis.

Yes

There were systems in place to enable the assessment of patients with presumed sepsis in line with National Institute for Health and Care Excellence (NICE) guidance.

Yes


Information to deliver safe care and treatment

Question Y/N

Individual care records, including clinical data, were written and managed in line with current guidance and relevant legislation.

Yes

Referral letters contained specific information to allow appropriate and timely referrals. Yes

Referrals to specialist services were documented. Yes

The practice had a documented approach to the management of test results and this was managed in a timely manner.

Yes

The practice demonstrated that when patients use multiple services, all the information needed for their ongoing care was shared appropriately and in line with relevant protocols.

Yes


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Appropriate and safe use of medicines

Indicator Practice CCG

average

England

average

England

comparison

Number of antibacterial prescription items prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU) (01/07/2017 to 30/06/2018) NHS Business Service Authority -

NHSBSA)

1.09 1.05 0.95 Comparable with other practices

The number of prescription items for

co-amoxiclav, cephalosporins and quinolones

as a percentage of the total number of

prescription items for selected antibacterial

drugs (BNF 5.1 sub-set). (01/07/2017 to

30/06/2018) (NHSBSA)

8.4% 8.6% 8.7% Comparable with other practices

Medicines Management Y/N

The practice had a process and clear audit trail for the management of information about changes to a patient’s medicines including changes made by other services.

Yes

Staff had the appropriate authorisations in place to administer medicines (including Patient Group Directions or Patient Specific Directions).

Yes

Prescriptions (pads and computer prescription paper) were kept securely and monitored. Yes

There was a process for the management of medicines including high risk medicines (for example, warfarin, methotrexate and lithium) with appropriate monitoring and clinical review prior to prescribing.

Yes

The practice monitored the prescribing of controlled drugs. (For example audits for unusual prescribing, quantities, dose, formulations and strength).

Yes

There were arrangements for raising concerns around controlled drugs with the NHS England Area Team Controlled Drugs Accountable Officer.

Yes

If the practice had controlled drugs on the premises there were systems for the safe ordering, checks on receipt, storage, administration, balance checks and disposal of these medicines in line with national guidance.

Yes

Up to date local prescribing guidelines were in use. Yes

Clinical staff were able to access a local microbiologist for advice. Yes

For remote or online prescribing there were effective protocols in place for identifying and verifying the patient in line with General Medical Council guidance.

NA

The practice held appropriate emergency medicines and risk assessments were in place to determine the range of medicines held.

Yes

The practice had arrangements to monitor the stock levels and expiry dates of emergency medicines/medical gases.

Yes

There was medical oxygen on site. Yes

The practice had a defibrillator. Yes

8

Both were checked regularly and this was recorded. Yes

Medicines that required refrigeration were appropriately stored, monitored and transported in line with PHE guidance to ensure they remained safe and effective in use.

Yes


9

Dispensing practices only Y/N

There was a GP responsible for providing effective leadership for the dispensary. Yes

Access to the dispensary was restricted to authorised staff only. Yes

The practice had clear Standard Operating Procedures for their dispensary staff to follow. Yes

The practice had a clear system of monitoring compliance with Standard Operating Procedures.

Yes

Prescriptions were signed before medicines were dispensed and handed out to patents. There was a risk assessment or surgery policy for exceptions such as acute prescriptions.

Yes

If the dispensary provided medicines in weekly or monthly blister packs (Monitored Dosage Systems) there were systems to ensure appropriate and correct information on medicines were supplied with the pack.

NA

Staff were aware of medicines that were not suitable for inclusion in such packs and had access to appropriate resources to identify these medicines. Where such medicines had been identified staff provided alternative options that kept patients safe.

NA

The home delivery service, or remote collection points, had been risk assessed (including for safety, security, confidentiality and traceability).

NA

Information was provided to patients in accessible formats e.g. large print labels, braille labels, information in variety of languages etc.

Yes

There was the facility for dispensers to speak confidentially to patients and protocols described process for referral to clinicians.

Yes

Explanation of any answers

10

Track record on safety and lessons learned and improvements made

Significant events Y/N

There was a system for recording and acting on significant events Yes

Staff understood how to report incidents both internally and externally Yes

There was evidence of learning and dissemination of information Yes

Number of events recorded in last 12 months. 12

Number of events that required action 12

Example(s) of significant events recorded and actions by the practice;

Event Specific action taken

A home visit was booked on the wrong day for the patient.

As a result of this the practice changed their procedure and home visit forms were now placed in the GP’s tray. The practice also introduced a new contact slip to include telephone numbers and emergency contact details to prevent this from happening again.

An examination of an elderly patient revealed that they had a particular device fitted but did not recollect this had been fitted and therefore had not come in to have it removed.

The practice introduced a recall system for patients who had this device fitted as they felt there might be other patients with memory issues who might be in the same situation.

A patient called the surgery to say that she had received an appointment from an optician having been referred by a GP. There were two patients with the same name and the wrong one had been booked into the appointment with the GP.

The notes of both patients were corrected following this incident. The optician was provided with details of the correct patients. A warning was put on the patient records to alert staff that two patients had the same name.

Safety Alerts Y/N

There was a system for recording and acting on safety alerts Yes

Staff understand how to deal with alerts Yes

Comments on systems in place: Alerts were received by the Practice Manager and forwarded to one of the three Practice Pharmacists for distribution and action. The practice manager maintained an alert log which included details of receipt, type of alert, action taken and completion date.

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We reviewed the log during the inspection and saw that the practice took action when required. For example, we saw an alert about a shortage of EpiPens. The practice contacted affected patients and advised them what they should do.

12

Effective

Effective needs assessment, care and treatment

Prescribing

Indicator Practice

performance

CCG

average

England

average

England

comparison

Average daily quantity of Hypnotics prescribed per Specific Therapeutic group Age-sex Related Prescribing Unit (STAR PU) (01/07/2017 to

30/06/2018) (NHSBSA)

0.56 0.72 0.83 Comparable with other practices

People with long-term conditions

Diabetes Indicators

Indicator Practice

performance

CCG

average

England

average

England

comparison

The percentage of patients with diabetes, on the

register, in whom the last IFCC-HbA1c is 64

mmol/mol or less in the preceding 12 months

(01/04/2016 to 31/03/2017) (QOF)


QOF Exceptions

Practice Exception rate

(number of exceptions)

CCG Exception

rate

England Exception

rate

5.7% (43) 8.7% 12.4%

Indicator Practice

performance

CCG

average

England

average

England

comparison


register, in whom the last blood pressure reading

(measured in the preceding 12 months) is

140/80 mmHg or less (01/04/2016 to 31/03/2017)

(QOF)


QOF Exceptions



CCG Exception

rate

England Exception

rate

4.1% (31) 6.7% 9.3%

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Indicator Practice

performance

CCG

average

England

average

England

comparison


register, whose last measured total cholesterol

(measured within the preceding 12 months) is 5

mmol/l or less (01/04/2016 to 31/03/2017) (QOF)


QOF Exceptions



CCG Exception

rate

England Exception

rate

11.5% (87) 12.4% 13.3%

Other long term conditions


average

England

average

England

comparison

The percentage of patients with asthma, on the

register, who have had an asthma review in the

preceding 12 months that includes an

assessment of asthma control using the 3 RCP

questions, NICE 2011 menu ID: NM23

(01/04/2016 to 31/03/2017) (QOF)


QOF Exceptions



CCG Exception

rate

England Exception

rate

1.4% (12) 4.8% 7.7%


average

England

average

England

comparison

The percentage of patients with COPD who have

had a review, undertaken by a healthcare

professional, including an assessment of

breathlessness using the Medical Research

Council dyspnoea scale in the preceding 12

months (01/04/2016 to 31/03/2017) (QOF)


QOF Exceptions



CCG Exception

rate

England Exception

rate

2.6% (4) 8.4% 11.4%

14


average

England

average

England

comparison

The percentage of patients with hypertension in

whom the last blood pressure reading measured

in the preceding 12 months is 150/90mmHg or

less (01/04/2016 to 31/03/2017) (QOF)

90.8% 84.1% 83.4% Variation (positive)

QOF Exceptions



CCG Exception

rate

England Exception

rate

2.2% (34) 2.5% 4.0%


average

England

average

England

comparison

In those patients with atrial fibrillation with a

record of a CHA2DS2-VASc score of 2 or more,

the percentage of patients who are currently

treated with anti-coagulation drug therapy

(01/04/2016 to 31/03/2017) (QOF)


QOF Exceptions



CCG Exception

rate

England Exception

rate

8.9% (16) 12.2% 8.2%

Any additional evidence or comments

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Families, children and young people

Child Immunisation

Indicator Numerator Denominator Practice

%

Comparison

to WHO

target

The percentage of children aged 1 who have

completed a primary course of immunisation

for Diphtheria, Tetanus, Polio, Pertussis,

Haemophilus influenza type b (Hib)((i.e. three

doses of DTaP/IPV/Hib) (01/04/2016 to

31/03/2017)(NHS England)

134 138 97.1%

Met 95% WHO

based target

(significant

variation positive)


received their booster immunisation for

Pneumococcal infection (i.e. received

Pneumococcal booster) (PCV booster)

(01/04/2016 to 31/03/2017) (NHS England)

164 170 96.5%

Met 95% WHO

based target

(significant

variation positive)


received their immunisation for Haemophilus

influenza type b (Hib) and Meningitis C

(MenC) (i.e. received Hib/MenC booster)

(01/04/2016 to 31/03/2017) (NHS England)

164 170 96.5%

Met 95% WHO

based target

(significant

variation positive)


received immunisation for measles, mumps

and rubella (one dose of MMR) (01/04/2016 to

31/03/2017) (NHS England)

164 170 96.5%

Met 95% WHO

based target

(significant

variation positive)


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Working age people (including those recently retired and students)

Cancer Indicators


average

England

average

England

comparison

The percentage of women eligible for cervical

cancer screening at a given point in time who

were screened adequately within a specified

period (within 3.5 years for women aged 25 to 49,

and within 5.5 years for women aged 50 to 64)

(01/04/2016 to 31/03/2017) (Public Health England)


Females, 50-70, screened for breast cancer in last

36 months (3 year coverage, %) (PHE)

72.6% 75.9% 70.3% N/A

Persons, 60-69, screened for bowel cancer in last

30 months (2.5 year coverage, %)(PHE)

60.6% 58.9% 54.6% N/A

The percentage of patients with cancer,

diagnosed within the preceding 15 months, who

have a patient review recorded as occurring within

6 months of the date of diagnosis. (PHE)

78.3% 78.4% 71.2% N/A

Number of new cancer cases treated (Detection

rate: % of which resulted from a two week wait

(TWW) referral) (01/04/2016 to 31/03/2017) (PHE)



17

People experiencing poor mental health (including people with dementia)

Mental Health Indicators


average

England

average

England

comparison

The percentage of patients with schizophrenia,

bipolar affective disorder and other psychoses

who have a comprehensive, agreed care plan

documented in the record, in the preceding 12

months (01/04/2016 to 31/03/2017) (QOF)


QOF Exceptions



CCG Exception

rate

England Exception

rate

13.3% (10) 9.3% 12.5%


average

England

average

England

comparison

The percentage of patients with schizophrenia,

bipolar affective disorder and other psychoses

whose alcohol consumption has been recorded

in the preceding 12 months (01/04/2016 to

31/03/2017) (QOF)


QOF Exceptions



CCG Exception

rate

England Exception

rate

13.3% (10) 6.9% 10.3%


average

England

average

England

comparison

The percentage of patients diagnosed with

dementia whose care plan has been reviewed in

a face-to-face review in the preceding 12 months

(01/04/2016 to 31/03/2017) (QOF)


QOF Exceptions



CCG Exception

rate

England Exception

rate

7.6% (6) 4.8% 6.8%


Monitoring care and treatment


average

England

average

Overall QOF score (out of maximum 559) 554 550 539

Overall QOF exception reporting (all domains) 4.0% 4.2% 5.7%

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Coordinating care and treatment

Indicator Y/N

The contractor has regular (at least 3 monthly) multidisciplinary case review meetings where all

patients on the palliative care register are discussed (01/04/2016 to 31/03/2017) (QOF)

Yes

Helping patients to live healthier lives


average

England

average

England

comparison

The percentage of patients with any or any

combination of the following conditions: CHD,

PAD, stroke or TIA, hypertension, diabetes,

COPD, CKD, asthma, schizophrenia, bipolar

affective disorder or other psychoses whose

notes record smoking status in the preceding 12

months (01/04/2016 to 31/03/2017) (QOF)


QOF Exceptions



CCG Exception

rate

England Exception

rate

0.5% (13) 0.4% 0.8%

Consent to care and treatment

Description of how the practice monitors that consent is sought appropriately

During the inspection we reviewed copies of consent forms for minor surgery and were assured

consent was taken in line with current guidelines.

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Caring

Kindness, respect and compassion

CQC comments cards

Total comments cards received 40

Number of CQC comments received which were positive about the service 38

Number of comments cards received which were mixed about the service 2

Number of CQC comments received which were negative about the service 0

Examples of feedback received:

Source Feedback

For example, comments cards, NHS Choices

On NHS Choices there were four reviews about the practice. Three out of four of the reviews gave the practice a five-star rating.

One patient commented that their child had been unwell overnight. They were promptly seen when they bought the child to the surgery the following morning and treatment commenced.

Another patient stated that reception staff were friendly and helpful. They were also pleased about the continuity of seeing the same GP.

Another patient stated that they have been in the practice for over 20 years and has always been treated with dignity and respect.

One of the reviews gave the practice a one-star rating. They commented that they were happy with the overall service of the practice however they have found it difficult to obtain appointments.

The CQC comment cards were very positive about the service provided by the practice and the branch surgery. Patients commented on the high quality of care and how accessible the doctors were. Many patients commented that they could get appointments on the same day.

Two patients gave mixed reviews and said they were happy to be able to obtain same day appointments at the practice but felt they did not always get to see the GP of their choice for same day appointments.

20

Friends and Family Test

(extremely likely or likely to recommend the practice to Friends and Family)

September: 94% (396 replies out of 422)

August: 93% (386 replies out of 415)

July: 96% (174 replies out of 181)

June: 100% (5 replies out of 5)

May: No responses

April: 92% (361 replies out of 392)

March: 95% (417 replies out of 439)

There was no collection in May whilst the Practice sought clarification regarding the implications of General Data Protection Regulation on the use of text messaging.

21

National GP Survey results

Practice

population size Surveys sent out Surveys returned

Survey

Response rate%

% of practice

population

13,623 239 117 48.95% 1%


average

England

average

England

comparison

The percentage of respondents to the GP patient

survey who stated that they would definitely or

probably recommend their GP surgery to

someone who has just moved to the local area

(01/01/2017 to 31/03/2017)

99.3% 81.1% 78.9% Significant Variation (positive)


survey who stated that the last time they saw or

spoke to a GP,

the GP was good or very good at listening to them

(01/01/2017 to 31/03/2017)



survey who answered positively to question 22

“Did you have confidence and trust in the GP you

saw or spoke to?” (01/01/2017 to 31/03/2017)




spoke to a GP, the GP was good or very good at

treating them with care and concern (01/01/2017 to

31/03/2017)




spoke to a nurse, the nurse was good or

very good at listening to them (01/01/2017 to

31/03/2017)




spoke to a nurse, the nurse was good or very good

at treating them with care and concern (01/01/2017

to 31/03/2017)



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Question Y/N

The practice carries out its own patient survey/patient feedback exercises. No

Any additional evidence

During the inspection the GPs shared some of the positive feedback they had received from the survey. Patients commented that they felt involved in their care and that doctors were approachable and caring. Patients also commented how easy it was to book an appointment with the practice.

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Involvement in decisions about care and treatment

Examples of feedback received:

Source Feedback

Patient Feedback

During the inspection the practice shared letters and emails they had received from patients. A few patients, who had joined the practice as temporary patients whilst visiting family, were positive about the care they had received.



average

England

average

England

comparison




explaining tests and treatments (01/01/2017 to

31/03/2017)





involving them in decisions about their care

(01/01/2017 to 31/03/2017)




spoke to a nurse, the nurse was good or very

good at explaining tests and treatments

(01/01/2017 to 31/03/2017)

96.8% 91.5% 89.9% Variation (positive)



spoke to a nurse, the nurse was good or very good

at involving them in decisions about their care

(01/01/2017 to 31/03/2017)


Any additional evidence or comments We spoke with the managers of the care homes the GPs looked after. The feedback was very positive. The care home managers felt that the GPs responded to them in a timely manner and were accessible.

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Question Y/N

Interpretation services were available for patients who did not have English as a first language.

Yes

Patient information leaflets and notices were available in the patient waiting area which told patients how to access support groups and organisations.

Yes

Information leaflets were available in easy read format. Yes

Information about support groups was available on the practice website. Yes

Carers Narrative

Percentage and number of carers identified

311 patients were carers which was 2% of the practice list.

How the practice supports carers

Carers were offered flu vaccines. The practice displayed support information in the waiting area for carers.

How the practice supports recently bereaved patients

There was no set protocol. The practice assessed the situation on a patient by patient basis. If the GPs knew the families well they would visit, otherwise they wrote to the families. If GPs had concerns about bereaved families they offered support information to them.

25

Privacy and dignity

Question Y/N

Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations, investigations and treatments.

Yes

Narrative

Arrangements to ensure confidentiality at the reception desk

We saw curtains in consulting rooms during our interviews with GPs and the nurse. Chaperone posters were displayed in consulting rooms and the waiting room.

Question Y/N

Consultation and treatment room doors were closed during consultations. Yes

A private room was available if patients were distressed or wanted to discuss sensitive issues.

Yes

Examples of specific feedback received:

Source Feedback

Interviews with administrative staff

Administrative staff informed us they would offer a private room to a patient if a patient was visibly upset in the reception area. They shared an example of when this happened.

26

Responsive

Responding to and meeting people’s needs

Practice Opening Times

Day Time

Monday 7am to 8pm

Tuesday 8am to 6.30pm

Wednesday 7am to 6.30pm

Thursday 8am to 6.30pm

Friday 8am to 6.30pm

Appointments available

During these times

Extended hours opening

Two Saturdays per month 8am to 11am

Branch Surgery opening hours

Monday 8am to 12.30pm

Tuesday 7.30am to 12.30pm

Wednesday 8am to 12.30pm

Thursday 8am to 12.30pm

Friday 8am to 12.30pm

Home visits Y/N

The practice had a system to assess whether a home visit was clinically necessary and the urgency of the need for medical attention

Yes

If yes, describe how this was done

The receptionists booked home visit slots on the practice computer system. Home visits were triaged and allocated by the on-call doctor.

27

Timely access to the service


Practice

population size Surveys sent out Surveys returned

Survey

Response rate%

% of practice

population

13,623 239 117 48.95% 1%


average England average

England comparison


survey who were ‘Very satisfied’ or ‘Fairly

satisfied’ with their GP practice opening hours

(01/01/2017 to 31/03/2017)



survey who gave a positive answer to ‘Generally,

how easy is it to get through to someone at your

GP surgery on the phone?’ (01/01/2017 to

31/03/2017)



survey who stated that the last time they wanted

to see or speak to a GP or nurse from their GP

surgery they were able to get an appointment

(01/01/2017 to 31/03/2017)



survey who responded positively to the overall

experience of

making an appointment (01/01/2017 to 31/03/2017)



28

Listening and learning from complaints received

Complaints Y/N

Number of complaints received in the last year. 12

Number of complaints we examined 12

Number of complaints we examined that were satisfactorily handled in a timely way 12

Number of complaints referred to the Parliamentary and Health Service Ombudsman 0

Additional comments:

Examples of the practice’s response to complaints

Complaints were actioned in accordance with the practice’s complaints policy.

We saw an example of a complaint made by a patient who had come to the practice for a twenty-minute appointment due to the treatment they required. The GP had thought the patient was twenty minutes late and the patient was not happy about this so subsequently complained to the practice manager. Upon investigation it was noted that there had been an error and the patient was only a few minutes late so the practice sent out a letter of apology to the patient.

We saw another example where a patient had written a letter of complaint as they were unhappy a medicine had not been prescribed to them by the GP which they had requested. The GP wrote a letter explaining that the medicine was contra-indicated due to the risk factors of this patient. This patient went on to escalate their complaint to NHS England. NHS England felt that the complaint had been handled appropriately and took no further action.

29

Well-led

Leadership capacity and capability

Examples of how leadership, capacity and capability were demonstrated by the practice

There was regular communication at the practice which demonstrated clear leadership:

• Weekly meetings with the GP partners, practice manager, practice nurse and reception manager.

• Monthly staff meetings with the practice manager, administration team, reception and nursing teams.

• Monthly End of Life meetings with one of the GP partners, the Macmillan nurses and district nurses.

• Regular significant events meetings. Usually the practice waited until they had approximately six significant events and had a meeting to discuss them. In the meantime, they would discuss significant events in the weekly partners’ meetings and monthly staff meetings.

• Quarterly meetings with partners, salaried GPs and GP Registrars.

• Educational meetings as required.

• Safeguarding meetings were held every six to eight weeks with the safeguarding lead and health visitors.

• Quarterly meetings with the Clinical Commissioning Group (CCG) and the GPs looking after patients on the violent and aggressive scheme.

• Extended access meetings as required. This practice was the lead provider for extended access in Redditch and Bromsgrove.

• Meeting with the Health & Care Trust regarding the Princess of Wales community hospital as required. The practice was the lead provider for the provision of GP medical cover.

• Monthly meetings for promoting clinical excellence referral meetings with the lead GP and practice manager.

• Monthly promoting clinical excellence prescribing meeting with the lead GP and a pharmacist.

• Monthly alliance board meetings with one of the GP partners as the Neighbourhood Team Representative for the Bromsgrove Practices.

• Monthly neighbourhood team meetings with one of the GP partners.


Vision and strategy

Practice Vision and values

The practice vision was to deliver holistic care in partnership with patients, relatives and carers. In addition, the practice wanted to encourage patient engagement in making better lifestyle and health choices across the whole health and social care spectrum. The practice aimed to provide a response service which enabled medical and nursing staff to provide continuity and support to its patients.

30

Culture

Examples that demonstrate that the practice has a culture of high-quality sustainable care

Violent Patient Scheme: Two of the GP partners provided clinical leadership and delivery of the Tier 2 violent patient scheme for the county. The practice volunteered to sign up to this scheme with the CCG as they wanted to help vulnerable patients and saw this as an opportunity to upskill themselves. There were 57 patients on the scheme at the time of the inspection. The two GPs who ran this service for the practice had both worked in prisons previously so decided to take this on. The scheme was for patients who had been removed from their own patient list because of violent or aggressive behaviour. The practice would receive an incident form from NHS England with the referral details.

If the patient had been allocated to the scheme for a breakdown in communication then they would be reallocated to a different GP practice. Other patients were reviewed after a year. If the patient had been seen by the GP in the year a decision would be made as to whether they should remain on the scheme or were able to go back to their own GP. The two GPs who looked after patients on the scheme would do so on the ground floor of the practice. They would alert security to stay around the room if required. Quite often the GPs would help to rehabilitate the patients to be back in the practice. Sometimes the GPs would see patients on the scheme in hospital or homeless hostels. Community Hospital GP Cover: The practice looked after a ward in the Princess of Wales community hospital a mile away called Red Ward . There were 12 beds in Red Ward for patients. The types of patients looked after by the practice in Red Ward were patients who were often frail and elderly though some younger patients with predominantly movement related disabilities were also treated on the ward. For example patients with Multiple Sclerosis or a urinary tract infection leading to decreased mobililty. The older patients were usually patients with infections and frailty or immobility problems. Sometimes the practice also dealt with more unusual diagnoses such as patients with side effects from chemotherapy treatment such as constipation or patients who were unwell due to sodium deficiency. The practice have also looked after a number of patients with exacerbations of chronic heart failure and Parkinsons Disease. The practice shared examples of patients with fractures they had looked after on Red Ward. This service was accessible by GPs in surrounding practices by calling a dedicated number to make the referral. Therefore patients from other practices benefited from this service. The patients were usually discharged from Red Ward within a week. One of the GPs went to A&E three days a week to identify patients who could be treated at Red Ward. Patients were given the choice of moving to Red Ward or remaining in the acute hospital. Physiotherapists and occupational therapists also saw patients on Red Ward. The GPs went to the other wards in the community hospital to see if there were patients that could be managed on Red Ward. If this was the case then patients would be moved here. This resulted in fewer unplanned acute admissions. This figure was currently at 9% of the practice population which was lower than other practices in the area. The practice had carried out an audit over a two month period which showed 66 referrals made to Red

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Ward. Out of the 66 patients reviewed 55 of the patients had prevented an acute admission. Minor Surgery: The practice carried out minor surgery for their own patients and for patients of neighbouring practices hence reducing referral rates to secondary care. Clinics: The practice ran one stop vascular clinics where the reviews were done and the patients could have their tests, see a nurse and a GP all in one go. At the time of the inspection the practice informed us of their plans to run diabetic clinics in the same way with HCAs, nurses and GPs present similar to what a patient would experience in hospital outpatients. They were moving towards the one-stop service.

Examples of feedback from staff or other evidence about working at the practice

Source Feedback

Conversations with non-clinical staff

During the inspection we spoke with four of the administrative staff who worked at the practice. They informed us that the practice manager and GPs were very supportive. They all enjoyed working at the practice and were proud to be there.

Feedback from Registrars at the practice

One of the GP trainees at the practice commented on how supportive they found the GPs. They said the GPs were friendly and approachable. The GP trainee had a named supervisor and each day discussed patients with the named supervisor. They had a thorough induction to the practice and were able to shadow GPs, nurses and pharmacists as part of the induction.


There was an emphasis on training and developing at the practice. For example: One member of the administrative staff had completed their business administration NVQ. This enabled them to move from a reception role and become a document handling administrator. Another member of the team who was currently a junior dispenser was doing their NVQ2 as a dispenser alongside doing the pharmacy skills course. They were due to finish in April but as they were progressing so well were likely to have completed by the end of the year. Another secretary had a particular interest in finance. They undertook some extra training sponsored by the practice and were now in a finance role.

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Governance arrangements

Examples of structures, processes and systems in place to support the delivery of good

quality and sustainable care.

Practice specific policies Incident management procedure – June 2014. Medical emergency procedure – November 2014. Disaster handling and business continuity plan – October 2018. Clinical Supervision policy – October 2018 Clinical Governance Policy- October 2018.

Y/N

Staff were able to describe the governance arrangements Yes

Staff were clear on their roles and responsibilities Yes

Managing risks, issues and performance

Major incident planning Y/N

Major incident plan in place Yes

Staff trained in preparation for major incident Yes

Examples of actions taken to address risks identified within the practice

Risk Example of risk management activities

Interviews with staff The induction process was thorough and staff had the opportunity to shadow colleagues.

Risk assessments The practice had a comprehensive range of risk assessments that covered all areas of the practice premises and staff working conditions. These were regularly checked and updated as needed.

Staff files Staff were offered an annual appraisal to assess learning needs and were given protected time to undertake training.

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Appropriate and accurate information

Question Y/N

Staff whose responsibilities include making statutory notifications understood what this entails.

Yes

Engagement with patients, the public, staff and external partners

Feedback from Patient Participation Group (PPG);

Feedback

We spoke to a member of the PPG before inspecting the practice. The member of the PPG explained that they and their partner had been patients at the practice for a number of years. They described the care they received as exceptional. The member of the PPG confirmed that they will be working more closely with the practice to help to develop a newsletter and to have more face to face meetings rather than the virtual PPG that they now have. They felt supported by the practice.

Continuous improvement and innovation

Examples of improvements demonstrated as a result of clinical audits in past two years

Audit area Improvement

Gestational Diabetes

The aim of the audit was to look at how good the practice was at following women up with a history of gestational diabetes. The practice only had 22 patients with a documented history of gestational diabetes which seemed like a small number given the 13,600 practice list size.

It was agreed that patients with gestational diabetes would be checked for diabetes at the six week postnatal check. If the postnatal test was normal they would be checked again in 12 months. Diet and lifestyle advice would be given to the patient and they would be asked to report any symptoms of diabetes. If the test came back as abnormal they would see the GP with a special interest in diabetes in the diabetic clinic. A year later this was re-audited. This time 50 patients were identified. Of the 50 patients two patients had gone on to develop diabetes and 10 patients were in the ‘pre-diabetic’ range. The practice was pleased to see a big improvement in their coding and following up of patients with gestational diabetes.

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Methotrexate audit

The practice carried out an audit to review patients taking methotrexate to ensure that they were being monitored in line with the updated guidelines from June 2017. The purpose of the audit was to minimise

unnecessary blood tests and the associated costs and to update patient records so that their monitoring requirements were readily visible. The audit findings showed that the all patients at the practice were prescribed 2.5mg tablets with the exception of one patient who was on weekly injections. Most of the patients had been on a stable dose for at least six weeks, there was only one patient who was initiated on methotrexate by the practice under instruction of the dermatologist, this is not in line with the shared care arrangements and a breech form was completed for this. There were certain aspects of the blood tests that needed to be checked at least every 12 months, but upon doing the audit the practice realised that most patients had theirs checked each time they attended for a blood test. They realised this could be reduced to six monthly. Following this the practice ensured the audit findings were discussed at a practice meeting. They obtained shared care agreements from secondary care when a patient was initiated on methotrexate.


In total the practice had carried out nine audits: Gestational Diabetes – July 2015 and October 2018 Methotrexate Monitoring and Prescribing – March and October 2018 Minor Surgery – Reviews carried out in July 2017 and August 2018 Infection Control – April 2018 Audit of Patients taking Direct Acting Oral Anticoagulants (DOAC) – August 2018 Audit of Women of Childbearing Age taking Sodium Valproate – August 2017 Minor Surgery Extended Access Learning Disabilities

Notes: CQC GP Insight

GP Insight assesses a practice's data against all the other practices in England. We assess relative performance for the majority of indicators using a “z-score”

(this tells us the number of standard deviations from the mean the data point is), giving us a statistical measurement of a practice's performance in relation to

the England average. We highlight practices which significantly vary from the England average (in either a positive or negative direction). We consider that

z-scores which are higher than +2 or lower than -2 are at significant levels, warranting further enquiry. Using this technique we can be 95% confident that the

practices performance is genuinely different from the average. It is important to note that a number of factors can affect the Z score for a practice, for example

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a small denominator or the distribution of the data. This means that there will be cases where a practice’s data looks quite different to the average, but still

shows as comparable, as we do not have enough confidence that the difference is genuine. There may also be cases where a practice’s data looks similar

across two indicators, but they are in different variation bands.

The percentage of practices which show variation depends on the distribution of the data for each indicator, but is typically around 10-15% of practices. The

practices which are not showing significant statistical variation are labelled as comparable to other practices.

N.B. Not all indicators in the evidence table are part of the GP insight set and those that aren’t will not have a variation band.

The following language is used for showing variation:

Variation Band Z-score threshold

1 Significant variation (positive) Z ≤-3

2 Variation (positive) -3 < Z ≤ -2

3 Comparable to other practices -2 < Z < 2

4 Variation (negative) 2 ≤ Z < 3

5 Significant variation (negative) Z ≥3

6 No data Null

Note: for the following indicators the variation bands are different:

• Child Immunisation indicators. These are scored against the World Health Organisation target of 95% rather than the England average.

It is important to note that z-scores are not a judgement in themselves, but will prompt further enquiry, as part of our ongoing monitoring of GP practices.

Guidance and Frequently Asked Questions on GP Insight can be found on the following link:

http://www.cqc.org.uk/what-we-do/how-we-use-information/monitoring-gp-practices

Glossary of terms used in the data.

• COPD: Chronic Obstructive Pulmonary Disease • PHE: Public Health England • QOF: Quality and Outcomes Framework (see https://qof.digital.nhs.uk/). • RCP: Royal College of Physicians. • STAR-PU: Specific Therapeutic Group Age-sex weightings Related Prescribing Units. These weighting allow more accurate and meaningful comparisons within a specific

therapeutic group by taking into account the types of people who will be receiving that treatment.( See NHS Choices for more details).

http://www.cqc.org.uk/what-we-do/how-we-use-information/monitoring-gp-practices

https://qof.digital.nhs.uk/

https://www.nhs.uk/Scorecard/Pages/IndicatorFacts.aspx?MetricId=443

Documents

Care Quality Commission€¦ · Care Quality Commission Inspection Evidence Table St Johns Surgery (1-567953435) Inspection date: 22 October 2018 Date of data download: 04 September