The Dower House Quality Report 27 Pyle Street, Newport, Isle of Wight. PO30 1JW Tel: 01983 523525 Website: www.dowerhousesurgery.co.uk Date of inspection visit: 11 February 2016 Date of publication: 07/04/2016 This report describes our judgement of the quality of care at this service. It is based on a combination of what we found when we inspected, information from our ongoing monitoring of data about services and information given to us from the provider, patients, the public and other organisations. Ratings Overall rating for this service Good ––– Requires improvement ––– Are services effective? Good ––– Are services caring? Good ––– Are services responsive to people’s needs? Good ––– Are services well-led? Good ––– Are services safe? 1 The Dower House Quality Report 07/04/2016 Summary of findings Contents Summary of this inspection Page Overall summary 2 The five questions we ask and what we found 4 The six population groups and what we found 7 10 What people who use the service say Detailed findings from this inspection Our inspection team 11 Background to The Dower House 11 Why we carried out this inspection 11 How we carried out this inspection 11 Detailed findings 13 Action we have told the provider to take 21 Overall summary Letter from the Chief Inspector of General Practice We carried out an announced comprehensive inspection at Dower House Surgery on 11 February 2016. Overall the practice is rated as good. Our key findings across all the areas we inspected were as follows: • There was an open and transparent approach to safety and an effective system in place for reporting and recording significant events. • Risks to patients were assessed and managed. • Staff assessed patients’ needs and delivered care in line with current evidence based guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment. • Patients said they were treated with compassion, dignity and respect and they were involved in their care and decisions about their treatment. • Information about services and how to complain was available and easy to understand. 2 The Dower House Quality Report 07/04/2016 • Patients said they found it easy to make an appointment with a named GP and that there was continuity of care, with urgent appointments available the same day. • The practice had good facilities and was well equipped to treat patients and meet their needs. • There was a clear leadership structure and staff felt supported by management. The practice proactively sought feedback from staff and patients, which it acted on. • The provider was aware of and complied with the requirements of the Duty of Candour. • When there were unintended or unexpected safety incidents, reviews and investigations were not always thorough enough and lessons learned were not communicated widely enough to support improvement. • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. The areas where the provider must make improvement are: Summary of findings • Ensure all nursing staff had received up to date safeguarding training. 3 The Dower House Quality Report 07/04/2016 Professor Steve Field (CBE FRCP FFPH FRCGP) Chief Inspector of General Practice Summary of findings The five questions we ask and what we found We always ask the following five questions of services. Are services safe? The practice is rated as requires improvement for providing safe services. Requires improvement ––– Good ––– • Staff understood their responsibilities to raise concerns, and to report incidents and near misses. However, when there were unintended or unexpected safety incidents, reviews and investigations were not always thorough enough and lessons learned were not always communicated widely enough to support improvement. • Although risks to patients who used services were assessed, the systems and processes to address these risks were not implemented well enough to ensure patients were kept safe. An area of concern was found with regards to safeguarding. Not all nursing staff had received up to date safeguarding training. • Arrangements for managing medicines kept patients safe. This included obtaining, prescribing, recording, handling, storage and security, safe administration and disposal. • Patient’s individual records were written and managed in a way that kept them safe. • Standards of cleanliness and hygiene were maintained. • Reliable systems were in place to prevent and protect patients from a healthcare-associated infection. • The design, maintenance and use of facilities and premises kept patients safe. • The maintenance and use of equipment kept patients safe. Are services effective? The practice is rated as good for providing effective services. • Data from the Quality and Outcomes Framework showed patient outcomes were at or above average for the locality and compared to the national average. • Staff assessed needs and delivered care in line with current evidence based guidance. • Clinical audits demonstrated quality improvement. • Staff had the skills, knowledge and experience to deliver effective care and treatment. • There was evidence of appraisals and personal development plans for all staff. • Staff worked with multidisciplinary teams to understand and meet the range and complexity of patients’ needs. 4 The Dower House Quality Report 07/04/2016 Summary of findings Are services caring? The practice is rated as good for providing caring services. Good ––– Good ––– Good ––– • Data from the National GP Patient Survey showed patients rated the practice higher than others for several aspects of care. • Patients said they were treated with compassion, dignity and respect and they were involved in decisions about their care and treatment. • Information for patients about the services available was easy to understand and accessible. • We saw staff treated patients with kindness and respect, and maintained patient and information confidentiality. Are services responsive to people’s needs? The practice is rated as good for providing responsive services. • Practice staff reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group to secure improvements to services where these were identified. • Patients said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day. • The practice had good facilities and was well equipped to treat patients and meet their needs. • Information about how to complain was available and easy to understand and evidence showed the practice responded quickly to issues raised. Learning from complaints was shared with staff and other stakeholders. Are services well-led? The practice is rated as good for being well-led. • The practice had a clear vision and strategy to deliver high quality care and promote good outcomes for patients. Staff were clear about the vision and their responsibilities in relation to this. • There was a clear leadership structure and staff felt supported by management. The practice had a number of policies and procedures to govern activity and held regular governance meetings. • There was an overarching governance framework which supported the delivery of the strategy and good quality care. This included arrangements to monitor and improve quality and identify risk. The provider was aware of and complied with the requirements of the Duty of Candour. The partners encouraged a culture of 5 The Dower House Quality Report 07/04/2016 Summary of findings openness and honesty. The practice had systems in place for knowing about notifiable safety incidents but did not always ensure this information was shared with staff to ensure appropriate action was taken. • The practice proactively sought feedback from staff and patients, which it acted on. The patient participation group was active. • There was a strong focus on continuous learning and improvement at all levels. 6 The Dower House Quality Report 07/04/2016 Summary of findings The six population groups and what we found We always inspect the quality of care for these six population groups. Older people The practice is rated as good for the care of older people. Good ––– Good ––– Good ––– • The practice offered proactive, personalised care to meet the needs of the older patients in its population. • The practice was responsive to the needs of older patients, and offered home visits and urgent appointments for those with enhanced needs. • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable patients. • The practice had an over 75 year health programme for patients and health navigators to assist patients with care. People with long term conditions The practice is rated as good for the care of people with long-term conditions. • Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. • 97% of patients with diabetes had received influenza immunisation in the preceding 12 months. The national average was 95%. • Longer appointments and home visits were available when needed. • All these patients had a named GP and a structured annual review to check their health and medicines needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care. Families, children and young people The practice is rated as good for the care of families, children and young people. • There were systems in place to identify and follow up children living in disadvantaged circumstances and who were at risk, for example, children and young people who had a high number of accident and emergency attendances. Immunisation rates were relatively high for all standard childhood immunisations. • 73% of patients diagnosed with asthma, on the register, who had an asthma review in the last 12 months, this was slightly lower that the national average at 76%. 7 The Dower House Quality Report 07/04/2016 Summary of findings • Patients told us that children and young people were treated in an age-appropriate way and were recognised as individuals, and we saw evidence to confirm this. • 82% of women patients aged 25-64 had recorded that a cervical screening test had been performed in the preceding five years. This is the same as the national average. • Appointments were available outside of school hours and the premises were suitable for children and babies. • We saw positive examples of joint working with midwives, health visitors and school nurses. Working age people (including those recently retired and students) The practice is rated as good for the care of working-age people (including those recently retired and students). Good ––– Good ––– • The needs of the working age population, those recently retired and students had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. • The practice was proactive in offering online services as well as a full range of health promotion and screening that reflects the needs for this age group. People whose circumstances may make them vulnerable The practice is rated as good for the care of people whose circumstances may make them vulnerable. • The practice held a register of patients living in vulnerable circumstances including homeless patients, travellers and those with a learning disability. • The practice offered longer appointments for patients with a learning disability. • The practice regularly worked with multi-disciplinary teams in the case management of vulnerable patients. • The practice informed vulnerable patients about how to access various support groups and voluntary organisations. • Staff knew how to recognise signs of abuse in vulnerable adults and children. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours. 8 The Dower House Quality Report 07/04/2016 Summary of findings People experiencing poor mental health (including people with dementia) The practice is rated as good for the care of people experiencing poor mental health (including people with dementia). • 91% of patients diagnosed with dementia that had had their care reviewed in a face to face meeting in the last 12 months, which is slightly higher than the national average at 89%. • The practice regularly worked with multi-disciplinary teams in the case management of patients experiencing poor mental health, including those with dementia. • The practice carried out advance care planning for patients with dementia. • The practice had told patients experiencing poor mental health about how to access various support groups and voluntary organisations. • The practice had a system in place to follow up patients who had attended accident and emergency where they may have been experiencing poor mental health. • Staff had a good understanding of how to support patients with mental health needs and dementia. 9 The Dower House Quality Report 07/04/2016 Good ––– Summary of findings What people who use the service say The national GP patient survey results published on 2 July 2015. The results showed the practice was performing in line with local and national averages. 260 survey forms were distributed and 116 were returned. This represented 1% of the practice’s patient list. • 71% found it easy to get through to this surgery by phone compared to a clinical commissioning group (CCG) average of 88% and a national average of 74%. • 97% were able to get an appointment to see or speak to someone the last time they tried compared to a CCG average of 92% and a national average of 86%. 10 The Dower House Quality Report 07/04/2016 • 95% described the overall experience of their GP surgery as fairly good or very good compared to a national average of 85%. • 90% said they would definitely or probably recommend their GP surgery to someone who has just moved to the local area compared to national average of 80%. We spoke with 16 patients during the inspection. All 16 patients said they were happy with the care they received and thought staff were approachable, committed and caring. The Dower House Detailed findings Our inspection team Our inspection team was led by: Our inspection team was led by a CQC Lead Inspector. The team included a GP specialist adviser, a second CQC inspector and a practice manager specialist adviser. Background to The Dower House Dower House Surgery, 27 Pyle Street, Newport, Isle of Wight. PO30 1JW also known as Pyle Street Surgery occupies a grade two listed building and is situated in Newport, Isle of Wight. The practice has an NHS general medical services (GMS) contract to provide health services to approximately 12500 patients. Surgeries are held daily between the hours of 8.30am and 6.30pm, Monday to Friday. Early morning GP surgeries are held on Mondays from 7.15am and Saturdays between 8am and 10am. The practice has opted out of providing out-of-hours services to its patients and refers them to Beacon Health out-of-hours service via the 111 service. The mix of patient’s gender (male/female) is almost half and half. The practice has a higher number of patients aged over 65 years old when compared to the England average. The practice has a high number of patients who have a long term condition and those in receipt of disability related benefits when compared to the England average and is situated in an area of high deprivation. 11 The Dower House Quality Report 07/04/2016 The practice has four GP partners and three salaried GPs. In total there are three male and four female GPs. The practice also has two nurse practitioners, a lead nurse and six practice nurses and three health care assistants. GPs and nursing staff are supported by a practice manager, assistant practice manager and a team of 17 administration staff. The practice administration team consists of receptionists, secretaries, a quality control assistant, a scanning clerk, an IT lead, an office manager and the practice manager. Dower House Surgery is also a training practice for doctors training to be GPs and medical students. This practice was previously inspected by the Care Quality Commission in March 2015 at this inspection the practice was rated as requiring improvement overall. Specifically it was rated as required improvement in the domains of safe and well led and good in the domains of effective, caring and responsive. The provider was asked to provide an action plan to meet the care quality commission essential standards. The Practice provided this information and this inspection was to check that the action plan submitted had been adhered to. Why we carried out this inspection We inspected this service as part of our new comprehensive inspection programme. We carried out a comprehensive inspection of this service under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. The inspection was planned to check whether the provider is meeting the legal Detailed findings requirements and regulations associated with the Health and Social Care Act 2008, to look at the overall quality of the service, and to provide a rating for the service under the Care Act 2014. • • • • • Is it safe? Is it effective? Is it caring? Is it responsive to people’s needs? Is it well-led? How we carried out this inspection We also looked at how well services were provided for specific groups of people and what good care looked like for them. The population groups are: Before visiting, we reviewed a range of information we hold about the practice and asked other organisations to share what they knew. We carried out an announced visit on 11 February 2016. • • • • During our visit we: • Spoke with a range of staff and spoke with patients who used the service. • Observed how patients were being cared for and talked with carers and/or family members • Reviewed an anonymised sample of the personal care or treatment records of patients. To get to the heart of patients’ experiences of care and treatment, we always ask the following five questions: 12 The Dower House Quality Report 07/04/2016 Older people People with long-term conditions Families, children and young people Working age people (including those recently retired and students) • People whose circumstances may make them vulnerable • People experiencing poor mental health (including people with dementia) Please note that when referring to information throughout this report, for example any reference to the Quality and Outcomes Framework data, this relates to the most recent information available to the CQC at that time. Requires improvement ––– Are services safe? Our findings Safe track record and learning. There was an effective system in place for reporting and recording significant events. • Staff told us they would inform the practice manager of any incidents and there was a recording form available on the practice’s computer system. • The practice carried out an analysis of the significant events. We reviewed safety records, incident reports, national patient safety alerts and minutes of meetings where these were discussed. Some lessons had been shared to make sure action was taken to improve safety in the practice but not always. For example, we saw details of warfarin dosing incident in a care home due to a failure in their fax machine and communication issues within the home. The practice made sure that care home staff were asked to ensure that they were alert to the anticipation of dose changes associated with blood testing of patients and to have reliable pathways for receiving the dosing instructions. When there were unintended or unexpected safety incidents, patients received reasonable support, truthful information, a verbal or written apology and were told about any actions to improve processes to prevent the same thing happening again. Although it was seen that another incident relating to warfarin dosing in a care home had taken place this may be due to reviews and investigations not always being thorough enough and lessons learned not always being communicated widely enough to support improvement. Overview of safety systems and processes. The practice had clearly defined and embedded systems, processes and practices in place to keep patients safe, although the practice did not have a robust system to ensure that children were safeguarded from abuse, which included: • There were some arrangements in place to safeguard children and vulnerable adults from abuse that reflected relevant legislation and local requirements and a policy was accessible to all staff. • The GPs attended safeguarding meetings when possible and always provided reports where necessary for other agencies. Staff demonstrated they had a good understood their responsibilities and what the 13 The Dower House Quality Report 07/04/2016 • • • • principles of safeguarding children and vulnerable adults were but not all staff had received up to date training relevant to their role. GPs were trained to Safeguarding level 3. At the previous inspection in March 2015, it was highlighted that not all the practice nursing staff had received safeguarding training. At this inspection only four out of ten practice nurses had received updated safeguarding training. A notice in the waiting room advised patients that chaperones were available if required. All staff who acted as chaperones were trained for the role and had received a Disclosure and Barring Service check (DBS check). DBS checks identify whether a person has a criminal record or is on an official list of people barred from working in roles where they may have contact with children or adults who may be vulnerable. The practice maintained appropriate standards of cleanliness and hygiene. We observed the premises to be clean and tidy. A practice nurse was the infection control clinical lead who liaised with the local infection prevention teams to keep up to date with best practice. There was an infection control protocol in place and staff had received up to date training. Annual infection control audits were being undertaken and we saw evidence that action was taken to address any improvements identified as a result. The arrangements for managing medicines, including emergency drugs and vaccines, in the practice kept patients safe (including obtaining, prescribing, recording, handling, storing and security). The practice carried out regular medicines audits, with the support of the local CCG pharmacy teams, to ensure prescribing was in line with best practice guidelines for safe prescribing. Prescription pads were securely stored and there were systems in place to monitor their use. One of the nurses had qualified as an Independent Prescriber and could therefore prescribe medicines for specific clinical conditions. They received mentorship and support from the medical staff for this extended role. Patient Group Directions had been adopted by the practice to allow nurses to administer medicines in line with legislation. The practice had a system for production of Patient Specific Directions to enable Health Care Assistants to administer vaccines after specific training when a doctor or nurse were on the premises. Requires improvement ––– Are services safe? • We reviewed three personnel files and found appropriate recruitment checks had been undertaken prior to employment. For example, proof of identification, evidence of satisfactory conduct in previous employment in the form of references, qualifications, registration with the appropriate professional body and the appropriate checks through the Disclosure and Barring Service. • There were systems in place to ensure results were received for all samples sent for the cervical screening programme and the practice followed up women who were referred as a result of abnormal results. Monitoring risks to patients. Risks to patients were assessed and well managed. • There were procedures in place for monitoring and managing risks to patient and staff safety. There was a health and safety policy available with a poster in the reception office which identified local health and safety representatives. The practice had up to date fire risk assessments and carried out regular fire drills. All electrical equipment was checked to ensure the equipment was safe to use and clinical equipment was checked to ensure it was working properly. The practice had a variety of other risk assessments in place to monitor safety of the premises such as control of substances hazardous to health and infection control and legionella (Legionella is a term for a particular bacterium which can contaminate water systems in buildings). 14 The Dower House Quality Report 07/04/2016 • Arrangements were in place for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs. There was a rota system in place for all the different staffing groups to ensure that enough staff were on duty. Arrangements to deal with emergencies and major incidents. The practice had adequate arrangements in place to respond to emergencies and major incidents. • There was an instant messaging system on the computers in all the consultation and treatment rooms which alerted staff to any emergency. • All staff received annual basic life support training and there were emergency medicines available in the treatment room. • The practice had a defibrillator available on the premises and oxygen with adult and children’s masks. A first aid kit and accident book were available. • Emergency medicines were easily accessible to staff in a secure area of the practice and all staff knew of their location. All the medicines we checked were in date and fit for use. • The practice had a comprehensive business continuity plan in place for major incidents such as power failure or building damage. The plan included emergency contact numbers for staff. Good ––– Are services effective? (for example, treatment is effective) Our findings Effective needs assessment. The practice assessed needs and delivered care in line with relevant and current evidence based guidance and standards, including National Institute for Health and Care Excellence (NICE) best practice guidelines. • The practice had systems in place to keep all clinical staff up to date. Staff had access to guidelines from NICE and used this information to deliver care and treatment that met patients’ needs. • The practice monitored that these guidelines were followed through risk assessments, audits and random sample checks of patient records. Management, monitoring and improving outcomes for people. The practice used the information collected for the Quality and Outcomes Framework (QOF) and performance against national screening programmes to monitor outcomes for patients. (QOF is a system intended to improve the quality of general practice and reward good practice). The most recent published results were 99% of the total number of points available, with 12% exception reporting. (Exception reporting is the removal of patients from QOF calculations where, for example, the patients are unable to attend a review meeting or certain medicines cannot be prescribed because of side effects). This practice was not an outlier for any QOF (or other national) clinical targets. Data from 2014-2015 showed; • Performance for diabetes related indicators was comparable to other practices and the national average. • The percentage of patients with hypertension having regular blood pressure tests at 91% was better than national average at 84%. • Performance for mental health related indicators was comparable to other practices and the national average. Clinical audits demonstrated quality improvement. • The practice had a system in place for completing clinical audit cycles. Examples of clinical audits included the monitoring of patients being treated with Allopurinol for kidney stones, Alendronic acid for fragile bones and patients undergoing treatment for menopausal symptoms. Both of these audits were completed where the practice was able to demonstrate the changes resulting since the initial audit. 15 The Dower House Quality Report 07/04/2016 • The practice participated in local audits, national benchmarking, accreditation, peer review and research. For example we saw some comparative prescribing data from the clinical commissioning group showed that the practice were much towards the lower end of the range of rates of prescription in this drug group this was a positive quality marker. • Findings were used by the practice to improve services. Patients who were diagnosed with long term conditions, such as, asthma and chronic obstructive pulmonary disease, (COPD is a condition which causes breathing difficulties), had care plans in place detailing the care and support they needed. Effective staffing. Staff had the skills, knowledge and experience to deliver effective care and treatment. • The practice had an induction programme for all newly appointed staff. It covered such topics as safeguarding, infection prevention and control, fire safety, health and safety and confidentiality. • The practice could demonstrate how they ensured role-specific training and updating for relevant staff for example, for those reviewing patients with long-term conditions. Staff administering vaccines and taking samples for the cervical screening programme had received specific training which had included an assessment of competence. Staff who administered vaccines could demonstrate how they stayed up to date with changes to the immunisation programmes, for example by access to on line resources and discussion at practice meetings. • The learning needs of staff were identified through a system of appraisals, meetings and reviews of practice development needs. Staff had access to appropriate training to meet their learning needs and to cover the scope of their work. This included ongoing support during sessions, one-to-one meetings, appraisals, coaching and mentoring, clinical supervision and facilitation and support for revalidating GPs. All staff had had an appraisal within the last 12 months. • Staff received training that included: fire procedures, basic life support and information governance awareness. Staff had access to and made use of e-learning training modules and in-house training. Good ––– Are services effective? (for example, treatment is effective) Coordinating patient care and information sharing. The information needed to plan and deliver care and treatment was available to relevant staff in a timely and accessible way through the practice’s patient record system and their intranet system. • This included care and risk assessments, care plans, medical records and investigation and test results. Information such as NHS patient information leaflets were also available. • The practice shared relevant information with other services in a timely way, for example when referring patients to other services. Staff worked together and with other health and social care services to understand and meet the range and complexity of patients’ needs and to assess and plan ongoing care and treatment. This included when patients moved between services, including when they were referred, or after they were discharged from hospital. We saw evidence that multi-disciplinary team meetings took place on a monthly basis and that care plans were routinely reviewed and updated. Consent to care and treatment. Staff sought patients’ consent to care and treatment in line with legislation and guidance. • Staff understood the relevant consent and decision-making requirements of legislation and guidance, including the Mental Capacity Act 2005. • When providing care and treatment for children and young people, staff carried out assessments of capacity to consent in line with relevant guidance. • Where a patient’s mental capacity to consent to care or treatment was unclear the GP or practice nurse assessed the patient’s capacity and, recorded the outcome of the assessment. • The process for seeking consent was monitored through records audits. 16 The Dower House Quality Report 07/04/2016 Supporting patients to live healthier lives. The practice identified patients who may be in need of extra support. • These included patients in the last months of their lives, carers, those at risk of developing a long-term condition and those requiring advice on their diet, smoking and alcohol cessation. Patients were then signposted to the relevant service. • A dietician was available on the premises and smoking cessation advice was available from a local support group. The practice’s uptake for the cervical screening programme was 82%, which was comparable to the national average of 82%. There was a policy to offer telephone reminders for patients who did not attend for their cervical screening test. The practice demonstrated how they encouraged uptake of the screening programme by using information in different languages and for those with a learning disability and they ensured a female sample taker was available. The practice also encouraged its patients to attend national screening programmes for bowel and breast cancer screening. Childhood immunisation rates were comparable to clinical commissioning group (CCG) averages. For example, childhood immunisation rates given to under two year olds ranged from 94% to 100%, compared to the clinical commissioning group average of 90% to 93% and five year olds from 91% to 97%,compared to the clinical commissioning group average of 67% to 98%. Patients had access to appropriate health assessments and checks. These included health checks for new patients and NHS health checks for patients aged 40–74. Appropriate follow-ups for the outcomes of health assessments and checks were made, where abnormalities or risk factors were identified. Good ––– Are services caring? Our findings Kindness, dignity, respect and compassion. We observed members of staff were courteous and very helpful to patients and treated them with dignity and respect. • Curtains were provided in consulting rooms to maintain patients’ privacy and dignity during examinations, investigations and treatments. • We noted that consultation and treatment room doors were closed during consultations; conversations taking place in these rooms could not be overheard. • Reception staff knew when patients wanted to discuss sensitive issues or appeared distressed they could offer them a private room to discuss their needs. All of the 16 patients we spoke with were positive about the service experienced. Patients said they felt the practice offered an excellent service and staff were helpful, caring and treated them with dignity and respect. We spoke with one member of the Patient Participation Group. They also told us they were satisfied with the care provided by the practice and said their dignity and privacy was respected. Comments highlighted that staff responded compassionately when they needed help and provided support when required. Results from the national GP patient survey showed patients felt they were treated with compassion, dignity and respect. The practice was above average for its satisfaction scores on consultations with GPs and nurses. For example: • 93% said the GP was good at listening to them compared to the clinical commissioning group (CCG) average of 92% and national average of 89%. • 89% said the GP gave them enough time compared to the CCG average of 89% and national average of 87%. • 96% said they had confidence and trust in the last GP they saw compared to the CCG average of 97% and national average of 96%. • 86% said the last GP they spoke to was good at treating them with care and concern compared to the CCG average of 90% and national average of 86%. • 99% said the last nurse they spoke to was good at treating them with care and concern compared to the CCG average of 94% and national average of 91%. 17 The Dower House Quality Report 07/04/2016 • 97% said they found the receptionists at the practice helpful compared to the CCG average of 92% and national average of 87%. Care planning and involvement in decisions about care and treatment. Patients told us they felt involved in decision making about the care and treatment they received. They also told us they felt listened to and supported by staff and had sufficient time during consultations to make an informed decision about the choice of treatment available to them. Patient feedback on the comment cards we received was also positive and aligned with these views. Results from the national GP patient survey showed patients responded positively to questions about their involvement in planning and making decisions about their care and treatment. Results were in line with local and national averages. For example: • 93% said the last GP they saw was good at explaining tests and treatments compared to the CCG average of 87% and national average of 86%. • 90% said the last GP they saw was good at involving them in decisions about their care compared to the CCG average of 84% and national average of 82%. • 93% said the last nurse they saw was good at involving them in decisions about their care compared to the CCG average of 88% and national average of 85%. Staff told us that translation services were available for patients who did not have English as a first language. We saw notices in the reception areas informing patients this service was available. Patient and carer support to cope emotionally with care and treatment. Notices in the patient waiting room told patients how to access a number of support groups and organisations. The practice’s computer system alerted GPs if a patient was also a carer. The practice had identified a practice list as carers. Written information was available to direct carers to the various avenues of support available to them. Staff told us that if families had suffered bereavement, their usual GP contacted them or sent them a sympathy card. This call was either followed by a patient consultation at a flexible time and location to meet the family’s needs and/or by giving them advice on how to find a support service. Good ––– Are services responsive to people’s needs? (for example, to feedback?) Our findings Responding to and meeting people’s needs. The practice reviewed the needs of its local population and engaged with the NHS England Area Team and Clinical Commissioning Group (CCG) to secure improvements to services where these were identified. • There were longer appointments available for patients with a learning disability. • Home visits were available for older patients and patients who would benefit from these. • Same day appointments were available for children and those with serious medical conditions. • Patients were able to receive travel vaccines available on the NHS as well as those only available privately/ were referred to other clinics for vaccines available privately. • There were disabled facilities, a hearing loop and translation services available. • The practice had a lift to improve access for patients with limited mobility. Access to the service. The practice was open from 8.00am to 6.30pm, Monday to Friday and held surgeries daily between the hours of 8.30am and 6.30pm, Monday to Friday. Early morning GP surgeries were held on Mondays from 7.15am and Saturdays between 8am and 10am. The practice had opted out of providing out-of-hours services to its patients and referred them to Beacon Health out-of-hours service via the 111 service. The practice also conducted a drop in clinic and patients told us that they were happy with this service. On the day of inspection we observed one mother and child attend the drop in clinic. The patient told us they were happy to wait to see a nurse as they had always received good advice and the nurses were always friendly and professional. Results from the national GP patient survey showed that patient’s satisfaction with how they could access care and treatment was comparable to local and national averages. 18 The Dower House Quality Report 07/04/2016 • 87% of patients were satisfied with the practice’s opening hours compared to the CCG average of 84% and national average of 75%. • 71% patients said they could get through easily to the surgery by phone compared to the CCG average of 88% and national average of 74%. • 66% patients said they always or almost always see or speak to the GP they prefer compared to the CCG average of 67% and national average of 60%. Patients told us on the day of the inspection that they were able to get appointments when they needed them. For example a patient we spoke with told us that they had contacted the practice for an appointment that day and within three hours they were seeing a GP. The practice had also reacted to the need to have a better telephone system and on the day of our inspection we saw that a telephone engineer was working on the system to make it more efficient and easier for patients to get through to the practice. Listening and learning from concerns and complaints. The practice had an effective system in place for handling complaints and concerns. • Its complaints policy and procedures were in line with recognised guidance and contractual obligations for GPs in England. • There was a designated responsible person who handled all complaints in the practice. • We saw that information was available to help patients understand the complaints system. For example details were explained in the practice leaflet and we saw information displayed in the waiting areas. We looked at six complaints received in the last 12 months and found these were satisfactorily handled, dealt with in a timely way, with openness and transparency when dealing with the complaint. Lessons were learnt from concerns and complaints and action was taken to as a result to improve the quality of care. For example, a letter of apology from the practice about misspelling a name on the patient notes. Good ––– Are services well-led? (for example, are they well-managed and do senior leaders listen, learn and take appropriate action) Our findings Vision and strategy. The practice had a clear vision to deliver high quality care and promote good outcomes for patients. • The practice had a new vision statement which was displayed on the staff notice board and staff knew and understood the values. • The practice had a strategy and supporting business plans which reflected the vision and values. Governance arrangements. The practice had an overarching governance framework which supported the delivery of the strategy and good quality care. This outlined the structures and procedures in place and ensured that: • There was a clear staffing structure and that staff were aware of their own roles and responsibilities. • Practice specific policies were implemented and were available to all staff • A comprehensive understanding of the performance of the practice was maintained • A programme of continuous clinical and internal audit which was used to monitor quality and to make improvements. • There were arrangements for identifying, recording and managing risks, issues and implementing mitigating actions. Although when there were unintended or unexpected safety incidents, reviews and investigations were not always thorough enough and lessons learned were not communicated widely enough to support improvement. Leadership and culture. The partners in the practice had the experience, capacity and capability to run the practice and ensure high quality care. They prioritise safe, high quality and compassionate care. The partners were visible in the practice and staff told us they were approachable and always took the time to listen to all members of staff. The provider was aware of and complied with the requirements of the Duty of Candour. The partners encouraged a culture of openness and honesty. The practice had systems in place for knowing about notifiable safety incidents. 19 The Dower House Quality Report 07/04/2016 When there were unexpected or unintended safety incidents: • The practice gave affected patients reasonable support, truthful information and a verbal and written apology. • They kept written records of verbal interactions as well as written correspondence. There was a clear leadership structure in place and staff felt supported by management. • Staff told us the practice held regular team meetings. • Staff told us there was an open culture within the practice and they had the opportunity to raise any issues at team meetings and felt confident in doing so and felt supported if they did. • Staff said they felt respected, valued and supported, particularly by the partners in the practice. All staff were involved in discussions about how to run and develop the practice, and the partners encouraged all members of staff to identify opportunities to improve the service delivered by the practice. Seeking and acting on feedback from patients, the public and staff. The practice encouraged and valued feedback from patients, the public and staff. It proactively sought patients’ feedback and engaged patients in the delivery of the service. • The practice had gathered feedback from patients through the patient participation group (PPG) and through surveys and complaints received. The practice was working towards an active PPG which met regularly, carried out patient surveys and submitted proposals for improvements to the practice management team. For example, the practice has a healthcare assistant for the elderly. She has her own direct phone line which all over 75 year old patients who have a care plan can use to contact her with any problems or queries. • The practice had gathered feedback from staff through staff meetings, appraisals and discussion. Staff told us they would not hesitate to give feedback and discuss any concerns or issues with colleagues and management. Staff told us they felt involved and engaged to improve how the practice was run. Continuous improvement. There was a focus on continuous learning and improvement at all levels within the practice. The practice Are services well-led? Good ––– (for example, are they well-managed and do senior leaders listen, learn and take appropriate action) team was forward thinking and had worked to improve the areas that were highlighted as requiring improvement in the Care Quality Commission inspection of March 2015. We observed that the practice was endeavouring to meet the 20 The Dower House Quality Report 07/04/2016 challenges they faced and whilst there was a lot of work in progress they seemed motivated to continue make effective improvement to provide a better service for patients. This section is primarily information for the provider Requirement notices Action we have told the provider to take The table below shows the legal requirements that were not being met. The provider must send CQC a report that says what action they are going to take to meet these requirements. Regulated activity Diagnostic and screening procedures Family planning services Maternity and midwifery services Surgical procedures Treatment of disease, disorder or injury Regulation Regulation 13 HSCA (RA) Regulations 2014 Safeguarding service users from abuse and improper treatment Service users must be protected from abuse and improper treatment in accordance with this regulation. Systems and processes must be established and operated effectively to prevent abuse of service users. The provider did not ensure that all staff received safeguarding training that was relevant and at a suitable level for their role. Training should be updated at appropriate intervals and should keep staff up to date and enable them to recognise different types of abuse and the ways they can report concerns. This was in breach of regulation 13(1) and 13(2) of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014. 21 The Dower House Quality Report 07/04/2016