Pinfold Medical Practice NewApproachComprehensive … · 9 Pinfold Medical Practice Quality Report 19/11/2015. Wealsolookedathowwellservicesareprovidedfor specificgroupsofpeopleandwhatgoodcarelookslikefor

This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe 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 –––

PinfPinfoldold MedicMedicalal PrPracticacticeeQuality Report

Loughborough Medical CentrePinfold GateLoughboroughLE11 1DQTel: 01509 274033/08444771881Website: www.pinfoldmedicalpractice.co.uk

Date of inspection visit: 20 May 2015Date of publication: 19/11/2015

1 Pinfold Medical Practice Quality Report 19/11/2015

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 3

The six population groups and what we found 5

What people who use the service say 8

Detailed findings from this inspectionOur inspection team 9

Background to Pinfold Medical Practice 9

Why we carried out this inspection 9

How we carried out this inspection 9

Detailed findings 11

Overall summaryLetter from the Chief Inspector of GeneralPracticeWe carried out an announced comprehensive inspectionat Pinfold Medical Practice on 20 May 2015. Overall thepractice is rated as good.

Specifically, we found the practice to be good forproviding well-led, effective, caring and responsiveservices. It was also good for providing services for olderpeople, people with long-term conditions, families,children and young people, working age people(including those recently retired and students), peopleliving in vulnerable circumstances, and peopleexperiencing poor mental health (including people withdementia).

Our key findings across all the areas we inspected were asfollows:

• Staff understood and fulfilled their responsibilities toraise concerns, and to report incidents and nearmisses. Information about safety was recorded,monitored, appropriately reviewed and addressed.

• Risks to patients were assessed and well managed.

• Patients’ needs were assessed and care was plannedand delivered following best practice guidance. Staffhad received training appropriate to their roles andany further training needs had been identified andplanned.

• Patients said they were treated with compassion,dignity and respect and they were involved in theircare and decisions about their treatment.

• Information about services and how to complain wasavailable and easy to understand.

• Urgent appointments and telephone consultationswere available on the same day but not necessarilywith patients having a choice of GP.

• The practice made good use of audits to improvepatient care.

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

• There was a clear leadership structure and staff feltsupported by management. The practice proactivelysought feedback from staff and patients which it actedon.

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

Summary of findings


The five questions we ask and what we foundWe always ask the following five questions of services.

Are services safe?The practice is rated as good for providing safe services. Staffunderstood and fulfilled their responsibilities to raise concerns, andto report incidents and near misses. Lessons were learned andcommunicated widely to support improvement. Information aboutsafety was recorded, monitored, appropriately reviewed andaddressed. Risks to patients were assessed and well managed.There were enough staff to keep patients safe.

Good –––

Are services effective?The practice is rated as good for providing effective services. Datashowed patient outcomes were at or above average for the locality.Staff referred to guidance from the National Institute for Health andCare Excellence and used it routinely. Patients’ needs were assessedand care was planned and delivered in line with current legislation.This included assessing capacity and promoting good health. Staffhad received training appropriate to their roles and any furthertraining needs had been identified and appropriate training plannedto meet these needs. There was evidence of appraisals and personaldevelopment plans for all staff. Staff worked with multidisciplinaryteams.

Good –––

Are services caring?The practice is rated as good for providing caring services. Datashowed that patients rated the practice higher than others forseveral aspects of care. Patients said they were treated withcompassion, dignity and respect and they were involved in decisionsabout their care and treatment. Information for patients about theservices available was easy to understand and accessible. We alsosaw that staff treated patients with kindness and respect, andmaintained confidentiality.

Good –––

Are services responsive to people’s needs?The practice is rated as good for providing responsive services. Itreviewed the needs of its local population and engaged with theNHS England Area Team and Clinical Commissioning Group (CCG) tosecure improvements to services where these were identified.Patients said they found it easy to make an appointment with anamed GP and that there was continuity of care, with urgentappointments available the same day. The practice had goodfacilities and was well equipped to treat patients and meet their

Good –––

Summary of findings


needs. Information about how to complain was available and easyto understand and evidence showed that the practice respondedquickly to issues raised. Learning from complaints was shared withstaff and other stakeholders.

Are services well-led?The practice is rated as good for being well-led. It had a clear visionand strategy. Staff were clear about the vision and theirresponsibilities in relation to this. There was a clear leadershipstructure and staff felt supported by management. The practice hada number of policies and procedures to govern activity and heldregular governance meetings. There were systems in place tomonitor and improve quality and identify risk. The practiceproactively sought feedback from staff and patients, which it actedon. The patient participation group (PPG) was active. Staff hadreceived inductions, regular performance reviews and attended staffmeetings and events. The practice carried out proactive successionplanning.

Good –––

Summary of findings


The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older peopleThe practice is rated as good for the care of older people. Thepractice offered proactive, personalised care to meet the needs ofthe older people in its population. It had developed a proactive caretemplate which it used to ensure patients’ needs were assessed andtreated appropriately. This included people requiring end of lifecare. Patients with complex needs were discussed with members ofthe multidisciplinary teams to ensure appropriate care andsupport was provided. It had a register of patients who were housebound. Their care was reviewed at least annually and a GP maderegular visits to them. The practice provided care and support to theresidents of two care homes with two visits each week to eachhome. The GP took summary care records with them to ensurecontinuity of care. Patients were offered flu and shinglesvaccinations with an active recall system if patients missed them.

Good –––

People with long term conditionsThe practice is rated as good for the care of people with long-termconditions. Nursing staff had lead roles in chronic diseasemanagement and were supported by nurse specialists who visit thepractice regularly. There were GP leads for diabetes, asthma, COPD,mental health, CKD and cardio vascular diseases. The practiceprovided a full anticoagulation service and improving the quality ofthat was a main focus.

The practice had developed a system it called integrated recallwhich was a streamlined approach to identifying patients whoneeded annual checks, organising these in a timely and effectiveway and ensuring all the results were available when the patient hadtheir annual review with the GP.

The practice kept a register of patients with more complex needsincluding those requiring end of life care. The named GP workedwith other health and care professionals to ensure care and supportwas provided. Relevant information was made available to out ofhours providers for those patients receiving end of life care to ensureappropriate treatment and support.

Good –––

Families, children and young peopleThe practice is rated as good for the care of families, children andyoung people. There were systems in place to identify looked afterchildren and children at risk. The practice monitored children andyoung people who had a high number of A&E attendances and Outof Hours service use. The practice offered postnatal and six-week

Good –––

Summary of findings


baby checks and a full in-house immunisation and vaccinationservice. The practice had an emergency care nurse and duty doctorand was able to provide on the day appointments which wasparticularly well used by parents with sick children.

Working age people (including those recently retired andstudents)The practice is rated as good for the care of working-age people(including those recently retired and students). Appointments andrepeat prescriptions could be arranged online. The firstappointment each day was 8.10am and the practice was open till8pm on Monday evenings. Daily telephone consultations wereavailable to help provide minimal disruption to working people. Afull contraceptive service including on the day eveningappointments with a specialist nurse was provided.

Flu vaccination clinics were provided on a Saturday to enableworking people to attend or to bring an elderly friend or relativewithout disruption. A fully trained travel nurse was available toadvise patients about travel vaccinations.

Good –––

People whose circumstances may make them vulnerableThe practice is rated as good for the care of people whosecircumstances may make them vulnerable. The practice hadidentified those of its patients who had a learning disability. Thesepatients were offered annual health check and longerappointments. The practice was working closely with the CCG on ascheme for homeless people. People could use the practice withouthaving a permanent address and were offered help and care withmental and physical health, vaccinations and where appropriate,substance misuse. It had also developed a good workingrelationship with a local project providing support for homelesspeople.

Staff knew how to recognise signs of abuse in vulnerable adults andchildren. Staff were aware of their responsibilities regardinginformation sharing, documentation of safeguarding concerns andhow to contact relevant agencies in and outside normal workinghours.

Good –––

People experiencing poor mental health (including peoplewith dementia)The practice is rated as good for the care of people experiencingpoor mental health (including people with dementia). The practicehad a register of people with mental illness which was reviewedannually and patients were offered an annual physical health checkwith a nurse which their GP would encourage them to attend. The

Good –––

Summary of findings


practice undertook dementia screening and offered check-ups tocarers. It worked closely with pharmacists to ensure that patientswith memory impairment had their medication prescribed safelyusing dossett boxes where appropriate.

There was an in-house mental health practitioner who providedcounselling and the practice also worked closely with secondarycare mental health services including the CRISIS team andcommunity psychiatric nurses. The practice provided information topatients experiencing poor mental health about support groups andvoluntary organisations. This was also on the practice website.

Staff had received training on how to care for people with mentalhealth needs and dementia.

Summary of findings


What people who use the service sayWe spoke with nine patients including two members ofthe patient participation group (PPG). The PPG is a groupof patients who work with the practice to highlightpatient concerns and work with it to improve the qualityof care and services.

We received 37 comment cards written by patients. Themajority of the comments were very positive. Patientsdescribed staff as friendly and very helpful and said thatthey were listened to and treated with respect and care.Several said they had recommended the practice tofriends and relatives. There were several commentsabout recent improvements with booking appointments.

The PPG had worked with the practice to design patientsurveys, the last of which took place in the autumn of2013. This received 433 responses which helped thepractice identify areas of concern, for example, the needto improve the premises and to explain how the practiceappointment system worked. Subsequently, the PPG

added a question to the Friends and Family test whichasked patients to ’name one thing we could do toimprove the service that we offer’. The practice has actedon the main areas suggested for improvement, whichincluded providing a local telephone number, a simplerappointment system and more receptionists at peaktimes. 92% of patients asked said they would definitelyrecommend the practice to their friends and family. Thiswas mirrored in the results from the national GP patientsurvey about the practice which showed that 90% ofrespondents said the last GP they saw or spoke with wasgood at involving them in decisions about their care but40% expressed frustration with the appointment andtelephone system.

We also spoke with representatives from care homeswhere residents were registered with the practice. Theytold us they were generally satisfied with the care andservice their residents received.

Summary of findings


Our inspection teamOur inspection team was led by:

a CQC lead inspector and the team included a GP, a GPpractice manager and another CQC inspector.

Background to PinfoldMedical PracticePinfold Medical Practice is a GP practice in the town ofLoughborough in Leicestershire. It provides a range ofprimary medical services to approximately 10,700 patients.The services are provided by seven GP partners, onesalaried GP and one long-term locum GP, three practicenurses (including a nurse practitioner) and three healthcaresupport workers. They are supported by a managementteam and reception and administration staff. The practiceprovides 48 GP sessions each week. There are four maleGPs and five female GPs. The practice is a training practice.It has registrars who are fully qualified doctors who aretraining to work in general practice and also medicalstudents who spend some time learning about generalpractice.

The practice is supported by local community health teamswhich provide maternity and health visitor services.

The practice occupies part of Loughborough MedicalCentre, which is a single-storey building with parkingavailable including designated disabled bays. There areautomatic doors and a wheelchair available for patient use.

The practice holds a General Medical Services (GMS)contract to deliver essential primary care services. It workswithin West Leicestershire Clinical Commissioning Group(CCG). A CCG is an NHS organisation that brings together

GPs and health professionals to take on commissioningresponsibilities for local services. We reviewed informationfrom the CCG and Public Health England which showedthat the practice population had deprivation levels similarto the average in England.

The practice is open between 8am and 8pm on Mondayand 8am to 6.30pm Tuesday to Friday. (Closed 12.30pm to1.30pm on Tuesdays.) Appointments are available between8.10am and 5.30pm. (7.45 on Mondays). The practice hasopted out of providing an out of hours service when thesurgery is closed. This is provided by the Leicester,Leicestershire and Rutland out of hours service whichcovers the area and can be accessed through the NHS 111number.

Why we carried out thisinspectionWe carried out a planned comprehensive inspection tocheck whether the provider was meeting the legalrequirements and regulations associated with the Healthand Social Care Act and to provide a rating for the serviceunder the Care Act 2014.

How we carried out thisinspectionTo get to the heart of patients’ experiences of care andtreatment, 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?

PinfPinfoldold MedicMedicalal PrPracticacticeeDetailed findings


We also looked at how well services are provided forspecific groups of people and what good care looks like forthem. 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)

Before visiting, we reviewed a range of information that wehold about the practice and asked other organisations to

share what they knew. We carried out an announced visiton 20 May 2015. During our visit we spoke with a range ofstaff including GPs, nurses, healthcare assistants, receptionand clerical staff and members of the management team.We reviewed comment cards where patients shared theirviews and experiences of the service. These had beenprovided by the Care Quality Commission (CQC) forcompletion before the inspection took place. We spokewith patients and representatives who used the service,including two members of the Patient Participation Group(PPG). The PPG includes representatives from variouspatient groups who work with practice staff to improve theservice and quality of care. We observed how people werebeing cared for and talked with patients, carers and/orfamily members.

Detailed findings


Our findingsSafe track record

The practice prioritised safety and used a range ofinformation to help identify risks and improve patientsafety. This included reported incidents and nationalpatient safety alerts as well as comments and complaintsreceived from patients. The staff we spoke with were awareof their responsibilities to raise concerns and knew how toreport incidents and near misses. For example, it wasthought that a patient had been given an incorrectvaccination. Further investigation revealed that the batchnumber had been noted and this showed that the correctvaccination had been given. Staff were reminded to ensurethey made correct entries in patient notes and to continueto check and note batch numbers when givingvaccinations.

We reviewed safety records, incident reports and minutesof meetings where these were discussed. This showed thepractice had managed these consistently over time and socould show evidence of a safe track record over the longterm.

Learning and improvement from safety incidents

The practice had a system in place for reporting, recordingand monitoring significant events, incidents and accidents.We reviewed records of significant events that had occurredduring the previous 18 months and saw this system wasfollowed appropriately. We saw evidence that significantevents were regularly discussed at staff meetings and thatthe practice regularly reviewed actions and learning fromsignificant events and complaints. There was evidence thatthe practice had learned from these and that the findingswere shared with all relevant staff. Staff, includingreceptionists, administrators and nursing staff told us theyknew how to report a significant incident and that they feltencouraged to do this.

Staff completed incident forms from the practice intranetand sent them to the patient services manager. Theyshowed us the system on the practice shared drive used tomanage and monitor incidents. We tracked severalincidents and saw records were completed in acomprehensive and timely manner. We saw evidence ofaction taken as a result and that learning had been shared.We looked at an incident where a patient had complainedabout the attitude of remember of reception staff. Further

investigation showed that this was caused by amisunderstanding but the member of staff involvedreviewed what had happened and shared the issue withtheir colleagues. Where patients had been affected bysomething that had gone wrong they were given anapology and informed of the actions taken to prevent thesame thing happening again.

National patient safety alerts were disseminated accordingto a safety alerts protocol which covered drug and medicaldevice alerts. The alerts were received by three members ofstaff. These were forwarded to GPs and nursing staff and acopy of the alert was placed on the staff noticeboard. Staffwe spoke with were able to give examples of recent alertsthat were relevant to the care for which they wereresponsible. They also told us alerts were discussed at GPand practice meetings to ensure all staff were aware of anythat were relevant to the practice and where they neededto take action.

Reliable safety systems and processes includingsafeguarding

The practice had systems to manage and review risks tochildren, young people and vulnerable adults. We lookedat training records which showed that all staff had receivedrelevant role specific training on safeguarding. Staff knewhow to recognise signs of abuse in older people, vulnerableadults and children. They were also aware of theirresponsibilities and knew how to share information,properly record safeguarding concerns and how to contactthe relevant agencies in and out of normal working hours.Contact details were easily accessible.

The practice had a GP lead in safeguarding vulnerableadults and children, who had been trained in both adultand child safeguarding and could demonstrate they hadthe necessary competency and training to enable them tofulfil this role. All staff we spoke with were aware of who tospeak with in the practice if they had a safeguardingconcern.

There was a system to highlight vulnerable patients on thepractice’s electronic records. This included information tomake staff aware of any relevant issues when patientsattended appointments, for example, children subject tochild protection plans and looked after children. Staffdescribed a situation to us where they had raised a concernabout a child’s safety and what action was taken whichincluded informing social services. The practice monitored

Are services safe?

Good –––


frequent attendance of children and young people ataccident and emergency departments and the out of hoursservice to identify any potential safeguarding issues. Therewas active engagement in local safeguarding proceduresand effective working with other relevant organisationsincluding regular meetings with health visitors.

There was a chaperone policy which was explained in plainEnglish on the practice web site and on posters on thewaiting room noticeboard and in consulting rooms. (Achaperone is a person who acts as a safeguard and witnessfor a patient and health care professional during a medicalexamination or procedure). All nursing staff, health careassistants and receptionists had received appropriatetraining. Staff understood their responsibilities when actingas chaperones. All staff undertaking chaperone duties hadreceived Disclosure and Barring Service (DBS) checks. (DBSchecks identify whether a person has a criminal record or ison an official list of people barred from working in roleswhere they may have contact with children or withvulnerable adults.)

Medicines management

We checked medicines stored in the treatment rooms andmedicine refrigerators and found they were stored securelyand were only accessible to authorised staff. There was apolicy for ensuring that medicines were kept at therequired temperatures, which described the action to takein the event of a potential failure. Records showed fridgetemperature checks were carried out which ensuredmedication was stored at the appropriate temperature.

We found that there were not robust systems in place tocheck that emergency medicines and equipment werereplaced when required. It was not clear what equipmentor medicines were required and what should be done ifanything appeared to be missing. We told the practice whatwe had found and they decided to treat this as a significantincident. The practice has since provided evidence that ithas clarified what is required and emphasised to the staffinvolved what their responsibilities were for checking thesupplies.

All prescriptions were reviewed and signed by a GP beforethey were given to the patient. Both blank prescriptionforms for use in printers and those for hand writtenprescriptions were handled in accordance with nationalguidance. They were tracked through the practice and keptsecurely at all times. The practice had clear systems in

place to monitor the prescribing of controlled drugs(medicines that require extra checks and special storagearrangements because of their potential for misuse) Theprescriptions were marked and patients signed for themwhen collecting.

We saw records for reviewing the prescribing of drugs suchas antibiotics, hypnotics, sedatives and anti-psychoticswithin the practice. We saw an audit into anti-psychoticsprescribing for patients with dementia using CCGguidelines which was discussed at a clinician’s meeting andwhich emphasised the need for annual reviews of dosage.

There was a system in place for the management of highrisk medicines such as warfarin, methotrexate and otherdisease modifying drugs, which included regularmonitoring in line with national guidance. Computersystems showed alerts for blood tests and other checksand how they were acted upon. The practice haddeveloped a pro-active recall system to ensure patientswere contacted to help ensure they attended for relevanttests.

The nurses used Patient Group Directions (PGDs) toadminister vaccines and other medicines that had beenproduced in line with legal requirements and nationalguidance. Health care assistants administered vaccinesand other medicines using Patient Specific Directions(PSDs) that had been produced by the prescriber. We sawevidence that nurses and health care assistants hadreceived appropriate training and been assessed ascompetent to administer the medicines referred to. Amember of the nursing staff was qualified as anindependent prescriber and she received regularsupervision and support in her role as well as updates inthe specific clinical areas of expertise for which sheprescribed.

The practice held limited stocks of controlled drugs(medicines that require extra checks and special storagearrangements because of their potential for misuse). Therewere procedures in place that set out how they weremanaged which were being followed by the practice staff.For example, controlled drugs were stored in a safe within alocked room with limited access.

Cleanliness and infection control

We observed the premises to be clean and tidy. We sawthere were cleaning schedules in place and cleaningrecords were kept. Patients we spoke with told us they

Are services safe?

Good –––


always found the practice clean and had no concernsabout cleanliness or infection control. Cleaning wasprovided by the landlord of the building but the practicehad arranged for the cleaners to have training in basicinfection control. We saw evidence of regular checks by thepractice to ensure the premises were kept clean.

The practice had a lead for infection control who had beentrained to enable them to provide advice on the practiceinfection control policy and carry out staff training. All staffreceived induction training and annual updates aboutinfection control specific to their role. We saw evidence thatthe lead had carried out audits on a six-monthly basis andthat any improvements identified for action werecompleted. Minutes of practice meetings showed that anyissues about infection control were discussed in the regularhealth and safety slot.

An infection control policy and supporting procedures wereavailable which enabled staff to plan and implementmeasures to control infection. For example, there weredetailed instructions for cleaning the treatment room usedfor minor surgery before and after use. We saw staff usingpersonal protective equipment including disposable glovesand aprons. Staff knew the protocol to follow if there was aneedle stick injury.

Notices about hand hygiene techniques were displayed instaff and patient toilets. Hand washing sinks with handsoap, hand gel and hand towel dispensers were available intreatment rooms.

The owners of the building arranged checks for themanagement, testing and investigation of legionella (abacterium which can contaminate water systems inbuildings). We saw records that confirmed the practice hadrecords of regular checks being carried out to reduce therisk of infection to staff and patients.

Equipment

Staff told us they had equipment to enable them to carryout diagnostic examinations, assessments and treatments.They told us that all equipment was tested and maintainedregularly and we saw servicing schedules and equipmentmaintenance logs that confirmed this. All portableelectrical equipment was routinely tested by the owner ofthe building. The practice had a system for checking toensure this was done as required and showed us the logs

they kept. We saw evidence of calibration of relevantequipment, for example, weighing scales, spirometers,blood pressure measuring devices (including 24hrmonitors).

Staffing and recruitment

The practice had a recruitment policy that set out theprocedures it followed when recruiting clinical andnon-clinical staff. Records we looked at contained evidencethat appropriate recruitment checks had been undertakenprior to employment. For example, proof of identification,references, qualifications, registration with the appropriateprofessional body and the appropriate checks through theDisclosure and Barring Service (DBS). (These checksidentify whether a person has a criminal record or is on anofficial list of people barred from working in roles wherethey may have contact with children or adults who may bevulnerable). The practice had risk assessments in place forthose staff roles where it had assessed DBS checks werenot needed.

Staff told us about the arrangements for planning andmonitoring the number of staff and mix of staff needed tomeet patients’ needs. We saw there was a rota system inplace to ensure that enough staff were on duty. Annualleave was managed to ensure that sufficient staff remainedat work.

Staff told us there were usually enough staff to maintainthe smooth running of the practice and there were alwaysenough staff on duty to keep patients safe. The practicehad signed up to an NHS initiative called ‘ProductiveGeneral Practice’ which was designed to help GPs continueto deliver high quality care while meeting increasing levelsof demand and expectation. This had helped the practicemap demand to capacity and ensure they had correctstaffing levels and skills mix wherever possible. One resultof this was the employment of an additional receptionistspecifically to work early in the morning when patientswere phoning to make appointments.

Monitoring safety and responding to risk

The practice had systems, processes and policies in placeto manage and monitor risks to patients, staff and visitorsto the practice. These included regular checks of thebuilding, the environment, medicines management,staffing, and dealing with emergencies and equipment. Thepractice also had a health and safety policy. Health and

Are services safe?

Good –––


safety information was displayed for staff to see and therewas an identified health and safety representative. Therewas also a health and safety slot at the regular practicemeetings.

Identified risks were included on a risk log. Each risk wasassessed and rated and mitigating actions recorded toreduce and manage the risk. Risks associated with servicewere included on the log. We saw an example of this(accommodation damage such as flooding or vandalism)and the mitigating actions that had been put in place. Themeeting minutes we reviewed showed risks were discussedat some practice meetings.

Arrangements to deal with emergencies and majorincidents

The practice had arrangements in place to manageemergencies. Records showed that all staff had receivedtraining in basic life support. Emergency equipment wasavailable including access to oxygen and an automatedexternal defibrillator (used in cardiac emergencies). Whenwe asked members of staff, they all knew the location ofthis equipment and records confirmed that it was checkedregularly. We checked that the pads for the automatedexternal defibrillator were within their expiry date.

Emergency medicines were easily accessible to staff in asecure area of the practice and all staff knew of their

location. These included those for the treatment of cardiacarrest, anaphylaxis and hypoglycaemia. However, we foundthat there was not a sufficiently robust system in place toensure that emergency drugs and equipment kept at thepractice and in the GP’s home visit bags were available inthe correct amounts. Following our visit, the practiceprovided evidence that this issue has been reviewed andsystems put into place to check that all necessaryemergency medicines and equipment were available andwithin their expiry date.

A detailed service continuity plan was in place to deal witha range of emergencies that could impact on the dailyoperation of the practice. Each risk was rated andmitigating actions recorded to reduce and manage the risk.Risks identified included power failure, adverse weather,unplanned sickness and access to the building. Thedocument also contained relevant contact details for staffto refer to. Anything related to the premises, for example,heating would be referred to the owners of the building.The plan was reviewed annually or whenever a new issuewas identified.

The practice had carried out a fire risk assessment thatincluded actions required to maintain fire safety. Recordsshowed that staff were up to date with fire training and thatthey practised regular fire drills.

Are services safe?

Good –––


Our findingsEffective needs assessment

The GPs and nursing staff we spoke with could clearlyoutline the rationale for their approaches to treatment.They were familiar with current best practice guidance andaccessed guidelines from the National Institute for Healthand Care Excellence (NICE) and from local commissioners.We saw that this guidance was accessible on-line for allstaff.

We discussed with the practice manager, GPs and nursingstaff how NICE guidance was received into the practice.They told us this was downloaded from the website anddisseminated to staff. We saw minutes of clinical meetingswhich showed this was discussed. Any implications for thepractice’s performance and patients were identified andrequired actions agreed. Staff we spoke with alldemonstrated a good level of understanding andknowledge of NICE guidance and local guidelines.

Staff described how they carried out comprehensiveassessments which covered all health needs and were inline with these national and local guidelines. Theyexplained how care was planned to meet identified needsand how patients were reviewed at required intervals toensure their treatment remained effective. For example,patients with diabetes were having regular health checksand were being referred to other services when required. Aspecialist diabetes nurse attended the practice on a weeklybasis and saw patients with sub-optimal results. They alsodealt with diabetic patients who needed advice aboutfasting during Ramadan or when travelling. Feedback frompatients confirmed they were referred to other services orhospital when required.

The GPs told us they lead in specialist clinical areas such asdiabetes, heart disease and asthma and the practice nursessupported this work, which allowed the practice to focuson specific conditions. Clinical staff we spoke with wereopen about asking for and providing colleagues withadvice and support. GPs told us this supported all staff toreview and discuss new best practice guidelines, forexample, for the management of respiratory disorders. Ourreview of the clinical meeting minutes confirmed that thishappened. The practice was also supported by a specialistChronic Obstructive Pulmonary Disease (COPD) nurse fromthe CCG.

The practice used computerised tools to identify patientswho were at high risk of admission to hospital. The practicehad developed a proactive care template for patients mostat risk of unplanned hospital admissions, for patients whohad problems such as pressure sores, and for thoserequiring end of life care. These patients were reviewedregularly to ensure multidisciplinary care plans weredocumented in their records and that their needs werebeing met to assist in reducing the need for them to go intohospital. We saw that after patients were discharged fromhospital they were followed up to ensure that their needswere continuing to be met.

Discrimination was avoided when making care andtreatment decisions. Interviews with GPs showed that theculture in the practice was that patients were cared for andtreated based on need and the practice took account ofpatient’s age, gender, race and culture as appropriate.

Management, monitoring and improving outcomes forpeople

Information about people’s care and treatment andoutcomes was routinely collected, monitored and used toimprove care. Staff across the practice had key roles inmonitoring and improving outcomes for patients. Theseroles included data input, scheduling clinical reviews, andmanaging child protection alerts and medicinesmanagement. The information collected was then collatedby administrative staff to support the practice to carry outclinical audits.

The practice showed us nine clinical audits that had beenundertaken during the last three years. Five of these werecompleted audits where the practice was able todemonstrate the changes to treatment or care whenneeded. The practice was partway through an audit relatedto stroke prevention in patients with atrial fibrillation (AF).As a result the practice developed a series of interventionsto reduce stroke risk in the patient population. Thisincluded additional training for practice staff anddeveloping a new protocol for reviewing patients at risk ofdeveloping a stroke. The practice intended to initiatefurther data collection at the end of 2015 to measure theeffectiveness of the new protocols.

The GPs told us clinical audits were often linked tomedicines management information, safety alerts or as aresult of information from the Quality and OutcomesFramework (QOF). (QOF is a voluntary incentive scheme for

Are services effective?(for example, treatment is effective)

Good –––


GP practices in the UK. The scheme financially rewardspractices for managing some of the most commonlong-term conditions and for the implementation ofpreventative measures). For example, we saw an auditregarding the prescribing of antipsychotic drugs in patientswith dementia. Following the audit, the GPs carried outmedication reviews for patients who were prescribed thesemedicines often during the annual review of patients incare homes to consider whether there could be anyreduction in the dosage.

The practice also used the information collected for theQOF and performance against national screeningprogrammes to monitor outcomes for patients. Thispractice was not an outlier for any QOF (or other national)clinical targets, It achieved 99.4% of the total QOF target in2014, which was above the national average of 92.4%.Specific examples to demonstrate this included:

• Performance for diabetes related indicators was betterthan the national average.

• The percentage of patients with hypertension havingregular blood pressure tests was similar to the nationalaverage

• Performance for mental health related andhypertension QOF indicators was above the nationalaverage.

The practice continually monitored its performance toensure it was in line with national or CCG figures.

The team was making use of clinical audit tools, clinicalsupervision and staff meetings to assess the performanceof clinical staff. The staff we spoke with discussed how, as agroup, they reflected on the outcomes being achieved andareas where this could be improved. Staff spoke positivelyabout the culture in the practice around audit and qualityimprovement.

The practice’s prescribing rates were also slightly betterthan the national average. There was a protocol for repeatprescribing which followed national guidance. Thisrequired staff to regularly check that patients receivingrepeat prescriptions had been reviewed by a GP. They alsochecked all routine health checks were completed forlong-term conditions such as diabetes and that the latestprescribing guidance was being used. The IT systemflagged up relevant medicines alerts when the GP was

prescribing medicines. We saw evidence that after receivingan alert, the GPs had reviewed the use of the medicine inquestion and, where they continued to prescribe it,outlined the reason why they decided this was necessary.

The practice had made use of the gold standardsframework for end of life care. It had a register of patientswho needed palliative care and had regular internal as wellas multidisciplinary meetings to discuss the care andsupport needs of patients and their families.

The practice also kept a register of patients identified asbeing at high risk of admission to hospital and of those invarious vulnerable groups such as people with learningdisabilities, mental health problems and homeless people.Structured annual reviews were also undertaken for peoplewith long term conditions such as diabetes, COPD (chronicobstructive pulmonary disease), and AF.

The practice participated in local benchmarking run by theCCG. This is a process of evaluating performance data fromthe practice and comparing it to similar practices in thearea. This benchmarking data showed the practice hadoutcomes that were comparable to other services in thearea.

Effective staffing

The practice employed medical, nursing, managerial andadministrative staff. We reviewed staff training records andsaw that all staff were up to date with mandatory coursessuch as annual basic life support. We noted a good skill mixamong the doctors with several having additional trainingand being able to provide treatment and advice withmusculoskeletal problems, family planning, minor surgery,and ear nose and throat problems (ENT). All GPs were up todate with their yearly continuing professional developmentrequirements and either had been revalidated or had adate for revalidation. (Every GP is appraised annually, andundertakes a fuller assessment called revalidation everyfive years. Only when revalidation has been confirmed bythe General Medical Council can the GP continue topractise and remain on the performers list with NHSEngland).

All staff undertook annual appraisals that identifiedlearning needs from which action plans were documented.Our interviews with staff confirmed that the practice wasprovided training and funding for relevant courses. Thepractice was a training practice which meant that bothmedical students and GP registrars (these are qualified


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doctors who are training to be GPs) worked at the practice.We spoke with the registrars who told us that they weredebriefed on a daily basis by the duty doctor and that theyfelt they were challenged, supported and valued by thepractice.

Practice nurses and health care assistants had jobdescriptions outlining their roles and responsibilities andprovided evidence that they were trained appropriately tofulfil these duties. For example, on the administration ofvaccines, cervical cytology, and taking blood samples.Those with extended roles for example seeing patients withlong-term conditions such as asthma, COPD, diabetes andAF were also able to demonstrate that they hadappropriate training to fulfil these roles.

Staff files we reviewed showed that where any poorperformance had been identified appropriate action hadbeen taken to manage this.

Working with colleagues and other services

The practice worked with other service providers to meetpatient’s needs and manage those of patients withcomplex needs. It received blood test results, X ray results,and letters (including discharge summaries) from the localhospital and out-of-hours GP services and the 111 serviceboth electronically and by post. The practice had aprotocol outlining the responsibilities of all relevant staff inpassing on, reading and acting on any issues arising fromthese communications. Out-of hours reports, 111 reportsand pathology results were all seen and actioned by a GPon the day they were received. Discharge summaries andletters from outpatients were usually seen and actioned onthe day of receipt and all within five days of receipt. The GPwho saw these documents and results was responsible forthe action required. All staff we spoke with understoodtheir roles and felt the system in place worked well. Therewere no instances identified within the last year of anyresults or discharge summaries that were not followed up.

Emergency hospital admission rates for the practice werethe similar to the national average.

The practice held multidisciplinary team meetings monthlyto discuss patients with complex needs, for example, thosewith end of life care needs. A member of the administrativeteam kept the register of all of these patients whichincluded any issues the GP looking after that patientwanted to raise or if the patient was stable. These meetingswere attended by district nurses, the virtual ward sister

(who can organise social care when needed) andMacmillan nurses, as well as practice staff. Decisions aboutcare planning were documented in a shared care record.Staff felt this system worked well. Proactive care plansdeveloped by the practice, were in place for patients withcomplex needs and shared with other health and socialcare workers as appropriate.

There was regular attendance at the practice by themidwife, COPD, diabetes, and heart failure specialistnurses, and mental health nurse and a drug and alcoholabuse worker which helped the practice support patientswith complex needs.

Information sharing

The practice used several electronic systems tocommunicate with other providers. For example, there wasa shared system (EMIS) with the local GP out-of-hoursprovider to enable patient data to be shared in a secureand timely manner. We saw evidence there was a systemfor sharing appropriate information for patients withcomplex needs with the ambulance and out-of-hoursservices.

The practice had also signed up to the electronic SummaryCare Record. (Summary Care Records provide faster accessto key clinical information for healthcare staff treatingpatients in an emergency or out of normal hours).

The practice had systems to provide staff with theinformation they needed. Staff used an electronic patientrecord to coordinate, document and manage patients’care. All staff were fully trained on the system and followeda set protocol which ensured information was forwarded toGPs. This software enabled scanned papercommunications, such as those from hospital, to be savedin the system for future reference. We saw evidence thatthere were regular checks to ensure the completeness ofthese records.

Consent to care and treatment

We found that staff were aware of the Mental Capacity Act2005, the Children Acts 1989 and 2004 and their dutiesrelating to the legislation. All the clinical staff we spoke withunderstood the key parts of the legislation and were able todescribe how they implemented it giving relevantexamples.

Patients with a learning disability and those with dementiawere supported to make decisions through the use of care


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plans, which they were involved in agreeing. These careplans were reviewed annually (or more frequently ifnecessary) and had a section stating the patient’spreferences for treatment and decisions. Staff were able togive examples of how a patient’s best interests were takeninto account if a patient did not have capacity to make adecision. All clinical staff demonstrated a clearunderstanding of the Gillick competency test. (used to helpassess whether a child under the age of 16 has the maturityto make their own decisions and to understand theimplications of those decisions).

There was a practice protocol about consent to treatment.This emphasised the importance of giving patientssufficient information about the benefits and risks of anytreatment before seeking consent. It was also clear aboutdifferent kinds of consent and where consent should bedocumented in the electronic patient notes.

Health promotion and prevention

All new patients registering that the practice were offered ahealth check. Any health concerns were noted and a GPtasked to follow this up in a timely way. We noted that GPsand nursing staff used their contact with patients to helpimprove health and well-being. For example, patients whosmoked were offered smoking cessation advice.

The practice offered NHS Health Checks to all its patientsaged 40 to 75 years. We were shown the process forfollowing up patients if they had risk factors for diseaseidentified at the health check and how furtherinvestigations were scheduled.

The practice had carried out an audit of the take-up ofnational cancer screening programmes which was belowthe national average. It identified that this was particularlythe case amongst patients from ethnic minoritybackgrounds. As a result all staff were trained about thescreening programmes and encouraged to promote thesewithin the community. Several staff spoke communitylanguages.

The practice offered a full range of immunisations forchildren, and flu vaccinations in line with current nationalguidance.

• Flu vaccination rates for people over 65 were 77.12%,and at risk groups 59.71%. These were slightly abovenational averages.

• Childhood immunisation rates for the vaccinationsgiven to under twos and five year olds were comparableto national averages.


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Our findingsRespect, dignity, compassion and empathy

We reviewed the most recent data available for the practiceon patient satisfaction. This included information from thenational patient survey (2015), and a survey of 433 patientsundertaken by the practice’s patient participation group(PPG). (a PPG is a group of patients registered with apractice who work with the practice to improve servicesand the quality of care.)

The evidence from all these sources showed patients weresatisfied with how they were treated and that this was withcompassion, dignity and respect. The practice was aboveaverage for its satisfaction scores on consultations withdoctors and nurses. For example:

• 89% said the GP was good at listening to themcompared to the CCG average of 88% and nationalaverage of 89 %.

• 91% said the GP gave them enough time compared tothe CCG average of 86% and national average of 87 %.

• 98% said they had confidence and trust in the last GPthey saw compared to the CCG average of 95% andnational average of 95%.

• Patients reported similar levels of satisfaction withnurses at the practice

Patients completed CQC comment cards to tell us whatthey thought about the practice. We received 37 completedcards and the majority were positive about the serviceexperienced. Patients said they felt the practice offered anexcellent service and staff were professional, welcoming,friendly and easy to talk to. They said staff were caring andtreated them with dignity and respect. Three patients werepositive about their experience at the practice but lesspositive about the difficulties they had experienced gettingan appointment. We also spoke with nine patients on theday of our inspection. All told us they were satisfied withthe care provided by the practice. Several told us theywould and indeed had recommended the practice to otherpeople.

Staff and patients told us that all consultations andtreatments were carried out in the privacy of a consultingroom. Disposable curtains were provided in consultingrooms and treatment rooms so that patients’ privacy anddignity was maintained during any examinations andtreatments.

We saw that staff were careful to follow the practice’sconfidentiality policy when discussing patients’ treatments.The practice switchboard was separately located to thereception area which helped keep patient informationprivate. There was some distance between the seating areaand the reception desk which helped preventconversations being overheard.

There were notices in the patient reception area stating thepractice’s zero tolerance for abusive behaviour.

Care planning and involvement in decisions aboutcare and treatment

The patient survey information we reviewed showedpatients responded positively to questions about theirinvolvement in planning and making decisions about theircare and treatment and generally rated the practice well inthese areas. For example:

• 95% said the last GP they saw was good at explainingtests and treatments compared to the CCG average of85% and national average of 86%.

• 85% said the last GP they saw was good at involvingthem in decisions about their care compared to the CCGaverage of 80% and national average of 81%.

Patients we spoke with on the day of our inspection told usthat they felt involved in making decisions about the careand treatment they received. They also told us they feltlistened to and supported by staff and had sufficient timeduring consultations to make an informed decision aboutthe choices of treatment. Patient feedback on thecomment cards we received was also positive about thesematters.

Staff told us that interpretation services were available forpatients whose first language was not English. We sawnotices in the reception areas informing patents thisservice was available. Several staff spoke communitylanguages and this was useful when patients phoned orcalled in. They did not act as interpreters.

Patient/carer support to cope emotionally with careand treatment

The patient survey information we reviewed showedpatients were positive about the support provided by thepractice and rated it well in this area. For example:

Are services caring?

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• 89% said the last GP they spoke to was good at treatingthem with care and concern compared to the CCGaverage of 84% and national average of 85%.

• 93% said the last nurse they spoke to was good attreating them with care and concern compared to theCCG average of 89% and national average of 90%.

The patients we spoke with on the day of our inspectionand the comment cards we received were also consistentwith this survey information. For example, thesehighlighted that staff were friendly and compassionatewhen they needed help and provided support whenrequired.

Notices in the patient waiting room and information on thepractice website also told patients how to access a numberof support groups and organisations. The practice’scomputer system alerted GPs if a patient was also a carerso they could be directed to appropriate support services.

Staff told us that if patients had suffered bereavement,their usual GP telephoned them. This call was eitherfollowed by a patient consultation at a flexible time andlocation or by giving them advice about how to findappropriate support.

Are services caring?

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Our findingsResponding to and meeting people’s needs

We found the practice was responsive to patient’s needsand had systems in place to maintain the level of serviceprovided. The needs of the practice population wereunderstood and systems were in place to addressidentified needs in the way services were delivered. Forexample, all staff had been trained about National Cancerscreening programmes and were encouraged to giveinformation about these in the practice and within theethnic minority communities in the locality.

The NHS England Area Team and Clinical CommissioningGroup (CCG) told us that the practice engaged regularlywith them and other practices to discuss local needs andservice improvements that needed to be prioritised. Wesaw the practice had discussed this and recognise theimportance of involvement to improve services.

The practice had also implemented suggestions forimprovements and made changes to the way it deliveredservices in response to feedback from the patientparticipation group (PPG) (this is a group of patients whowork with the practice to improve services and the qualityof care). This included the introduction of a local telephonenumber and changes to the appointment system to makeit simpler and provide more on the day appointments withGPs and the nurse practitioner.

Tackling inequity and promoting equality

The practice had recognised the needs of different groupsin the planning of its services. For example, longerappointment times were available for patients withlearning disabilities. Patients with mental health issueswere offered appointments when the practice wasrelatively quiet to reduce any stress involved. People whowere homeless could register without giving a permanentaddress. The practice worked closely with a local projectworking with homeless people. A significant number of thepractice population did not have English as their firstlanguage. The practice could arrange interpreters and alsoaccess online and telephone interpretation services.

The premises and services had been designed to meet theneeds of people with disabilities. The practice wasaccessible to patients with mobility difficulties as facilitieswere all on one level and the doors automatic. There were

access enabled toilets and baby changing facilities. Therewas a large waiting area with plenty of space forwheelchairs and prams. The practice had a wheelchairavailable for patients to use.

Patients could choose to see a male or female doctor.

The practice provided equality and diversity training atinduction and through e-learning. Staff we spoke withconfirmed that they had completed the equality anddiversity training and that equality and diversity wasregularly discussed at staff appraisals and team events.

Access to the service

The surgery was open from 8am to 8pm on Monday andfrom 8am to 6.30pm Tuesday to Friday. Appointments weregenerally available from 30 minutes after the surgeryopened and 30 minutes before it closed. There was a dutydoctor every day who saw patients who needed an urgentappointment, took urgent telephone calls, and madeemergency visits. They also supported the GP registrarswith a daily debriefing session.

Comprehensive information was available to patientsabout appointments, including urgent appointments andhome visits on the practice website and in the patientinformation leaflet. Appointments could be booked inperson, by phone and online. When the practice wasclosed, an answerphone message gave advice and relevanttelephone numbers, depending on the circumstances. Thisincluded the out-of-hours service.

Longer appointments were also available for any patientwho requested them. The duty doctor telephoned patientsrequesting home visits to ensure this was appropriate. A GPvisited two local care homes twice a week.

The patient survey information we reviewed showedpatients has not been very satisfied with how they couldmake appointments. This did not take into account recentchanges in the appointment system. Patients we spokewith told us there have been problems in the past but itwas now much easier to get an appointment and thephone system had improved. They confirmed that theycould often see a doctor on the same day although thismight not be their GP of choice. Routine appointmentswere available for booking three weeks in advance.

Listening and learning from concerns and complaints

Are services responsive to people’s needs?(for example, to feedback?)

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The practice had a system in place for handling complaintsand concerns. Its complaints policy and procedures were inline with recognised guidance and contractual obligationsfor GPs in England. The Patient Services Manager handledall complaints in the practice.

Information was available to help patients understand thecomplaints system. There were posters and complaintsleaflets in reception. There was also a poster explainingthat the practice welcomed any feedback in order toimprove the service provided. Patients we spoke with wereaware of the complaints procedure. None we spoke withhad ever needed to make a complaint about the practice.

We saw that the practice recorded and investigated allcomplaints. Patients received an explanation about whathad happened and were told what the practice had learnedand what would be done differently in future. The practicealso held a meeting to review anonymised complaints. Thisinvolved members of the PPG and their comments andsuggestions were acted on to improve the quality of care.Minutes of practice meetings showed the complaints wereregularly discussed and any learning or improvementidentified by the whole staff group.

Are services responsive to people’s needs?(for example, to feedback?)

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Our findingsVision and strategy

The practice had a clear vision to deliver a high standard ofpersonalised care, treatment and advice in a friendly andsupportive environment and to involve patients in alldecisions about their treatment.

We spoke with 12 members of staff who all understood thevision and values and their own responsibilities. They toldus that these were discussed at the annual staff away dayand at team meetings. Staff told us they felt able tocontribute to these discussions and that managers listenedto them.

Governance arrangements

The practice had a number of policies and procedures inplace to govern activity and these were available to staff onany computer within the practice. All policies we looked atwere up-to-date and there was a system in place to ensurethese were reviewed regularly. There were systems in placeto monitor the quality of the service being provided. Thisincluded using the Quality and Outcomes Framework (QOF)to measure the practices’ performance (QOF is a voluntaryincentive scheme which financially rewards practices formanaging some of the most common long-term conditionsand for the implementation of preventative measures). TheQOF data for this practice showed its performance wasgenerally above national standards. The data wasdiscussed at practice meetings with a view to maintainingor improving outcomes.

The practice also had an on-going programme of clinicalaudits which it used to monitor quality and systems toidentify where action should be taken. For example, thepractice was part way through an audit related to stokeprevention in patients with atrial fibrillation (AF) but hadalready decided upon six action points to improve patientcare. We saw that incidents, complaints and otherfeedback were regularly discussed at staff meetings andlearning identified with actions taken to follow this up.Additionally, there were processes in place to reviewpatient satisfaction and that action had been taken, whenappropriate, in response to feedback from patients or staff.The practice regularly submitted governance andperformance data to the CCG.

The practice identified, recorded and managed risks. It hadcarried out risk assessments where some risks had beenidentified and action plans had been produced andimplemented, for example risks related to work, such aslone working.

We looked at minutes from the regular staff meetings andfound that performance, quality and risks had beendiscussed.

The patient services manager was responsible for humanresource policies and procedures. We reviewed a numberof policies, (for example disciplinary procedures, inductionpolicy, and management of sickness) which were in placeto support staff. We were shown the electronic staffhandbook that was available to all staff. This includedsections on equality, whistleblowing, and harassment andbullying at work. Staff we spoke with knew where to findthese policies when needed.

Leadership, openness and transparency

Staff told us the GPs and managers were approachable andlistened to all members of staff. All staff were involved indiscussions about how to run the practice and how todevelop and improve it. We saw from minutes that therewere regular team meetings. Staff told us that they feltconfident about raising any issues at team meetings. Wealso noted that team away days were held every year. Staffsaid they felt respected, valued and supported in theirwork.

Seeking and acting on feedback from patients, publicand staff

The practice encouraged and valued feedback frompatients. It had gathered feedback from patients throughthe patient participation group (PPG) (this is a group ofpatients who work with the practice to improve servicesand the quality of care), surveys and complaints received. Ithad an active PPG with 30 members which met everyquarter. A further 900 patients formed a virtual PPGreceiving minutes and contributing online. We spoke with 2members of the PPG and they were very positive about therole they played and told us they felt the practice engagedwell with the PPG.

The practice had also gathered feedback from staff at teammeetings, away days and discussions. Staff told us they

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

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would not hesitate to give feedback and discuss anyconcerns or issues with colleagues and management. Stafftold us they felt involved and engaged in the practice toimprove outcomes for both staff and patients.

Management lead through learning and improvement

Staff told us that the practice supported them to maintaintheir clinical professional development through trainingand mentoring. There were regular meetings to discussclinical matters. We looked at staff files and saw thatregular appraisals took place which included a personaldevelopment plan. Staff told us that the practice was verysupportive of training.

The practice was a GP training practice. GP registrars weresupported with daily debriefs and regular tutorials.

The practice had completed reviews of significant eventsand other incidents and shared any learning with staff atmeetings. For example, we saw evidence that following areview of a possible vaccination error, all staff werereminded of the need to correctly record both the nameand the batch number of the vaccination.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

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Documents

Pinfold Medical Practice NewApproachComprehensive … · 9 Pinfold Medical Practice Quality Report 19/11/2015. Wealsolookedathowwellservicesareprovidedfor specificgroupsofpeopleandwhatgoodcarelookslikefor