Heathville Medical Practice, Aspen Centre ... · Thisreportdescribesourjudgementofthequalityofcareatthisservice.Itisbasedonacombinationofwhatwefound whenweinspected

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 –––

HeHeathvilleathville MedicMedicalal PrPracticactice,e,AspenAspen CentrCentreeQuality Report

Horton Road,GloucesterGloucestershire GL1 3PXTel: 01452 337733Website:

Date of inspection visit: 27 October 2015Date of publication: 17/12/2015

1 Heathville Medical Practice, Aspen Centre Quality Report 17/12/2015

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 4

The six population groups and what we found 6

What people who use the service say 9

Detailed findings from this inspectionOur inspection team 10

Background to Heathville Medical Practice, Aspen Centre 10

Why we carried out this inspection 10

How we carried out this inspection 10

Detailed findings 12

Overall summaryLetter from the Chief Inspector of GeneralPractice

We carried out an announced comprehensive inspectionat Heathville Road Surgery and the branch surgery atTuffley Surgery, Warwick Avenue, Gloucestershire on the27 October 2015. Overall the practice is rated as good.

Specifically, we found the practice to be good forproviding safe, well led, effective, caring and responsiveservices. It was also rated as good for providing servicesfor all of the population groups.

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

• We found patients needs were assessed and care wasplanned and delivered following best practiceguidance.

• Patients told us 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.

• Patients said they found it easy to make anappointment with a named GP and there wascontinuity of care, with urgent appointments alwaysavailable the same day.

• Risks to patients were assessed and well managed.• Staff worked cohesively as a team and understood and

fulfilled their responsibilities to raise concerns, and toreport incidents and near misses. Information aboutsafety was recorded, monitored, appropriatelyreviewed and addressed.

• Staff had received training appropriate to their rolesand any further training needs had been identified andplanned.

• There was a strong leadership structure and staff feltsupported by management.

• The practice proactively sought feedback from staffand patients, which it acted upon.

• The leadership, governance and culture within thepractice were used to drive and improve the delivery ofhigh-quality person-centred care.

We saw an area of outstanding practice:

The practice participated in innovative pilot programmessuch as the Choice Plus project which

Summary of findings


increased patient access to urgent care appointmentsand chronic illness management.

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. We foundthe practice used every opportunity to learn from internal andexternal incidents, to support improvement. Information aboutsafety was highly valued and was used to promote learning andimprovement across the staff team. Risk management wascomprehensive, well embedded and recognised as theresponsibility of all staff. Staffing levels and skill mix was plannedand reviewed so that patients received safe care and treatment at alltimes. The arrangements in place to safeguard adults and childrenfrom abuse reflected relevant legislation and local requirements.The practice had arrangements in place to respond to emergenciesand other unforeseen situations such as the loss of utilities.

Good –––

Are services effective?The practice is rated as good for providing effective services. Wefound systems were in place to ensure all clinicians were up to datewith National Institute for Health and Care Excellence (NICE)guidelines and other locally agreed guidelines. We also sawevidence to confirm these guidelines were positively influencing andimproving practice and outcomes for patients such as in the teenagehealth check. Information about the outcomes of patients’ care andtreatment was routinely collected and monitored through auditingand data collection. For example, the practice undertook audits toidentify appropriate referral of patients to hospital. We found staffhad the skills, knowledge and experience to deliver care andtreatment and had undertaken additional training to support this.

Good –––

Are services caring?The practice is rated as good for providing caring services. Patients’feedback about the practice said they were treated with kindness,dignity, respect and compassion while they received care andtreatment. Patients told us they were treated as individuals andpartners in their care. We found the practice routinely identifiedpatients with caring responsibilities and supported them in theirrole. Patients told us their appointment time was always as long aswas needed, there was no time pressure, and patients werereassured that their emotional needs were listened toempathetically.

Good –––

Are services responsive to people’s needs?The practice is rated as good for providing responsive services. Thepractice had initiated positive service improvements for its patients.It acted upon suggestions for improvements and changed the way it

Good –––

Summary of findings


delivered services in response to feedback from the patientparticipation group (PPG). It reviewed the needs of its localpopulation and engaged with the NHS England Area Team andClinical Commissioning Group (CCG) to secure improvements toservices where these were identified. We found urgent and routineappointments were available the same day. Information about howto complain was available and easy to understand and evidenceshowed the practice responded quickly to issues raised.

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. There weresystems in place to monitor and improve quality and identify risk.There were systems in place to monitor and improve quality andidentify risk. High standards were promoted and owned by allpractice staff and teams worked together across all roles.Governance and performance management arrangements had beenproactively reviewed and took account of current models of bestpractice. The practice carried out proactive succession planning.There was a high level of constructive engagement with staff and ahigh level of staff satisfaction. The practice proactively soughtfeedback from staff and patients, which it acted upon. Staff hadreceived induction, regular performance reviews and attended staffmeetings and events.

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. Nationallyreported data such as that from NHS England, showed outcomes forpatients were good for conditions commonly found in older people.The practice offered proactive, personalised care to meet the needsof the older patients in its population and had a range of enhancedservices, for example, emergency admission avoidance. We foundintegrated working arrangements with community teams such asthe community lead nurse for older people. During the influenzavaccination campaign the practice ran Saturday clinics for patientswho could only get to the practice with the help of a workingrelative. The practice had signed up to the nursing home enhancedservice and one GP visits weekly. The practice worked closely withcarers and one staff member acted as the carer’s champion.

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. Patients diagnosed with long term conditions weresupported through a range of clinics held for specific conditionssuch as, asthma, chronic obstructive pulmonary disease (COPD) andheart failure. Nurse led clinics and home review visits were availableto patients diagnosed with long term conditions such as diabetes.Longer appointments and home visits were available when needed.All of these patients had a structured annual review to check theirhealth and medicines needs were being met. Patients receivingpalliative care, those with cancer diagnosis and patients likely torequire unplanned admissions to hospital were added to the Out ofHours system to share information and patient choices anddecisions with other service providers. There was nurse and GPleads for chronic disease management. The practice offered winterrescue packs to patients with Chronic Obstructive PulmonaryDisease. Patients were also able to access tele-health a monitoringsystem that promoted self-care.

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 and follow upchildren living in disadvantaged circumstances and who were at risk,for example, children and young people who had a high number ofA&E attendances. All the vulnerable families had a named GP and allout of hours contacts were reviewed and the practice arranged anappointment for anyone needed to be followed up by a GP. The

Good –––

Summary of findings


practice monitored children who did not attend appointments andinformed the health visitors of any concerns. They had a childprotection lead who attended child protection meetings and amonthly meeting with midwives and health visitors. Immunisationrates were relatively high for all standard childhood immunisations.Appointments were available outside of school hours and thepremises were suitable for children and babies. Students who areresident in the local area for study may choose to register with thepractice but alternatively were seen as a temporary patient ifnecessary.

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). The needs of theworking age population, those recently retired and students hadbeen identified and the practice had adjusted the service availabilityit offered to ensure these were accessible, flexible and offeredcontinuity of care. The practice was proactive in offering onlineservices as well as a full range of health promotion and screeningthat reflected the needs of this age group, such as NHS Healthchecks for those between 40 and 74 years. The practice offered goodaccess to GPs for telephone consultations. They offered extendedhours with both GPs and nurses for patients with chronic diseases.There were pre-bookable GP appointments and pre-bookabletreatment room appointments to help patients plan their healthcare. They offered on line access for patients to order prescriptionsand book appointments. The practice could refer patients to thecommunity health trainers to offer local support to patients toimprove health and well-being.

Good –––

People whose circumstances may make them vulnerableThe practice is rated as good for the care of people whosecircumstances may make them vulnerable. They held a register ofvulnerable patients including those patients living with a learningdisability. The practice support residents living at a residential homewhich was attached to the National Star College. Patients had adirect line to the practice, and had a dedicated GP overseeing theircare. The practice also maintains a supportive care register whichincluded patients with life-limiting conditions and those needingterminal or palliative care The practice regularly worked withmulti-disciplinary teams in the case management of vulnerablepatients. Staff knew how to recognise signs of abuse in vulnerableadults and children. Staff were aware of their responsibilitiesregarding safeguarding concerns and how to contact relevantagencies in normal working hours and out of hours. Patients couldaccess additional services onsite such as substance misuse services.

Good –––

Summary of findings


They had a GP who took the lead managing patients with learningdisabilities. The practice did not routinely register homeless patientsas these people were supported and catered for at a nearbyspecialist facility.

People experiencing poor mental health (including peoplewith dementia)The practice is rated as good for the care of people experiencingpoor mental health (including patients with dementia). The practiceregularly worked with multi-disciplinary teams in the casemanagement of patients experiencing poor mental health, includingthose living with dementia. The practice accessed community basedsupport services for patients living with dementia.

Staff had received training about how to care for patients withmental health needs and dementia. The practice had told patientsexperiencing poor mental health about how to access varioussupport groups and voluntary organisations such as talkingtherapies.

Good –––

Summary of findings


What people who use the service sayWe spoke with five patients visiting the practice andreceived five comment cards from patients. It should benoted that the practice did not receive comment cardsuntil two days prior to the inspection. We also looked atthe practices NHS Choices website to look at commentsmade by patients, all of which expressed a positive viewof the practice. (NHS Choices is a website which providesinformation about NHS services and allows patients tomake comments about the services they received). Wealso looked at data provided in the most recent NHS GPpatient survey.

We found that the national GP patient survey datapublished on 4 July 2015 was comparable or better thanthe average for the Gloucestershire ClinicalCommissioning Group (CCG), and reflected patientcomments as expressed on NHS Choices. There were 284survey forms distributed for the practice and 117 formswere returned. This was a response rate of 44.3%:

• 86.7% of respondents found it easy to get through tothe practice by phone compared to a CCG average of83.6% and a national average of 73.8%.

• 90.7% of respondents found the receptionists at thispractice helpful compared to a CCG average of 90.1%and a national average of 86.8%.

• 62% of respondents with a preferred GP usually get tosee or speak to that GP compared to a CCG average of68.5% and a national average of 60%.

• 96.2% of respondents were able to get anappointment to see or speak to someone the last timethey tried compared to a CCG average of 89.5% and anational average of 85.2%.

• 92.6% of respondents said the last appointment theygot was convenient this was lower than the CCGaverage of 92.9% and the national average of 91.8%.

• 74.2% usually wait 15 minutes or less after theirappointment time to be seen compared to a CCGaverage of 69.1% and a national average of 64.8%.

We read the commentary responses from patients on theCQC comment cards and Friends and Family Test andnoted they included observations such as

• The services were very good or excellent.• Appointment access was good for patients who

confirmed they were able to get appointments on theday if urgent.

• Staff were helpful, respectful and interested in thepatients.

• Patients felt treated with dignity and respect• Patients expressed their satisfaction overall with the

treatment received.

We also spoke to patients who were very positive, praisedthe care and treatment they received and felt confident intheir treatment.

The practice had a patient participation group (PPG) with46 members. The gender and ethnicity of group wasrepresentative of the total practice patient population,the group was widely advertised and information aboutthe group was available on the website and in thepractice. From the PPG action plan the practice hadmanaged the following issues :

• Put into place a telephone in the waiting area directlylinking to the reception to provide a direct contact tostaff.

• Implemented barrier control for the car park exit toprevent people parking so patients could exit the carpark safely.

• Worked with the landlord to improve the buildingsignage at the main entrance to make it clearer forpatients.

• Changed the Heathville waiting room layout to removeany hazards.

• Improved confidentiality for patients at the TuffleySurgery by the addition of a radio in the waiting roomto muffle noise from consulting rooms.

The practice had also commenced their ‘friends andfamily test’ which was available in a paper format placedin the reception area and online. The results fromDecember 2014 to date indicated that 201 of the patientswho responded stated they would recommend thepractice and commented about the efficiency andprofessionalism of the practice, whilst eight stated theywould not.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC Lead Inspector.The team included a GP special advisor, a nurse specialadvisor and a second CQC inspector.

Background to HeathvilleMedical Practice, AspenCentreHeathville Road Surgery is located within a purpose builtcentre called the Aspen Centre, in a suburb of Gloucester.They have approximately 10,100 patients registered.

The practice operates from two locations:

Heathville Road Surgery (main site)

Aspen Centre,

Horton Road,

Gloucestershire GL1 3PX

And

38 Warwick Avenue (branch surgery)

Tuffley

Gloucestershire

The main site is in a new purpose built health centre sharedwith other healthcare services. The branch surgery islocated in a converted bungalow. The consulting and

treatment rooms for the Heathville Road practice aresituated on the first floor. The practice has nine consultingrooms, one for each GP Partner and two allocated for anytrainee GPs on placement. There are three treatmentrooms for use by nurses, health care assistants and aphlebotomy room. The reception area and administrativestaff are sited on the ground floor; there is a waiting roomarea on the first floor. There is patient parking immediatelyoutside the practice with spaces reserved for those withdisabilities. The Heathville Road practice is fully accessibleand has easy access for children in pushchairs and hasbaby changing and feeding facilities on site. The branchsurgery at Warwick Avenue whilst having undergone arefurbishment and extension is limited by the constraints ofthe building. There is a patient waiting room, oneconsulting room and a treatment room and a receptionarea. Patients registered with the practice can access GPservices at both sites.

The practice is made up of six GP partners, three salariedGPs and the practice manager, working alongside threequalified nurses and one health care assistant and aphlebotomist. The practice is supported by anadministrative team made of medical secretaries,receptionists and administrators. The practice is open from8.30am until 6.30pm Monday to Friday for on the dayurgent and pre-booked routine GP and nurseappointments. Extended opening hours are available forprebookable appointments on a Thursday evening from18:30 to 20.00 at Heathville Road Surgery. The clinical staffwork across both sites whilst the administrative andreception staff work in one location.

The practice has a General Medical Services contract withNHS England (a nationally agreed contract negotiated

HeHeathvilleathville MedicMedicalal PrPracticactice,e,AspenAspen CentrCentreeDetailed findings


between NHS England and the practice). The practice iscontracted for a number of enhanced services includingextended hours access, patient participation,immunisations and unplanned admission avoidance.

The practice is a training practice and offers placements tomedical students and trainee GPs.

The practice does not provide out of hour’s services to itspatients, this is provided by the South West AmbulanceService Trust. Contact information for this service isavailable in the practice and on the website.

Patient Age Distribution

0-4 years old: 5.38%

5-14 years old: 10.53%

15-44 years old: 36.05%

45-64 years old: 27.04%

65-74 years old: 11.79%

75-84 years old: 6.88%

85+ years old: 2.33%

Gender

Male patients: 49.42 %

Female patients: 50.58 %

Other Population Demographics

% of Patients in a Residential Home: 0.44 %

% of Patients on Disability Living Allowance: 5.19 %

% of Patients from BME populations: 1.7 %

Why we carried out thisinspectionWe inspected this service as part of our newcomprehensive inspection programme under Section 60 ofthe Health and Social Care Act 2008 as part of ourregulatory functions. This inspection was planned to checkwhether the provider is meeting the legal requirements and

regulations associated with the Health and Social Care Act2008 (Regulated Activities) Regulations 2015, to look at theoverall quality of the service, and to provide a rating for theservice under the Care Act 2014.

Please note when referring to information throughout thisreport, for example any reference to the Quality andOutcomes Framework data, this relates to the most recentinformation available to the CQC at that time.

How we carried out thisinspectionBefore visiting, we reviewed a range of information we holdabout the practice and asked other organisations to sharewhat they knew. We carried out an announced visit on 27October 2015. During our visit we spoke with a range ofstaff including GPs, nurses, reception and administrativestaff and the management team, and spoke with patientswho used the service. We observed how patients werebeing cared for and talked with carers and/or familymembers and reviewed anonymised treatment records ofpatients.

To 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?

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 peoplewith dementia)

Detailed findings


Our findingsSafe track record and learning

There was an open and transparent approach and a systemin place for reporting and recording significant events.Patients affected by significant events received a timelyand sincere apology and were told about actions taken toimprove care. Staff told us they would inform the practicemanager of any incidents and there was also a recordingform available on the practice’s computer system. Allincidents received by the practice were entered onto thesystem and automatically treated as a significant event.The practice carried out an analysis of the significantevents.

We reviewed safety records, incident reports and minutesof meetings where these were discussed. Lessons wereshared to make sure action was taken to improve safety inthe practice. For example, we reviewed an incidentwhereby a patient had a particularly difficult diagnosiswhich had only been achieved after several consultations.The learning for the practice was to inform and accessfurther diagnostic pathways which may help diagnosis ofless common illnesses.

Safety was monitored using information from a range ofsources, including National Institute for Health and CareExcellence (NICE) guidance. This enabled staff tounderstand risks and gave a clear, accurate and currentpicture of safety. The practice used the National Reportingand Learning System (NRLS) eForm to report patient safetyincidents.

Overview of safety systems and processes

The practice had clearly defined and embedded systems,processes and practices in place to keep patients safe,which included:

• Arrangements were in place to safeguard adults andchildren from abuse that reflected relevant legislationand local requirements and policies were accessible toall staff. The policies clearly outlined who to contact forfurther guidance if staff had concerns about a patient’swelfare. There was a lead member of staff forsafeguarding. The GPs attended safeguarding meetings

when possible and always provided reports wherenecessary for other agencies. Staff demonstrated theyunderstood their responsibilities and all had receivedtraining relevant to their role.

• A notice was displayed in the waiting room, advisingpatients that nurses would act as chaperones, ifrequired. All staff who acted as chaperones were trainedfor the role and had received a disclosure and barringcheck (DBS). (DBS checks identify whether a person hasa criminal record or is on an official list of patientsbarred from working in roles where they may havecontact with children or adults who may be vulnerable).

• There were procedures in place for monitoring andmanaging risks to patient and staff safety. There was ahealth and safety policy available with a poster in thereception office. The practice had up to date fire riskassessments and regular fire drills were carried out. Allelectrical equipment was checked to ensure theequipment was safe to use and clinical equipment waschecked to ensure it was working properly. The practicealso had a variety of other risk assessments in place tomonitor safety of the premises such as control ofsubstances hazardous to health and infection controland legionella.

• Appropriate standards of cleanliness and hygiene werefollowed. We observed the premises to be clean andtidy. The practice nurse was the infection control clinicallead who liaised with the local infection preventionteams to keep up to date with best practice. There wasan infection control protocol in place and staff hadreceived up to date training. Annual infection controlaudits were undertaken and we saw evidence thataction was taken to address any improvementsidentified as a result. The practice had a dedicatedisolation room which could be used for patientspresenting with symptoms of a communicable illness.

• The arrangements for managing medicines, includingemergency drugs and vaccinations, in the practice keptpatients safe (including obtaining, prescribing,recording, handling, storing and security). Regularmedication audits were carried out with the support ofthe local CCG pharmacy teams to ensure the practicewas prescribing in line with best practice guidelines forsafe prescribing. Prescription pads were securely storedand there were systems in place to monitor their use.

• Recruitment checks were carried out and the two fileswe reviewed showed that appropriate recruitment

Are services safe?

Good –––


checks had been undertaken prior to employment. Forexample, proof of identification, references,qualifications, registration with the appropriateprofessional body and the appropriate checks throughthe Disclosure and Barring Service.

• Arrangements were in place for planning andmonitoring the number of staff and mix of staff neededto meet patients’ needs. There was a rota system inplace for all the different staffing groups to ensure thatenough staff were on duty.

Arrangements to deal with emergencies and majorincidents

There was an instant messaging system on the computersin all the consultation and treatment rooms which alertedstaff to any emergency. All staff received annual basic lifesupport training and there were emergency medicinesavailable in the treatment room. The practice had a

defibrillator available on the premises and oxygen withadult and children’s masks. There was also a first aid kitand accident book available. Emergency medicines wereeasily accessible to staff in a secure area of the practice andall staff knew of their location. All the medicines wechecked were in date and fit for use.

The practice had a comprehensive business continuity planin place for major incidents such as power failure orbuilding damage. The plan included emergency contactnumbers for staff to access and an alternate venue tooperate from.

Are services safe?

Good –––


Our findingsEffective needs assessment

The practice carried out assessments and treatment in linewith relevant and current evidence based guidance andstandards, including National Institute for Health and CareExcellence (NICE) best practice guidelines. The practice hadsystems in place to ensure all clinical staff were kept up todate. The practice had access to guidelines from NICE andused this information to develop how care and treatmentwas delivered to meet needs. Reviews of records wereconducted to provide assurance about best clinicalpractice.

Management, monitoring and improving outcomes forpeople

The practice participated in the Quality and OutcomesFramework(QOF). (This is a system intended to improve thequality of general practice and reward good practice). Thepractice used the information collected for the QOF andperformance against national screening programmes tomonitor outcomes for patients. The most recent resultswere provided by the practice for the year 2014-2015 where533.90 points had been achieved out of 559 of the totalnumber of points available. The practice had achievedmaximum points in the public health domain whichcovered cardiovascular disease prevention, blood pressuremonitoring, obesity and smoking advice. The practice hadachieved a lower than forecast target for the diabetesclinical domain. The practice had 633 patients (6%) withdiabetes who required regular reviews. We asked thepractice about this and were told about the action taken toaddress these issues. We were told a new member of staffhad been recruited who would be able to undertake thesereviews; the recall process had been changed, and existingstaff had been enrolled on specialist training to equip themto undertake diabetes care.

Data from 2013-14 showed:

• Performance achievement for the diabetes relatedindicators was 78.4% which was 17.2% below theClinical Commissioning Group (CCG) and 11.7% belowthe national average.

• The percentage of patients with hypertension havingregular blood pressure tests were 82.8% which wasbelow the CCG and national average, however the datafor 2014-15 showed this had improved and the practicehad achieved 100% of the available QOF points.

• Performance for mental health related andhypertension indicators was 84.2% which was 11.4%below the CCG and 6.2% below the national average,however the data for 2014-15 showed this had improvedand the practice had achieved 93.6% of the availableQOF points.

• The dementia indicators was 96.7% which wascomparable to the CCG average at 96.9% and above thenational average of 93.4%.

Clinical audits were carried out to demonstrate qualityimprovement and all relevant staff were involved toimprove care, treatment and patients’ outcomes. Therehad been seven clinical audits completed in the last year,one of these was a completed audit and the remainderwere ongoing so that improvements made wereimplemented and monitored. The practice participated inapplicable local audits, national benchmarking,accreditation, peer review and research. Findings wereused by the practice to improve services. For example, thepractice monitored and reviewed medicines prescribingwhich ensured patients received appropriate treatment.

We found information about patient’s outcomes was usedto signpost areas for clinical audit and make improvementssuch as a review of all existing and new patients with adiagnosis of prostate cancer was undertaken specifically ifpatients were overdue for prostate-specific antigen bloodtest (PSA) which measures the level in a patient's blood andis an indicator of prostate cancer. Of the 67 patientsreviewed, 15 required an intervention such as anoutpatient review or repeat blood test. The outcome fromthis identified the need for ongoing surveillance of patients’notes to ensure that they were followed up appropriately.

Effective staffing

Staff had the skills, knowledge and experience to delivereffective care and treatment.

• The practice had an induction programme for newlyappointed non-clinical members of staff that coveredsuch topics as safeguarding, fire safety, health andsafety and confidentiality.

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

Good –––


• The learning needs of staff were identified through asystem of appraisals, meetings and reviews of practicedevelopment needs. Staff had access to appropriatetraining to meet these learning needs and to cover thescope of their work. This included ongoing supportduring sessions, one-to-one meetings, appraisals,coaching and mentoring, clinical supervision andfacilitation and support for the revalidation of doctors.All staff had had an appraisal within the last 12 months.

• Staff received training that included: safeguarding, fireprocedures, basic life support and informationgovernance awareness. Staff had access to and madeuse of e-learning training modules and in-housetraining.

Coordinating patient care and information sharing

The information needed to plan and deliver care andtreatment was available to relevant staff in a timely andaccessible way through the practice’s patient record systemand their intranet system. This included care and riskassessments, care plans, medical records and test results.Information such as NHS patient information leaflets werealso available. All relevant information was shared withother services in a timely way, for example when patientswere referred to other services.

Staff worked together with other health and social careservices to understand and meet the range and complexityof patients needs and to assess and plan ongoing care andtreatment. This included when patients moved betweenservices, including when they were referred, or after theyare discharged from hospital. We saw evidence thatmulti-disciplinary team meetings took place on a monthlybasis and that care plans were routinely reviewed andupdated.

Consent to care and treatment

Patients’ consent to care and treatment was always soughtin line with legislation and guidance. Staff understood therelevant consent and decision-making requirements oflegislation and guidance, including the Mental Capacity Act2005. When providing care and treatment for children and

young patients, assessments of capacity to consent werealso carried out in line with relevant guidance. Where apatient’s mental capacity to consent to care or treatmentwas unclear the GP or nurse assessed the patient’s capacityand, where appropriate, recorded the outcome of theassessment.

Health promotion and prevention

Patients who may be in need of extra support wereidentified by the practice. These included patients in thelast 12 months of their lives, carers, those at risk ofdeveloping a long-term condition and those requiringadvice on their diet, smoking and alcohol cessation.Patients were then signposted to the relevant service. Adietician referral was available and smoking cessationadvice was available from a health care assistant.

The practice had a comprehensive screening programme.The practice’s uptake for the cervical screening programmeachieved 100% of expected QOF points. There was a policyto offer telephone reminders for patients who did notattend for their cervical screening test. The practice alsoencouraged its patients to attend national screeningprogrammes for bowel and breast cancer screening.

Childhood immunisation rates for the vaccinations givenwere comparable or above the Clinical CommissioningGroup (CCG) averages. For example, childhoodimmunisation rates for the vaccinations given to under twoyear olds ranged from 70.8% to 100% and five year oldsfrom 91.7% to 100%. The NHS England data whichbenchmarked the practice against others in the CCGindicated that the influenza vaccination rates for the over65s and for the ‘at risk’ groups, the practice was in theupper half of the group, these were above the CCG andnational averages.

Patients had access to appropriate health assessments andchecks. These included health checks for new patients andNHS health checks for patients aged 40–74. Appropriatefollow-ups on the outcomes of health assessments andchecks were made, where abnormalities or risk factorswere identified.

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

Good –––


Our findingsRespect, dignity, compassion and empathy

We observed throughout the inspection that members ofstaff were courteous and very helpful to patients bothattending at the reception desk and on the telephone andthat patients were treated with dignity and respect.Curtains were provided in consulting rooms so thatpatients’ privacy and dignity was maintained duringexaminations, investigations and treatments. We notedthat consultation and treatment room doors were closedduring consultations and that conversations taking place inthese rooms could not be overheard. Reception staff knewwhen patients wanted to discuss sensitive issues orappeared distressed they could offer them a private roomto discuss their needs.

All of the five patient CQC comment cards we received werepositive about the service experienced. Patients said theyfelt the practice offered an excellent service and staff werehelpful, caring and treated them with dignity and respect.We also spoke with a member of the patient participationgroup (PPG) on the day of our inspection. They also told usthey were satisfied with the care provided by the practiceand said their dignity and privacy was respected. Commentcards highlighted that staff responded compassionatelywhen they needed help and provided support whenrequired.

Results from the national GP patient survey published on 4July 2015 showed patients were happy with how they weretreated and that this was with compassion, dignity andrespect. The practice was well above average for itssatisfaction scores on consultations with doctors andnurses. For example:

• 93.8% said the GP was good at listening to themcompared to the Clinical Commissioning Group (CCG)average of 91% and national average of 88.6%.

• 93% said the GP gave them enough time compared tothe CCG average of 89.3% and national average of86.6%.

• 100% said they had confidence and trust in the last GPthey saw compared to the CCG average of 96.6% andnational average of 95.2%.

• 89.2% said the last GP they spoke to was good attreating them with care and concern compared to theCCG average of 87.9% and national average of 85.1%.

• 93.4% said the last nurse they spoke to was good attreating them with care and concern compared to theCCG average of 92.1% and national average of 90.4%.

• 90.7% patients said they found the receptionists at thepractice helpful compared to the CCG average of 90.1%and national average of 86.8%.

Care planning and involvement in decisions aboutcare and treatment

Patients we spoke with told us that health issues werediscussed with them and they felt involved in decisionmaking about the care and treatment they received. Theyalso told us they felt listened to and supported by staff andhad sufficient time during consultations to make aninformed decision about the choice of treatment availableto them. Patient feedback on the comment cards wereceived was also positive and aligned with these views.

Results from the national GP patient survey we reviewedshowed patients responded positively to questions abouttheir involvement in planning and making decisions abouttheir care and treatment and results were in line with localand national averages. For example:

• 93.2% said the last GP they saw was good at explainingtests and treatments compared to the ClinicalCommissioning Group (CCG) average of 89.1% andnational average of 86.0%.

• 88.7% said the last nurse they saw was good at involvingthem in decisions about their care compared to the CCGaverage of 86.5% and national average of 84.8%.

Staff told us that translation services were available forpatients who did not have English as a first language. Wesaw notices in the reception areas informing patients thisservice was available.

Patient and carer support to cope emotionally withcare and treatment

Notices in the patient waiting room told patients how toaccess a number of support groups and organisations.

The practice’s computer system alerted GPs if a patient wasalso a carer. There was a practice register of all patientswho were carers and 76 patients had been identified ascarers and were being supported by the practice carer’schampion. Additional support was offered through offering

Are services caring?

Good –––


health checks and referral for social services support.Written information was available for carers to ensure theyunderstood the various avenues of support available tothem.

Staff told us that if families had suffered bereavement, theirusual GP contacted them. This call was either followed by apatient consultation at a flexible time and location to meetthe family’s needs and/or by giving them advice on how tofind a support service.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needs

The practice worked with the local Clinical CommissioningGroup (CCG) to plan services and to improve outcomes forpatients in the area. For example, the practice hadparticipated in a pilot clinical audit with the CCG, whichascertained the appropriateness of referrals of patients forurgent care.

• Services were planned and delivered to take intoaccount the needs of different patient groups and tohelp provide ensure flexibility, choice and continuity ofcare. For example, urgent access appointments wereavailable for children and those with more acutemedical conditions.

• There were longer appointments available for patientswith long term chronic diseases.

• Extended hours appointments were available forworking patients

• The practice was part of a pilot scheme called ChoicePlus. This meant that patients registered with thepractice could access on the day appointments at thelocal walk in centre, the agreement was that the practicecould access up to 30 appointments each week. Thisfreed up time for the practice GPs to concentrate on themanagement of patients with chronic illness.

• The practice responded to requests from patientsunable to go to the surgery, for home visits. One GP wasallocated an afternoon each day to undertake thesevisits which allowed sufficient time for visits to be madewithout needing to return to the practice for afternoonsurgery. Any time not spent on urgent home visits wasused by GPs to make additional visits to chronically illpatients.

• A GP held regular clinics in three local care homes forolder people which promoted continuity of care for thepatients.

• The practice operated INR star which offered onsiteanticoagulant blood testing and allowed for immediateresults for patients who were monitored for the correctdosage of anticoagulant medicine.

• The practice hosted sessions with a mental health nursefor the mental health intermediate care team once aweek , they also attended the monthly multidisciplinaryteam meetings.

• The Aspen Centre was fully accessible for all patientswith services provided over two floors, an audio lift gaveaccess to the second floor; a hearing loop andtranslation services were available at both sites.

• The branch surgery gave patients choice andaccessibility to a local GP service.

• The practice had a number of patients with learningdisabilities and complex needs to whom they offered adirect telephone line to the practice and completedhome visits where appropriate including for fluvaccinations. The new building at the Aspen Centre isaccessible and these patients were encouraged to visitthe practice to be an inclusive community basedresource.

• The practice hosted additional healthcare services; bothNHS funded and privately funded, which allowedpatients single site access to a variety of treatments.

• The practice had been successful in its application tothe Prime Ministers fund to provide additionalrespiratory nursing support for their patients.

• Patients with a learning disability were invited to attenda yearly comprehensive health review whichfollowedthe Cardiff protocols. Patients were sent accessibleinformation in order to be prepared for theirappointment.

Access to the service

The practice was open between 8.30am and 6.00pmMonday to Friday. There were prebookable appointmentsup to six weeks ahead. They offered a number ofemergency appointments each day to support thosepatients who needed to be seen urgently. Extended hourssurgeries were offered until 8.00pm on Thursdays for thosepatients who found it difficult to get to the surgery duringnormal working hours. In addition the branch surgery wasopen between 8.30am and 5.30pm Monday to Wednesdayand 8.30am and 2.30pm Thursday and Friday. Both GP andnurse appointments were offered at the branch surgery.Midwife appointments were also available at both sites.

Results from the national GP patient survey published July2015 showed that patient’s satisfaction with how theycould access care and treatment was above the local andnational averages. Patients we spoke to on the day wereable to get appointments when they needed them. Forexample:

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

Good –––


• 86.7% patients said they could get through easily to thesurgery by phone compared to the ClinicalCommissioning Group (CCG) average of 83.6% andnational average of 73.3%

• 87.4%patients described their experience of making anappointment as good compared to the CCG average of80.9% and national average of 73.3%

• 74.2% patients said they usually waited 15 minutes orless after their appointment time compared to the CCGaverage of 69.1% and national average of 64.8%

• 96.2% of patients who were able to get an appointmentto see or speak with someone the last time they triedcompared to the CCG average of 89.5% and nationalaverage of 85.2%

Listening and learning from concerns and complaints

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. There was a designated responsibleperson who handled all complaints in the practice.

We saw that information was available to help patientsunderstand the complaints system on the practice websiteand posters displayed within the practice. Patients wespoke with were aware of the process to follow if theywished to make a complaint.

We looked at a selection of complaints received in the last12 months and found these were satisfactorily handled anddealt with in a timely way to achieve a satisfactory outcomefor the complainant. For example, complaints wereresponded to by the most appropriate person in thepractice and wherever possible by face to face or telephonecontact. The information from the practice indicated all thecomplaints received had been resolved without referenceto other outside agencies.

Lessons were learnt from concerns and complaints andaction was taken to as a result to improve the quality ofcare. We found the learning points from each complainthad been recorded and communicated through the teamsuch as greater awareness of explaining processes topatients who were offered appointments at the local walkin centre.

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

Good –––


Our findingsVision and strategy

Leaders within the practice had an inspiring sharedpurpose; they strove to deliver and motivate staff tosucceed. The practice had a clear vision to deliver highquality care and promote good outcomes for patients. Weheard from all the staff we spoke with that there was a‘patient first’ ethos within the practice. This wascorroborated by the patients with whom we spoke. Wefound that there was strong leadership and strategic visionwithin the practice.

We found the partners in the practice understood their rolein leading the organisation and enabling staff to providegood quality care. The practice had a strategic approach tofuture planning and had put in place successionarrangements to identify and address future risks topersonnel leaving or retiring. Another example of this wasthe time and attention by the practice to the Aspen Centrebuilding layout and ‘future proofing’ for development withadditional space being included in the plan. This hadresulted in other healthcare services being sited within thecentre offering a range of NHS and private services such asaortic aneurism screening and minor surgery.

We found details of the vision and practice values were partof the practice’s strategy and business planning. Thepractice vision and values included, providing the highestquality care which meets the identified needs of patientswhilst supporting patients to make decisions to improveand maintain their health. Staff told us that they treatedpatients with courtesy, dignity and respect at all times byputting patients at the centre of everything the practicedoes.

The practice also participated and engaged with colleaguesas part of the Gloucestershire Clinical CommissioningGroup (CCG) locality. There was a whole team approach tochange and innovation which involved the staff and thepatient participation group and related agencies such asthe CCG.

Governance arrangements

Staff were able to demonstrate their understanding andcommitment to providing high quality patient centred care.The leadership, governance and culture were used to driveand improve the delivery of high-quality person-centredcare.

We found the practice had systems in place for monitoringthe quality of care, for example, audits, procedures,reviews, monitoring mechanisms, questionnaires andmeetings. These individual aspects of governance providedevidence of how the practice functioned and the level ofservice quality and reflected the high quality of care weobserved was delivered to patients.

The practice held a series of meetings which contributed tothe governance of the practice. These included monthlywhole staff meetings, weekly partners meetingsandfortnightly nurses meetings which monitored patientoutcomes in respect of quality audits, serious andsignificant events, complaints, patient feedback,performance data and other information relating to thequality of the service. We saw meeting minutes and reportsthat demonstrated the practice routinely reviewed dataand information to improve quality of service andoutcomes for patients.

We found the practice approached governance andimprovement in a supportive and collaborative way,making use of additional resources such as the ClinicalCommissioning Group (CCG) purchase of online training.The practice had a number of policies and procedures inplace to govern activity and these were available on ashared drive which staff could access from any computer inthe practice. We looked at a number of these policies andprocedures and found that they had been reviewedregularly and were up to date. GPs and nursing staff wereprovided with clinical protocols and pathways to follow forsome of the aspects of their work such as written protocolsfor nursing procedures which followed best practice for theadministration of vaccines.

The GPs met informally on a daily basis to review, reflectand discuss any patients concerns or issues. The GPs wespoke to recognised this as being a valuable session bothas a supportive mechanism and a learning forum. SalariedGPs and trainees were included in meetings and this wasreflected in the conversations we had with them wherethey felt included and valued in the running anddevelopment of the service. The practice provided us witha list of the areas for which each partner GP took the

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

Good –––


professional lead in the practice. The practice also had theethos of completing the work that came in on the same dayincluding making sure all test results were reviewed on theday they arrived.

We spoke with 10 members of staff and they were all clearabout their roles and responsibilities. They told us they feltvalued, well supported and would go to the practicemanager with any concerns. We found that theresponsibility for improving outcomes for patients wasshared by all staff. For example, all the staff undertookdementia awareness training to be able to understand andcommunicate more effectively with patients living withdementia.

The practice used the Quality and Outcomes Framework(QOF) to measure its performance. The QOF data for thispractice was equitable with national standards. Whentargets were not met appropriate action had been taken toaddress the shortfall. For example, the practice recognisedthey had not achieved all the review targets for their largenumber of patients with diabetes. They had engagedanother member of staff who was experienced andqualified to undertake diabetes reviews and sponsoredanother member of staff to undertake specialist training inthis area. The practice had systems in place to monitor andimprove quality.

The practice ensured risks to the delivery of care wereidentified and mitigated before they became issues. Wefound risk assessments had been carried out where riskswere identified and action plans had been produced andimplemented, for example within the business continuityplan. We discussed how the practice monitored ‘at risk’patients to meet the requirements of the enhancedservices. For example, the ‘Avoiding UnplannedAdmissions' enhanced service meant the practice neededto be proactive in identifying vulnerable patients andensuring care plans were in place and were regularlyreviewed.

The practice had a continuous programme of clinical auditwhich it used to monitor quality and systems to identifywhere action should be taken, informed by outcomes forpatients. For example, the minor surgery outcomes wereaudited annually to ensure that patients had received safe,effective treatment. The practice periodically looked at

other indicators such as survey results, other forms ofpatient feedback, sudden deaths, diagnosis of new cancersand staff appraisals to provide an in depth review of serviceprovision and shape their ongoing business plan.

Leadership, openness and transparency

There was a well-established management structure withclear allocation of responsibilities. We spoke with a numberof staff, both clinical and non-clinical, and they were allclear about their own roles and responsibilities. They wereable to tell us what was expected of them in their role andhow they kept up to date. Staff told us there was an openculture in the practice and they could report any incidentsor concerns about the practice. This ensured honesty andtransparency was at a high level. We saw evidence ofincidents that had been reported by staff, and these hadbeen investigated and actions identified to prevent arecurrence. The staff we spoke with were clear about howto report incidents. Staff told us they felt supported by thepractice manager and the clinical staff and they workedwell together as a team. We were shown the online staffinformation and handbook which was available to all staff.Those we spoke with knew where to find these policies ifrequired.

The practice was proactive in planning for future needs;GPs and nurses were being provided the opportunities andaccess to additional training to improve services andenhance their skills. There was evidence that the practicetook the welfare of its staff seriously and performance wasreviewed to support staff to develop and improve. Thepartners and manager also had a yearly away day whichwas intended to review, consolidate and plan for theservice. The away day was an opportunity to undertake areview of the previous year, includingwhat had been thesuccesses and what could have been done better ordifferently, and looking forward to where the practice wasgoing. This demonstrated the practice took an innovativeapproach to team productivity and improvement.

A GP partner held lead responsibility within the practice asthe Caldicott Guardian and was clear about their role. ACaldicott Guardian is a senior person responsible forprotecting the confidentiality of patient and service-userinformation and enabling appropriate information-sharing.Each NHS organisation is required to have a CaldicottGuardian; this was mandated for the NHS by Health ServiceCircular: HSC 1999/012. The practice had protocols in placefor confidentiality, data protection and information sharing.


Good –––


Information on the practice website also told patientsabout policies such as confidentiality and how patientscould access their own records. The practice also had apolicy to follow for patients who made freedom ofinformation requests.

Seeking and acting on feedback from patients, publicand staff

The practice demonstrated a strong commitment toseeking and listening to patient views. They showed us arange of evidence, such as patient feedback, complimentsand complaints they had used to focus improvements onthe needs and wishes of patients. This included celebratingwhat had gone well as well as identifying areas forimprovement. For example, following the move from theold premises at Heathville Road to the new premises atHorton Road the practice had gathered feedback from 122patients through a patient survey specifically about thenew location. The survey included comments andobservations such as improving the signage to the practiceon the main road. This had been raised with the landlordby the practice manager and was in the process of beingactioned.

The patient participation group (PPG) includedrepresentatives from various population groups. The PPGhad been involved in the patient surveys twice yearly. Theresults and actions agreed from these surveys are availableon the practice website. Members were consulted aboutsurveys and changes within the practice such as using theAspen Centre proactively to promote health issues. ThePPG were highly regarded by the practice managementteam for their contributions to shaping the way the practicefunctioned.

The practice had gathered feedback from staff through staffaway days and generally through staff meetings, appraisalsand discussions. There was a low turnover of staff who toldus they would not hesitate to give feedback and discussany concerns or issues with colleagues and themanagement. The practice had a whistleblowing policywhich was available to all staff in the staff handbook andelectronically on any computer within the practice.

Innovation

There was a focus on improvement and learning shared byall staff. The practice was a GP training practice with twopartners taking lead responsibility for GP training. Theethos of the practice was that GPs in training brought newideas and ways of working to the practice, and were able tochallenge established practice. It also provided practicalexperience for medical students.

Staff told us that the practice supported them to maintaintheir clinical professional development through trainingand mentoring. In the staff files we looked at we sawregular appraisal took place which included a personaldevelopment plan. Staff told us that the practice was verysupportive of training.

The practice culture was innovative, forward looking andadaptable, they participated in joint working for localservice developments such as accessing the PrimeMinisters Challenge Fund to provide additional support tothe practice to address any shortfalls or any identifiedadditional needs of the patient population. In the practicethis had resulted in an additional four hours per week forsix weeks of a trained nurse experienced in managing longterm respiratory disease to undertake reviews. One of theGP partners acted as the CCG deputy chairperson.

The practice took part in research and pilot projects suchas the audit of direct patient discharges which hadreviewed the appropriateness of hospital referrals by thepractice. This involved an audit of direct discharges fromthe local emergency department to ensure referrals madeby the practice were appropriate. This was competed as apilot which after evaluation was rolled out to theGloucestershire CCG for completion. The practice was alsoinvolved with the ‘Atrial Fibrillation in Primary Care Projectfor Gloucestershire’ which was part of a national initiativeto increase diagnosis and reduce strokes. These projectscontributed to the practice remaining up to date with latestdevelopments in clinical care.

The practice collaborated with the two other practicesbased within the building to develop shared workingpractices which contributed to the safety and well-being ofpatients who used the services.


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Documents

Heathville Medical Practice, Aspen Centre ... · Thisreportdescribesourjudgementofthequalityofcareatthisservice.Itisbasedonacombinationofwhatwefound whenweinspected