Avenue Medical Practice NewApproachComprehensive Report ... · Families,childrenandyoungpeople...

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 –––

AAvenuevenue MedicMedicalal PrPracticacticeeQuality Report

5 Osborne AvenueNewcastle Upon TyneTyne and WearNE2 1JQTel: Tel: 0191 2810041Website: www.avenuemedicalpractice.co.uk

Date of inspection visit: 20 October 2015Date of publication: This is auto-populated when thereport is published

1 Avenue Medical Practice Quality Report This is auto-populated when the report is published

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 Avenue 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 GeneralPractice

We carried out an announced comprehensive inspectionat the Avenue Medical Practice on 20 October 2015.Overall the practice is rated as good.

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

• Staff understood and fulfilled their responsibilities toraise concerns, and report incidents and near misses.

• Risks to patients and staff were assessed and wellmanaged.

• Patients’ needs were assessed and care was plannedand delivered following best practice guidance. Staffhad received training appropriate to their roles andresponsibilities.

• The practice had good facilities and was well equippedto treat patients and meet their needs. Areas forfurther improvement had been identified and the staffteam was working with NHS England to secure these.

• Information about how to complain was available andeasy to understand.

• Patients said they were treated with compassion,dignity and respect and were involved in decisionsabout their care and treatment. Results from thenational GP Patient Survey showed good levels ofpatient satisfaction regarding the quality of the careand treatment provided by the GP partners and thepractice nurse.

• Patients reported good access to the practice andappointments.

• There was a clear leadership structure and staff feltsupported by the management team. Goodgovernance arrangements were in place.

• Staff had a clear vision for the development of thepractice and were committed to providing theirpatients with good quality care. This included a goodpractice development plan which set out theirpriorities for development.

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.

Staff understood and fulfilled their responsibilities to raise concerns,and to report incidents and near misses. Lessons were learned whenthings went wrong and shared with staff to support improvement.There was an effective system for dealing with safety alerts andsharing these with staff. Individual risks to patients had beenassessed and were well managed. Good medicines managementsystems and processes were in place and there were appropriatearrangements for recruiting and vetting staff. The premises wereclean and hygienic and there were good infection control processesin place.

Good –––

Are services effective?The practice is rated as good for providing effective services.

Nationally reported Quality and Outcomes Framework (QOF) datashowed the practice had performed well in providing recommendedcare and treatment to their patients. Staff referred to guidance fromthe National Institute for Health and Care Excellence (NICE) andused it routinely. Patients’ needs were assessed and care wasplanned and delivered in line with current legislation. This includedthe promotion of good health, and the provision of advice andsupport to patients to help them manage their health andwellbeing. Staff worked with other health care professionals to helpensure patients’ needs were met. There was an effective staffappraisal system, and staff had access to the training they needed tocarry out their duties. Staff had completed a variety of clinical auditsand used these to improve patient outcomes.

Good –––

Are services caring?The practice is rated as good for providing caring services.

Patients said they were treated with compassion, dignity andrespect and were involved in decisions about their care andtreatment. The practice had put good arrangements in place tomeet the needs of carers. Results from the national GP PatientSurvey showed patients were satisfied with the quality of the careand treatment they received from the GP partners and the practicenurse. During the inspection we saw staff treated patients withkindness and respect, whilst maintaining patient confidentiality. The

Good –––

Summary of findings


survey also showed that patient satisfaction levels with access to thepractice and appointments were significantly higher than both thelocal cinical commissioning group (CCG) and the national averages.This was reflected in the feedback we received from patients.

Are services responsive to people’s needs?The practice is rated as good for providing responsive services.

Staff had reviewed the needs of their patient population and wereproviding services to meet them. The practice engaged with thelocal CCG and worked with them to improve and develop patientcare. The practice had good facilities and was well equipped to treatpatients and meet their needs. Information about how to complainwas available and easy to understand. Evidence provided during theinspection showed that the practice responded quickly to any issuesraised. Patients said they found it easy to make an appointment witha named GP which helped provide continuity of care. Urgent, sameday appointments and telephone consultations were available.

Good –––

Are services well-led?The practice is rated as good for being well-led.

The GP partners and the practice manager had a clear vision abouthow they wanted the practice to grow and develop, and were takingsteps to deliver this. The practice had good governance processes,and these were underpinned by a range of policies and proceduresaccessible to all staff. There were systems and processes in place toidentify and minimise risks to patients and staff, and to monitor thequality of services provided. The practice team had taken action toensure their compliance with the national standards andunderpinning regulations. They had regularly monitored andreviewed their performance since their registration in order toimprove the quality of the services they provided. Regular practiceand multi-disciplinary team meetings took place, these helped toensure patients received effective and safe clinical care. The practiceproactively sought feedback from patients who were encouragedand supported to comment on how services were delivered.

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.

Staff provided proactive, personalised care which met the needs ofolder patients. Patients aged 75 and over had been allocated anamed GP to help ensure their needs were met. Good arrangementshad been made to meet the needs of ‘end of life’ patients. Staff heldregular palliative care meetings with other healthcare professionalsto review the needs of these patients and ensure they were met. Thepractice offered home visits and longer appointment times wherethese were needed by older patients. Nationally reported datashowed the practice had performed well in providing recommendedcare and treatment for the clinical conditions commonly associatedwith this population group. For example, the practice had obtained100% of the Quality and Outcomes Framework (QOF) pointsavailable to them for the cancer clinical indicator. This was 3.6%above the local clinical commissioning group (CCG) average and2.1% above the England average. 76.9% of patients aged 65 years orover received a seasonal influenza vaccination which was betterthan the national average of 73.2%.

Good –––

People with long term conditionsThe practice is rated as good for the care of people with long-termconditions.

Effective systems were in place which helped ensure patients withlong-term conditions received an appropriate service which mettheir needs. These patients all had a named GP and received anannual review to check that their needs were being met. For thosepeople with the most complex needs, the named GP worked withother relevant health and care professionals to deliver amultidisciplinary package of care. Nationally reported data showedthe practice had performed well in providing recommended careand treatment for the clinical conditions commonly associated withthis population group. For example, the practice had obtained 100%of the QOF points available to them for the chronic kidney diseaseindicator. This was 4.6% above the local CCG average and 5.3%above the England average. Patients at risk of hospital admissionwere identified as a priority, and steps were taken to manage theirneeds. Staff had completed the training they needed to providepatients with safe care.

Good –––

Summary of findings


Families, children and young peopleThe practice is rated as good for the care of families, children andyoung people.

Antenatal and baby clinics were held by midwifery and health visitorstaff attached to the practice. The GP partners provided support tothese clinics. A full, child immunisation programme was provided.For example, the data showed that 100% of eligible children hadreceived eight of the 18 childhood immunisations included in theprogramme and over 90% of eligible children had received seven ofthe other childhood immunisations. With regard to the other threeimmunisations over 87% had received these. Younger patients wereable to access contraceptive and sexual health services, andappointments were available outside of school hours. There weresystems in place to identify and follow up vulnerable children whowere at risk of harm and neglect. Nationally reported data showedthe practice had performed well in providing recommended careand treatment for this group of patients. For example, the QOF datafor 2014/15 showed the practice had obtained 100% of the overallpoints available to them for providing cervical services. This was1.8% above the local CCG average and 2.4% above the Englandaverage. 82.4% of women aged between 25 and 65 had received acervical screening test in the preceding five years compared to thenational target rate of 80%.

Good –––

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 practice had assessed the needs of this group of patients anddeveloped their services to help ensure they received a servicewhich was accessible, flexible and provided continuity of care. Thepractice was proactive in offering online services, as well as a fullrange of health promotion and screening that reflects the needs ofthis group of patients. Nationally reported data showed the practicehad performed well in providing recommended care and treatmentfor this group of patients. For example, the QOF data for 2014/15showed the practice had obtained 100% of the overall pointsavailable to them for providing for patients with hypertension. Thiswas 2.2% above both the local CCG and the England averages.

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 held a register of patients living in vulnerablecircumstances including patients with learning disabilities. Staffcarried out annual health checks for patients who had a learning

Good –––

Summary of findings


disability and offered longer appointments. Staff provided GPconsultations for homeless men at a local healthcare centre, and,where appropriate, had made referrals to secondary care so patientscould access appropriate healthcare. Staff provided vulnerablepatients with information about how to access various supportgroups and voluntary organisations. Staff knew how to recognisesigns of abuse in vulnerable adults and children. Staff understoodtheir responsibilities regarding information sharing, thedocumentation of safeguarding concerns and contacting relevantagencies.

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).

Nationally reported data showed the practice had performed well inproviding recommended care and treatment to patients with mentalhealth needs. For example, the QOF data for 2014/15 showed thepractice had obtained 100% of the overall points available to themfor providing care and treatment to patients with mental healthneeds. This was 7.3% above the local CCG average and 7.2% abovethe England average. Patients were provided with advice about howto access relevant support groups and voluntary organisations.Patients were also able to access in-house and local ‘TalkingTherapy’ services. There were written guidelines for staff setting outwhat they should do to meet the needs of patients with poor mentalhealth. Patients received annual healthcare reviews and had theopportunity to participate in the preparation of their personal careplans. One of the GP partners acted as the adult mental health leadfor the local CCG, to help improve and develop services for thisgroup of patients. The lead GP for patients with mental health needshad reviewed the reasons why some of these patients failed toattend planned appointments, and they had provided receptionstaff with guidance regarding how they should follow up patientswho did not attend.

Good –––

Summary of findings


What people who use the service sayWe spoke to five patients during our inspection, one ofwhom was a member of the practice’s patientparticipation group (PPG). All of these patients werecomplimentary about the practice, the staff who workedthere and the quality of service and care provided. Theytold us the staff were caring and helpful. They also saidthey were treated with respect and dignity at all times,they were very happy with the appointments system andthe premises were always kept clean and tidy.

As part of our inspection we asked practice staff to invitepatients to complete CQC comment cards. We received34 completed comment cards. All the respondents werepositive about the standard of care and treatmentprovided. Words used to describe the service included:pleasant; responsive; very impressive; very caring;welcoming; fantastic service; very professional andfriendly service; exceptional; very efficient; would highlyrecommend. None of the patients who completedcomment cards raised any concerns about the care andtreatment they received at the practice.

The results of the national GP Patient Survey of thepractice, published in July 2015, showed theirperformance was above, or in line with, most of the localCCG averages, and was above the national averages forall of the areas covered by the survey. (There were 112responses and a response rate of 26%.)

For example, of the patients who responded to thesurvey:

• 98% found it easy to get through to this surgery bytelephone, compared with the local CCG average of78% and the national average of 73%.

• 94% found the receptionists at this surgery helpful,compared with the local CCG and national averagesof 87%.

• 87% who had a preferred GP said they usually got tosee or speak to that GP, compared with the CCGaverage of 61% and the national average of 60%.

• 93% were able to get an appointment to see orspeak to someone the last time they tried, comparedwith the local CCG and national averages of 85%.

• 100% said the last appointment they got wasconvenient, compared with the local CCG average of93% and the national average of 92%.

• 96% had confidence and trust in the last GP theysaw, compared with the local CCG average of 96%and the national average of 95%.

• 88% said the last GP they saw or spoke with wasgood at treating them with care and concern,compared to the local CCG average of 87% and thenational average of 85%.

• 100% said they had confidence and trust in the lastnurse they saw or spoke to, compared with the localCCG average of 98% and the national average of97%.

• 95% said the last GP they saw or spoke with wasgood at treating them with care and concern,compared to the local CCG average of 92% and thenational average of 90%.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC Lead Inspector.The team included another CQC inspector, and a GPspecialist advisor.

Background to AvenueMedical PracticeThe Avenue Medical Practice is registered with the CareQuality Commission to provide primary care services. Thepractice provides services to approximately 2962 patientsfrom one location:

• 5 Osborne Avenue, Jesmond, Newcastle Upon Tyne,NE21JQ.

The Avenue Medical Practice is a small practice providingcare and treatment to patients of all ages, based on aGeneral Medical Services (GMS) contract. The practice issituated in the Jesmond area of Newcastle-Upon-Tyne andis part of the NHS Newcastle Gateshead clinicalcommissioning group (CCG.) The health of people who livein Newcastle is varied when compared to the Englandaverage. Deprivation is higher than average, with about13200 (29%) of children living in poverty. Life expectancy forboth men and women is lower than the England average.Life expectancy is 11.9 years lower for men and 9.1 yearslower for women, in the most deprived areas of Newcastle.

The Avenue Medical Practice is located in an adaptedresidential building and provides patients with fullyaccessible treatment and consultation rooms. All GP andnurse consultation rooms are on the ground floor. Thepractice provides a range of services and clinics including,

for example, services for patients with asthma and heartdisease. There are two GP partners (one male and onefemale), a practice manager, a practice nurse, and a teamof administrative and reception staff.

The practice is open on Monday and Tuesday between 8amand 6:30pm, and on Wednesday, Thursday and Fridaybetween 8:30am and 6pm. GP appointment times were asfollows:

Monday: 8:30am-10:50pm; 15:40pm to 6:30pm.

Tuesday: 8am to 10:30am and 4pm to 6:30pm.

Wednesday: 8am to 12 noon and 1pm to 6pm.

Thursday: 8:30am to 12 noon, 1pm to 2pm and 2:30pm to6pm.

Friday: 8:30pm to 10:30am and 3:30pm to 6pm.

Extended hours GP appointments were offered onalternate Saturdays, between 8:30am and 11am.

The service for patients requiring urgent medical attentionout of hours is provided by the NHS 111 service andNorthern Doctors Urgent Care Limited (NDUC).

Why we carried out thisinspectionWe inspected this service as part of our comprehensiveinspection programme.

We carried out a comprehensive inspection of this serviceunder Section 60 of the Health and Social Care Act 2008 aspart of our regulatory functions. This inspection wasplanned to check whether the registered provider is

AAvenuevenue MedicMedicalal PrPracticacticeeDetailed findings


meeting the legal requirements and regulations associatedwith the Health and Social Care Act 2008, to look at theoverall quality of the service, and to provide a rating for theservice under 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?

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 retiredand students)

• People whose circumstances may make themvulnerable

• People experiencing poor mental health (includingpeople with dementia)

The inspection team:

• Reviewed information available to us from otherorganisations, for example, such as NHS England.

• Reviewed information from the CQC intelligentmonitoring systems.

• Carried out an announced inspection visit on 20October 2015.

• Spoke to staff and patients.

• Looked at documents and information about how thepractice was managed and operated.

• Reviewed patient survey information, including thenational GP Patient Survey of the practice.

• Reviewed a sample of the practice’s policies andprocedures.

Detailed findings


Our findingsSafe track record and learning

There was an open and transparent approach to reportingand recording significant events. The practice had asignificant events policy which described how staff shouldrespond to and manage significant events. We were toldconcerns about patient safety were dealt with by one of theGP partners, and that lessons learned were communicatedto the staff team by the practice manager. The practicenurse told us all significant events were discussed at theweekly clinical meetings. External professionals wereinvited to attend significant event review meetings wherethe GP partners judged this would improve learningoutcomes. Three significant events had been recorded inthe previous 12 months. The records we looked at showedthese had been appropriately handled, and lessons hadbeen learned by the team. Where appropriate, we saw staffhad contacted patients affected by a significant event andopenly shared what had happened and why. Suitablearrangements had also been made to learn from otherincidents that occurred at the practice. We saw lessonswere shared to make sure action was taken to improvesafety in the practice.

Patient safety was monitored using information from arange of sources, including National Institute for Health andCare Excellence (NICE) guidance. All safety alerts receivedby the practice were read by one of the GP partners, andthen forwarded to the relevant team member for action. Anaudit trail was in place which provided the practicemanager with confirmation that staff had read relevantsafety alerts.

Overview of safety systems and processes

The practice had clearly defined and embedded systems,processes and practices in place to keep people safe. Wefound:

• There were arrangements for safeguarding adults andchildren from abuse that reflected relevant legislationand local requirements. Staff had access to relevantsafeguarding policies which included information wasavailable within the practice regarding which agenciesshould be contacted if there were safeguardingconcerns. The GP partners held lead responsibilities forsafeguarding and provided colleagues with guidance

and support whenever this was required. Staffdemonstrated they understood their responsibilitiesand all had received safeguarding training relevant totheir role.

• There was a notice in the waiting room advising patientsthat staff would act as chaperones, if required. All thestaff who took on this role had undergone a Disclosureand Barring Service (DBS) check. (DBS

• There were suitable arrangements for managingmedicines which kept patients safe. A safe system was inplace for handling repeat prescriptions and ensuringthey were authorised before being issued or sent to thepatient’s preferred pharmacist. Regular medicationaudits were carried out with the support of the localclinical commissioning group (CCG) pharmacy adviser,to ensure the practice was prescribing in line with bestpractice guidelines. Suitable arrangements were inplace to carry out medicines reviews and the practicehad a safe process for dealing with any changes topatients’ medicines. Prescription pads were securelystored to prevent potential misuse.

• There were suitable arrangements for carrying outrequired staff recruitment checks. The staff files wesampled showed that appropriate checks had beenundertaken on each member of staff prior to theiremployment. These included: checks that staff wereregistered with the appropriate professional body;obtaining references from previous employers; checkingthat staff had obtained the qualifications they needed tocarry out their roles and responsibilities; carrying out aDBS check to make sure, where appropriate, new staffwere safe to care for vulnerable adults and children.

• There were appropriate arrangements for maintainingstandards of cleanliness and hygiene at the practice.The premises were clean and tidy throughout. Estimateshad been obtained, and funding requested, to enableimprovements to be made to the examination rooms.For example, we were told this would include improvinghand wash facilities and providing more suitable floorcoverings.

Staff had completed an infection control annualstatement for 2015 which set out the practice’sarrangements for preventing the spread of infection. Thepractice had a designated infection control lead whoprovided staff with guidance and advice when

Are services safe?

Good –––


appropriate. This person had completed the moreadvanced training required to enable them to carry outthis lead role effectively. Following completion of theirtraining, they had carried out an infection control riskassessment in February 2015. Areas for improvementwere identified, and we saw evidence that these hadbeen addressed. For example, monthly cleaningschedules were created for all rooms and medicalequipment. We noted that since 1 February 2014, 15minor operations had been completed, and auditscarried out found no evidence of post-operativeinfections. There were suitable infection controlprotocols in place and all staff had received basicinfection control training. However, we found that thepractice’s induction checklist did not cover infectioncontrol. A legionella risk assessment had beencompleted in 2013, and regular water temperaturechecks were undertaken to help prevent the risk ofLegionella developing in the practice’s water systems.(Legionella is a bacterium that can grow incontaminated water and can be potentially fatal.)

Monitoring risks to patients:

There were appropriate procedures in place for monitoringand managing risks to patient and staff safety. The practicehad an up-to-date fire risk assessment and staff took partin a fire drill in May 2015. All electrical and clinicalequipment was checked to ensure it was safe to use and ingood working order. Staff had carried out a health andsafety risk assessment of the premises in May 2015 to helpidentify and minimise risks to staff and patients.

Arrangements were in place for planning and monitoringthe number and mix of staff required to meet patients’needs. There was a rota system for all the different staffinggroups to ensure that enough were on duty. Locum GPcover was rarely used because the GP partners covered

each other’s leave. We were told that when the practicenurse took leave, some of their clinical duties were coveredby the GP partners. There was no evidence that thedecision not to provide full holiday cover for the nurse hadimpacted upon the quality of care patients had received.

Arrangements to deal with emergencies and majorincidents

There was an instant messaging system on the computersused by all the staff which alerted them to any emergencyoccurring at the practice. All staff had received annual basiclife support training to help them deal with an emergency.

There were arrangements for making sure staff carried outregular checks of the practice’s emergency drugs andequipment. Medicines were available for the GPs to takeout with them on routine visits for use in an emergency.Our discussions with the GPs indicated they hadconsidered what emergency medicines they needed tocarry and, in doing so, had taken into account factors suchas the proximity of local hospitals and the opening hours oflocal pharmacies. Records we looked at confirmed thatchecks of the emergency medicines stored at the practice,and the medicines kept by the GPs in their ‘Doctor’s Bag’,were carried out by the practice nurse. With one exception,recorded checks had been carried out monthly during2015. All the medicines we checked were within date.Checks of the practice’s resuscitation equipment, includingthe defibrillator and oxygen supply, had also been carriedout, and a record of these had been kept since June 2015.

The practice had a comprehensive business continuity planfor major incidents such as power failure or buildingdamage. The plan included the emergency contactnumbers of staff. All staff had access to this documentwhich was kept on the practice’s intranet system.

Are services safe?

Good –––


Our findingsEffective needs assessment

Staff carried out assessments and treatment in line withrelevant and current evidence based guidance andstandards, including National Institute for Health and CareExcellence (NICE) and British Medical Association bestpractice guidelines. For example, staff showed us thelocally produced guidelines they followed when treatingpatients with high levels of blood fats. Clinical staff wereable to access NICE and local guidelines via the practice’sintranet system, and we saw evidence that changes tothese guidelines had been discussed in clinical meetings.

Management, monitoring and improving outcomes forpeople

The practice participated in the Quality and OutcomesFramework (QOF). (This is a system intended to improvethe quality of general practice and reward good practice).The practice used the information collected for the QOF,and their performance against national screeningprogrammes to monitor outcomes for patients. Overall, theQOF data for 2014/15 showed the practice had performedwell in obtaining 99.6% of the total points available tothem. (This was 4.1% above the local clinicalcommissioning group (CCG) average and 6.1% above theEngland average.) For example, with regards to specificclinical conditions the QOF data showed:

• The practice had obtained 100% of the points availableto them for providing recommended care and treatmentfor patients with cancer. This was 3.6% above the localCCG average and 2.1% above the England average.

• The practice had obtained 100% of the points availableto them for providing recommended care and treatmentfor patients with chronic obstructive pulmonary disease.This was 3% above the local CCG average and 4% abovethe England average.

The QOF data showed the practice had obtained 100% ofthe total points available to them for delivering care andtreatment aimed at improving public health. Thisachievement was 3.9% above the local CCG average and4.3% above the England average.

The practice’s clinical exception reporting rate was 9% for2014/15. This was 0.1% above the local CCG average and0.2% below the England average. We were told the

exception reporting rate was similar to other localpractices. (The QOF scheme includes the concept of‘exception reporting’ to ensure that practices are notpenalised where, for example, patients do not attend forreview, or where a medication cannot be prescribed due toa contraindication or side-effect.) This practice was not anoutlier for any QOF (or other national) clinical targets.

Records of the clinical audits undertaken by staffdemonstrated improvements to patient outcomes. Thosewe looked at included, for example, whether the GPs werefollowing NICE guidelines, regarding the care andtreatment provided to patients presenting with a sorethroat. This two-cycle audit showed there had been anincrease in the number of patients receiving the rightantibiotic for the right length of time as specified innational guidelines. Other audits had also been completedin response to feedback received from the practice’s localCCG. For example, staff had carried out a clinical audit tocheck whether patients with high blood fat levels werebeing prescribed the medicine recommended by the localCCG. Following a recent dementia coding audit, staff hadidentified that they had more patients with dementia thanthe number who were currently included on the practice’sdementia register. As a result of the audit, additionalpatients had been placed on this register. This meant thesepatients were able to benefit from being offered an annualhealth review, to help ensure their condition was beingappropriately managed.

Effective staffing

Staff had the skills, knowledge and experience required todeliver effective care and treatment. For example:

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

• The learning needs of staff were identified through aprocess of appraisals and regular meetings as well asthe work undertaken by the practice to quality checktheir performance against national standards andregulations. Staff had access to appropriate training toenable them to carry out their roles and responsibilitieseffectively. This included support for the revalidation ofthe GP partners. Training was provided in a variety ofways including clinical supervision and e-learningtraining modules. All staff had had an appraisal withinthe last 13 months.

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

Good –––


• All staff training included safeguarding, basic lifesupport, the Mental Capacity Act and the new Duty ofCandour.

Coordinating patient care and information sharing

The practice’s patient clinical record and intranet systemshelped make sure staff had access to the information theyneeded to plan and deliver care and treatment. Theinformation included, for example, patients’ medicalrecords and test results. All documents relating to patientswere scanned onto the practice’s clinical record system andthen any tasks that required attention were assigned to theappropriate clinician.

Staff worked well together, and with other health and socialcare professionals, to assess and plan ongoing care andtreatment, and to meet the range and complexity ofpatients’ needs. There were agreed systems for clinical staffto make referrals to community health staff. Appropriatearrangements were in place which ensured effectivecommunication between the practice and the localout-of-hours service. Special patient notes were used onthe practice’s intranet system to make sure that theemergency services had access to important informationabout the needs of patients with complex support needs.Staff had put a system in place to make sure that anycancer two-week-wait referrals were received by therelevant hospital department. We were told this helped tomake sure that none of the referrals staff made were lost.

Consent to care and treatment

Staff sought patients’ consent to care and treatment in linewith legislation and guidance. For example:

• Staff understood the relevant consent anddecision-making requirements of legislation andguidance, including the Mental Capacity Act (MCA, 2005),and had adopted the General Medical Council (GMC)guidance on consent. We saw evidence that all staff hadcompleted MCA training relevant to their roles andresponsibilities.

• When providing care and treatment to children andyoung people, clinical staff carried out assessments oftheir capacity to consent, in line with relevant guidance.

• Where a patient’s mental capacity to consent to care ortreatment was unclear, we were told the GP or practicenurse would carry out an assessment of the patient’scapacity and, where appropriate, would record theoutcome.

Health promotion and prevention

Patients had access to appropriate health assessments andchecks. These included health checks for new patients andNHS health checks for patients aged 40–74. Whereappropriate, the outcomes of health assessments werefollowed up with the patients concerned, if abnormalitiesor risk factors had been identified.

Arrangements had been made to provide women withaccess to cervical screening services. The QOF data for2014/15 showed the practice had obtained 100% of theoverall points available to them for providing cervicalscreening services. This was 1.8% above the local CCGaverage and 2.4% above the England average. The dataalso showed the practice had protocols that were in linewith national guidance. This included protocols for themanagement of cervical screening, and for informingwomen of the results of these tests. 82.4% of women agedbetween 25 and 65 had received a cervical screening test inthe preceding five years compared to the national targetrate of 80%.

Staff identified patients who may be in need of extrasupport. These included patients in the last 12 months oftheir lives, patients who were also carers, patients at risk ofdeveloping a long-term condition and patients requiringadvice on diet, smoking or alcohol cessation. Nationallyreported QOF data, for 2014/15, showed the practice hadobtained 100% of the overall points available to them forproviding recommended care and treatment to patientswho smoked. This was 5% above the local CCG average and4.9% above the England average. The data also confirmedthe practice had supported patients to stop smoking usinga strategy that included the provision of suitableinformation and appropriate therapy.

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. Patientsattending at the practice or calling by telephone weretreated with dignity and respect. Curtains/screens wereprovided in consulting rooms so that patients’ privacy anddignity could be maintained during examinations andtreatments. Consultation and treatment room doors wereclosed during consultations so that conversations takingplace in these rooms could not be overheard. Receptionstaff told us they knew when patients wanted to discusssensitive issues or appeared distressed and said theywould offer them a private room to discuss any mattersthey wanted to talk about. However, we saw that thenames of patients on their medical records were visible toothers through the reception window glass screen. Weshared this with the practice team who said they wouldtake action to address this.

As part of our inspection we asked practice staff to invitepatients to complete Care Quality Commission (CQC)comment cards. We received 34 completed commentcards. All respondents were positive about the standard ofcare and treatment provided. Words used to describe theservice included: pleasant; responsive; very impressive;very caring; welcoming; fantastic service; very professionaland friendly service; exceptional; very efficient; wouldhighly recommend. None of the patients who completedcomment cards raised any concerns about the care andtreatment they received at the practice. We spoke with amember of the Patient Participation Group (PPG) on theday of our inspection. They also said they were satisfiedwith the care provided by the practice and confirmed theirdignity and privacy was respected. They also told us theythought their care was ‘faultless’ and they did not thinkthey could find a better quality of care anywhere else.

The practice also used the Friends and Family Survey toobtain feedback from patients. 24 patients had completedthe survey during July, August and September 2015. All ofthe respondents said they would either be ‘extremely likely’or ‘likely’ to recommend the practice to friends and family.

Results from the national GP Patient Survey of the practice,published in July 2015, showed patients were satisfied with

how they were treated. Patient satisfaction levels weremostly above, or in line with, all local clinicalcommissioning group (CCG) and national averages. Ofpatients who responded to the survey:

• 96% said they had confidence and trust in the last GPthey saw. This was the same as local CCG average of96% and above the national average of 95%.

• 90% said the GP was good at listening to them. This wasthe same as the local CCG average of 90% and abovethe national average of 89%.

• 90% said the GP gave them enough time, compared tothe local CCG average of 88% and the national averageof 87%.

• 88% said the last GP they spoke to was good at treatingthem with care and concern, compared to the local CCGaverage of 87% and the national average of 85%.

• 100% said they had confidence and trust in the lastnurse they saw, compared to the local CCG average of98% and the national average of 97%.

• 95% said the last nurse they spoke to was good attreating them with care and concern, compared with thelocal CCG average of 92% and the national average of90%.

• 94% said they found the receptionists at the practicehelpful, compared with the local CCG and nationalaverages of 87%.

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 decisionsabout the care and treatment they received. They also toldus they felt listened to and supported by staff and hadsufficient time during consultations to make an informeddecision about the choice of treatments available to them.

Results from the national GP Patient Survey of the practiceshowed patients responded positively to questions abouttheir involvement in planning and making decisions abouttheir care and treatment. The results were either above, orbroadly in line with, local and national averages. Of thepatients who responded to the survey:

Are services caring?

Good –––


• 89% said the last GP they saw was good at explainingtests and treatments; compared to the CCG average of88% and national average of 86%.

• 81% said the last GP they saw was good at involvingthem in decisions about their care, compared to theCCG average of 84% and national average of 81%.

• 94% said the last nurse they saw was good at explainingtests and treatments; compared to the CCG average of91% and national average of 90%.

• 85% said the last nurse they saw was good at involvingthem in decisions about their care, compared to theCCG average of 87% and national average of 85%.

Staff told us that translation services were available forpatients who did not have English as a first language. Wesaw a notice in the reception area informing patients aboutthis service.

Patient and carer support to cope emotionally withcare and treatment

Suitable arrangements had been made to meet the needsof patients who were also carers. For example, one of theGP partners and the practice manager acted as carers’leads and had taken on the role of carers’ champion.(Carers’ champions are staff who have completedawareness training to enable them to provide leadership toother staff in identifying and supporting carers.) Staff kept aregister of patients who were also carers to help ensure theneeds of these patients were met. The practice managertold us planning was underway to provide carers with theinfluenza vaccination and the register had been a usefultool in helping them to do this. Written information wasavailable for carers to ensure they understood the variousavenues of support available to them.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needs

Services were planned and delivered to take into accountthe needs of different patient groups and to provideflexibility, choice and continuity of care. For example, staffused a local healthcare intelligence tool to help themidentify at-risk patients, and compare their performance inmeeting the needs of these patients against local andnational benchmarks. We saw that all of these patients hada personalised care plan. Staff had also contacted thosepatients who had been discharged from hospital, followingan unplanned admission, to review and ensure their needswere being met.

Clinical staff reviewed the reasons why patients withmental health problems might not have attended aplanned appointment. They provided reception staff withguidance regarding how they should follow up anynon-attendance by these patients. The practice hadperformed well in providing services to patients withmental health needs. They had obtained 100% of the QOFpoints available to them for providing recommended careand treatment to patients with mental health needs. Thiswas 7.3% above the local clinical commissioning group(CCG) average and 7.2% above the England average. Thedata showed that 100% of patients with the mental healthconditions covered by the QOF, had a comprehensive careplan which had been agreed with them and their carers.This was 15.3% above the local CCG average and 11.7%above the England average. One of the GP partners, whowas the adult mental health lead for the local CCG, alsoprovided GP consultations for homeless men, at a localhealthcare centre.

There were appropriate arrangements for meeting theneeds of patients with learning disabilities. The practicekept a register of these patients (8) to help ensure staffknew who they were, so they could make arrangements tomeet their needs. There were longer appointmentsavailable for people with a learning disability. The practicehad obtained 100% of the QOF points available to them in2014/15 for providing recommended care and treatment topatients with learning disabilities. This was in line with thelocal CCG average and 0.2% above the England average.

The practice offered extended hours appointments onalternate Saturdays, between 8am and 11am, for working

patients and students who could not attend during normalopening hours. Patients were able to book appointmentsand order repeat prescriptions on-line. Working agepatients had access to a range of services, including traveland minor surgery clinics. Staff had taken steps to meet theneeds of their student population. For example, thepractice website included a page for students which gaveadvice about how to register with the practice. We did notethat none of the information on the website was availablein any language other than English.

The practice had a good website which gave patientsaccess to information and advice to help them managetheir own health and well-being. This included a videolibrary providing information about common illnesses andhow to manage them.

Midwifes attached to the practice held fortnightlyante-natal clinics and a weekly baby clinic was held by theattached health visitor. The GP partners provided supportto both of these clinics. The practice provided a fullprogramme of child immunisations. Nationally reporteddata demonstrated that the practice performed well indelivering this programme. For example, the data showedthat 100% of eligible children had received eight of the 18childhood immunisations included in the programme andover 90% of eligible children had received seven of theother childhood immunisations. With regard to the otherthree immunisations over 87% had received these.

There were good arrangements for managing and meetingthe needs of older patients and patients with long-termconditions. There were clear procedures for staff to followwhen recalling patients for annual healthcare reviews. Ourinterview with the practice nurse provided good evidenceof the practice’s focus on supporting and encouragingpatients to manage their long-term conditions via anagreed care plan. A range of protocols were in place whichsupported staff to provide patients with a good level of careand treatment. Patients at risk of hospital admission wereidentified as a priority, and steps had been taken tomanage their needs.

Staff provided a range of services, including familyplanning, Well Women and Well Man clinics, sexual healthadvice, and smoking cessation support. Older patients hada named GP who oversaw their care and treatment. Good

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

Good –––


arrangements were in place to support patients nearing theend of their life. One of the GPs acted as the palliative carelead, and patients received palliative care that was in linewith the Gold Standards Framework.

Reasonable adjustments had been made which helpedpatients with disabilities and those whose first languagewas not English, to use the practice. For example, theconsultation and treatment rooms were located on theground floor. An automatic door had recently beeninstalled to make it easier for patients with disabilities toaccess the practice. There was a disabled toilet which hadappropriate aids and adaptations. A loop system wasavailable for hearing impaired patients. The waiting areawas spacious, making it easier for patients in wheelchairsto manoeuvre. Staff had access to a telephone translationservice and interpreters, should they be needed. On-streetdisabled parking was available at the front of the surgery.

Access to the service

The practice was open from 8am to 6.30pm on Monday andTuesday, and between 8am and 6pm on Wednesday,Thursday and Friday. The practice was also open between8am and 11am on alternative Saturdays. GP appointmenttimes were as follows:

Monday: 8:30am-10:50pm and 15:40pm to 6:30pm.

Tuesday: 8am to 10:30am and 4pm to 6:30pm.

Wednesday: 8am to 12 noon and 1pm to 6pm.

Thursday: 8:30am to 12 noon, 1pm to 2pm and 2:30pm to6pm.

Friday: 8:30pm to 10:30am and 3:30pm to 6pm.

Extended hours GP appointments were offered onalternate Saturdays between 8:30am and 11am.

Patients were able to book routine appointments inadvance, and same-day and urgent appointments wereavailable for patients that needed them. Telephoneconsultations were also provided. Appointments could bebooked online by patients who had registered for thatservice. Discussions with staff indicated that, shoulddemand for appointments increase, the practice managerwould notify the GP partners, who would then provide extrasessions. Patients told us they were able to obtain

appointments when they needed them. Administrativetime had been included in each of the GP’s appointmentsessions and we were told this helped reduce patientappointment waiting times.

Results from the national GP Patient Survey of the practice,published in July 2015, showed that patient satisfactionlevels with access to the practice and appointments, weresignificantly higher than both the local CCG and thenational averages. Of the patients who responded to thesurvey:

• 86% were satisfied with the practice’s opening hours,compared to the local CCG average of 78% and thenational average of 75%.

• 98% said they could get through easily to the surgery bytelephone, compared to the local CCG average of 78%and the national average of 73%.

• 95% described their experience of making anappointment as good, compared to the local CCGaverage of 74% and the national average of 73%.

• 83% said they usually waited 15 minutes or less aftertheir appointment time, compared to the local CCGaverage of 68% and the national average of 65%.

Listening and learning from concerns and complaints

The practice had an effective system in place for handlingcomplaints and concerns. We found that:

• The practice’s complaints policy and procedures were inline with recognised guidance and contractualobligations for GPs in England.

• The practice manager was the designated personresponsible for handing complaints. The GP partnersundertook this role in their absence.

• Appropriate information was available to help patientsunderstand the complaints system. For example, thepractice had a patient friendly complaints leaflet andinformation about complaints was on display in thewaiting area.

• Staff held an annual complaints meeting to review thecomplaints they had received and ensure that learningpoints had been followed through, to help preventreoccurrences.

The practice had received two complaints since April 2015.We found these had been satisfactorily handled and dealt


Good –––


with in an open, transparent and timely way. Lessons werelearnt from concerns and complaints and, whereappropriate, an apology was offered where staff judgedthey had not got things right.


Good –––


Our findingsVision and strategy

The practice had a clear vision to deliver high quality careand promote good outcomes for patients. This included:

• A recorded and up-to-date vision and strategystatement, which emphasised the promotion ofpatients’ safety through clinical and management audit,as well as the promotion of openness and transparencywithin the practice.

• A detailed and up-to-date practice development plan.The plan had, in part, been informed by the completionof standardised planning tools to help staff identify theirpriorities. The practice manager told us all staff hadbeen involved in the development of the practice’sdevelopment plan. Our interviews with staff confirmedthey clearly understood the values of the practice.

• Working as part of a Federation with other GP practicesto develop better services for patients in their localcommunities.

Governance arrangements

We saw evidence of good governance arrangements. Thepractice team had taken action to ensure their compliancewith the national standards and underpinning regulations.They had regularly monitored and reviewed theirperformance since their registration in order to improve thequality of the services they provided. The practice’sgovernance arrangements included:

• A range of policies and procedures that governed staff’sday-to-day activities. This included an overarchinggovernance policy.

• Systems to monitor and improve quality and identifyareas of risk and how to minimise these.

• The allocation of lead roles to designated staff so theycould provide their colleagues with leadership andguidance in the areas of responsibility that had beendelegated to them.

• Regular practice and multi-disciplinary team meetingswhich helped to ensure patients received effective andsafe clinical care.

• Arrangements which supported staff to learn lessonswhen things went wrong, and to support theidentification, promotion and sharing of good practice.

• The completion of clinical audits to identify whereimprovements could be made with regards to outcomesfor patients.

• Actively seeking feedback from patients.

• Good arrangements for making sure the premises, andthe equipment used by staff, were maintained in a safecondition and were in good working order.

• Arrangements which ensured that staff understood theirown roles and responsibilities.

Leadership, openness and transparency

The GP partners and practice manager had the experience,capacity and capabilities needed to run the practice andensure high quality care. Staff had created a culture whichencouraged and sustained learning at all levels in thepractice. Through their partnership working with otheragencies, they had promoted quality and continuingimprovement. Staff told us they would feel comfortableraising issues.

The practice had a policy setting out how they wouldcomply with the requirements of the Duty of Candourregulation. Everything we saw and heard at the practicedemonstrated that the GP partners and the practicemanager encouraged a culture of openness and honesty,and treated patients’ safety as a high priority. Duty ofCandour training had also been completed by some staff tosupport the practice’s commitment to ensuring candour.There was a clear leadership structure in place and staff feltsupported by the practice manager and GP partners. Stafftold us regular staff meetings were held and they said theyfelt respected, valued and supported.

Seeking and acting on feedback from patients, thepublic and staff

The practice clearly valued feedback from patients, thepublic and staff, and they proactively sought feedback frompatients. We found:

• The practice had gathered feedback from patients viatheir Patient Participation Group (PPG) and the use of apatient survey. There was an active PPG which had mettwice during the previous nine months. The PPG helpedcarry out the most recent in-house patient survey of the

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

Good –––


practice. Evidence submitted to us demonstrated thatmembers of the PPG had also taken part in discussionswith staff about potential areas for improvement andhow these might be implemented. The PPG member wespoke with said the practice really welcomed theirinvolvement and responded positively to anysuggestions they made. Following discussions with thePPG, staff had provided a folder in the waiting areawhich contained information for patients about howthey could access services as well as other informationthey thought might be helpful to patients.

• The practice had also gathered feedback about theirperformance from staff through yearly appraisals andstaff meetings. Staff told us they would not hesitate to

give feedback and discuss any concerns or issues withthe GP partners or the practice manager. They told usthey felt involved and engaged in how the practice wasrun.

Management lead through learning and improvement

Staff told us that the practice supported them to maintaintheir clinical professional development by providing themwith access to ongoing training that related to their rolesand responsibilities. Staff told us that the practice was verysupportive of training. The documentary evidence welooked confirmed that regular staff appraisals took place.The practice had completed reviews of significant eventsand other incidents and had used these to help ensure thepractice improved outcomes for patients.

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

Good –––


Avenue Medical Practice NewApproachComprehensive Report ... · Families,childrenandyoungpeople...

Documents

Transcript of Avenue Medical Practice NewApproachComprehensive Report ... · Families,childrenandyoungpeople...