Enki Medical Practice NewApproachComprehensive Report ...

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 Requires improvement –––

Are services safe? Requires improvement –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive to people’s needs? Good –––

Are services well-led? Requires improvement –––

EnkiEnki MedicMedicalal PrPracticacticeeQuality Report

Orsborn House55 Terrace RoadHandsworthBirminghamB19 1BPTel: 01212501585Website: www.vitalitypartnership.nhs.uk

Date of inspection visit: 11 February 2016Date of publication: 19/05/2016

1 Enki Medical Practice Quality Report 19/05/2016

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 4

The six population groups and what we found 6

What people who use the service say 9

Areas for improvement 9

Detailed findings from this inspectionOur inspection team 10

Background to Enki Medical Practice 10

Why we carried out this inspection 10

How we carried out this inspection 10

Detailed findings 12

Action we have told the provider to take 23

Overall summaryLetter from the Chief Inspector of GeneralPracticeWe carried out an announced comprehensive inspectionat 11 February 2016. Overall the practice is rated asrequires improvement.

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

• There was an open and transparent approach to safetyand an effective system in place for reporting andrecording significant events.

• Some risks to patients were assessed and managed,with the exception of some relating to recruitmentchecks, management of medicines and medicalemergencies as well as infection prevention andcontrol.

• Staff assessed patients’ needs and delivered care inline with current evidence based guidance.

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

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

• Patients said they could get an appointment whenneeded but found the telephone appointment systemconfusing.

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

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

The areas where the provider must make improvementare:

• Ensure appropriate emergency medicines areavailable.

• Improve infection prevention and control (IPC)measure to stop the risk and spread of infections.

• Systems or processes must be operated effectively toensure there are no gaps in recruitment and staffingprocesses.

Summary of findings


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 requires improvement for providing safeservices. There was a system in place for reporting and recordingsignificant events. Lessons were shared to make sure action wastaken to improve safety in the practice. When there were unintendedor unexpected safety incidents, patients received reasonablesupport, truthful information, a verbal and written apology. Theywere told about any actions to improve processes to prevent thesame thing happening again. Infection prevention and controlaudits were not robust to detect and control risks related to spreadof infection. There were limited emergency medicines available andan adequate risk assessment had not been conducted to determinethe type of emergency medicines that should be kept.

Requires improvement –––

Are services effective?The practice is rated as good for providing effective services. Datashowed patient outcomes were generally above average for thelocality. Staff referred to guidance from the National Institute forHealth and Care Excellence (NICE) and used it routinely. Patients’needs were assessed and care was planned and delivered in linewith current legislation. The lead GP partner told us that they did notregularly have multidisciplinary meetings but worked to ensureneeds of patients including those on end of life care were metthrough ad-hoc communication with other professionals. However,the practice confirmed after the inspection that multidisciplinarymeetings took place with district nurses, health visitors, andoccasion with social workers. Most staff had received trainingappropriate to their roles and any further training needs had beenidentified and planned to meet these needs. There was evidence ofappraisals and personal development plans for all staff.

Good –––

Are services caring?The practice is rated as good for providing caring services. Patientssaid they were treated with compassion, dignity and respect andthey were involved in decisions about their care and treatment. Thereception opened into the waiting area and we saw reception staffwere caring towards patients and maintained confidentiality.Information for patients about the services available and was easyto understand. Data showed that patients rated the practice higherthan others for several aspects of care.

Good –––

Are services responsive to people’s needs?The practice is rated as good for providing responsive services. Itreviewed the needs of its local population and engaged with the

Good –––

Summary of findings


Clinical Commissioning Group (CCG) to secure improvements toservices where these were identified. A CCG is an NHS organisationthat brings together local GPs and experienced health professionalsto take on commissioning responsibilities for local health services.

Patients we spoke with said they found the telephone systemconfusing but the practice had made the system simpler followingfeedback. Patients said that urgent appointments were available thesame day. The practice was purpose built, had good facilities andwas well equipped to treat patients and to meet their needs.Information about how to complain was available and easy tounderstand and evidence showed that the practice respondedquickly to issues raised. Learning from complaints was shared withstaff and other stakeholders. Staff were able to speak some of thelanguages spoken by patients and staff knew how to arrange atranslation service where appropriate. The practice website could betranslated in various languages to ensure information aboutservices was accessible to all.

Are services well-led?The practice is rated as requires improvement for being well-led.There was a clear corporate vision and strategy to deliver integratedcare and the some of the services offered, such as theelectrocardiogram (ECG) reflected this. There was a clear centralcorporate leadership structure to help support the practice and staff.This was further supported by clinical and administration leadershipin the practice. The practice had a number of policies andprocedures to govern activity and held regular governancemeetings. There were systems in place to monitor and improvequality and identify risk. However, systems and processes were notalways operated effectively to ensure there were no gaps inrecruitment and staffing processes.

The practice proactively sought feedback from staff and patients,which it acted on. The practice had a patient participation group(PPG) and responded to feedback from patients about ways thatimprovements could be made to the services offered. Staff hadreceived inductions, regular performance reviews and attended staffmeetings and events.


Summary of findings


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

Older peopleThe provider was rated as require improvement for safe and wellled. The concerns which led to these ratings apply to everyone usingthe practice, including this population group.

The practice is rated as requires improvement for the care of olderpeople. Nationally reported data showed that outcomes for patientswere good for conditions commonly found in older people. Thepractice offered proactive, personalised care to meet the needs ofthe older people in its population and had a range of enhancedservices, for example, in dementia and end of life care. It wasresponsive to the needs of older people, and offered home visitsand rapid access appointments for those with enhanced needs. Thepractice had carried out reviews of patients over the age of 75 yearswho were taking eight or more medicines.


People with long term conditionsThe provider was rated as require improvement for safe and wellled. The concerns which led to these ratings apply to everyone usingthe practice, including this population group.

The practice is rated as requires improvement for the care of peoplewith long-term conditions. The practice nurses had lead roles inchronic disease management. Patients at risk of hospital admissionwere identified as a priority. Longer appointments and home visitswere available when needed. All patients diagnosed with a longterm condition had a named GP and a structured annual review tocheck that their health and medicine needs were being met. Forthose patients with the most complex needs, the clinicians workedto meet their needs working with other relevant health careprofessionals where appropriate. This included specialist clinics formore complex patients such as the electrocardiogram (ECG) service.One of the GP partners told us that a salaried GP had an interest incardiology and they were planning to offer a wider service for thesegroups of patients.


Families, children and young peopleThe provider was rated as require improvement for safe and wellled. The concerns which led to these ratings apply to everyone usingthe practice, including this population group.

The practice is rated as requires improvement for the care offamilies, children and young people. There were systems in place toidentify and follow up children living in disadvantagedcircumstances and who were at risk, for example, children and


Summary of findings


young people who had a high number of A&E attendances. Staff hadaccess to safeguarding folders in the reception with contact detailsfor the relevant safeguarding team. Same day appointments wereavailable for children and appointments were available outside ofschool hours. The practice building was purpose built and wassuitable for children and babies. We saw parents with pushchairswere able to access the practice and there was adequate space inthe reception area.

Working age people (including those recently retired andstudents)The provider was rated as require improvement for safe and wellled. The concerns which led to these ratings apply to everyone usingthe practice, including this population group.

The practice is rated as requires improvement for the care ofworking-age people (including those recently retired and students).The needs of the working age population, those recently retired andstudents had been identified and the practice had adjusted theservices it offered to ensure these were accessible, flexible andoffered continuity of care. The practice offered online services andtelephone consultations as well as a full range of health promotionand screening that reflected the needs of this age group. Forexample, the provider had developed a smart phone applicationwhere patients could use to make appointments, order repeatprescriptions, access self-help guides as well as provide real timefeedback.


People whose circumstances may make them vulnerableThe provider was rated as require improvement for safe and wellled. The concerns which led to these ratings apply to everyone usingthe practice, including this population group.

The practice is rated as requires improvement for the care of peoplewhose circumstances may make them vulnerable. The practice hada large register of substance misuse patients and three drug workerswere assigned to the practice. The drug workers were based in thepractice and they told us that they worked closely with the practiceto improve outcomes for these patients. The practice also had alarge number of mental health patients registered. Because thecommunity mental health team was also located in the samebuilding, this facilitated better care for these patients. One of theAdvanced Nurse Practitioner (ANP) was trained in substance misuseand the lead GP had also attended further training in primarymental health care. Vulnerable patients were discussed at regularpractice and staff knew how to recognise signs of abuse in


Summary of findings


vulnerable adults and children. Staff were aware of theirresponsibilities regarding information sharing, documentation ofsafeguarding concerns and how to contact relevant agencies innormal working hours and out of hours.

People experiencing poor mental health (including peoplewith dementia)The provider was rated as require improvement for safe and wellled. The concerns which led to these ratings apply to everyone usingthe practice, including this population group.

The practice is rated as requires improvement for the care of peopleexperiencing poor mental health (including people with dementia).The practice utilised local services for counselling support such asHealthy minds. Patients were also signposted to a variety of groupsand voluntary organisations for self-referral. Those with morecomplex mental health needs were referred into the localcommunity mental health services who were housed within thesame building helping to better facilitate this process. The lead GPhad also attained advanced University certificate in Primary MentalHealth Care. There was a system in place to follow up patients whohad attended accident and emergency (A&E) where they may havebeen experiencing poor mental health.


Summary of findings


What people who use the service sayThe national GP patient survey results published on7Janury 2016 showed the practice performance wasmixed in comparison with local and national averages. Ofthe 409 survey forms that were distributed 74 werereturned. This represented an 18% completion rate.

• 52% found it easy to get through to this surgery byphone compared to a CCG average of 62% and anational average of 73%.

• 88% were able to get an appointment to see orspeak to someone the last time they tried (CCGaverage 76%, national average 85%).

• 62% described the overall experience of their GPsurgery as fairly good or very good (CCG average63%, national average 73%).

• 65% said they would definitely or probablyrecommend their GP surgery to someone who hasjust moved to the local area (CCG average 65%,national average 78%).

We also asked for CQC comment cards to be completedby patients prior to our inspection. We received 17comment cards which were all positive about thestandard of care received. Most of the comments cardsstated that they had received an excellent service fromthe GPs and the practice.

We spoke with six patients including a member of thePatient Participation Group (PPG) during the inspection.All six patients said they were happy with the care theyreceived and thought staff were approachable,committed and caring. Some patients also stated thatthey found the telephone appointment system a littleconfusing. The practice also carried out the friends andfamilies test. The practice had displayed its performanceof the friends and family test from November 2015 toJanuary 2016. We saw that 515 patients were extremelylikely to recommend the practice to their friends andfamily. Also, 284 were likely to recommend, 51 were eitherlikely or unlikely, and 68 were unlikely.

Areas for improvementAction the service MUST take to improve

• Ensure appropriate emergency medicines areavailable.

• Improve infection prevention and control (IPC)measure to stop the risk and spread of infections.

• Systems or processes must be operated effectively toensure there are no gaps in recruitment and staffingprocesses.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC Lead Inspector.The team included a GP specialist adviser and a practicemanager specialist adviser.

Background to Enki MedicalPracticeEnki Medical Practice provides primary medical services toapproximately 7750 patients in the local community inLozells in Birmingham. The practice is part of a corporatepartnership and one of the partners (female) worked at thepractice. Five salaried GPs (three male and two female)worked part time at the practice. The GPs are supported bya two Advanced Nurse Practitioners (ANPs), two practicenurses and two health care assistants. The non-clinicalteam consists of an administrative and reception staff anda practice/operations manager and deputy practicemanager. The governance and quality team as well as otherfunctions (such as the finance team) of the corporatepartnership were also housed in the practice building.

The practice has a General Medical Services contract (GMS)with NHS England. A GMS contract ensures practicesprovide essential services for people who are sick as wellas, for example, chronic disease management and end oflife care. The practice also provides some directedenhanced services such as, childhood vaccination andimmunisation schemes. Enhanced services require anenhanced level of service provision above what is normallyrequired under the core GP contract.

The practice opening times are 8am to 6pm Mondays,Tuesdays and Fridays. The practice closes at 1pm onWednesdays. On Thursdays the practice provides anextended hours service till 8pm.

The practice has opted out of providing out-of-hoursservices to their own patients. This service is provided bythe external out of hours service provider when the practiceis closed including Wednesdays when the practice closedfor the afternoon.

Home visits are available for patients who are unable toattend the practice for appointments. There is also anonline service which allows patients to order repeatprescriptions and book new appointments without havingto phone the practice. The corporate provider hasdeveloped a smart phone application for makingappointments and requesting repeat prescriptions as wellas to provide feedback of their experience.

Why we carried out thisinspectionWe inspected this service as part of our newcomprehensive inspection 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. The inspection wasplanned to check whether the provider is meeting the legalrequirements and regulations associated with the Healthand Social Care Act 2008, to look at the overall quality ofthe service, and to provide a rating for the service under theCare Act 2014.

EnkiEnki MedicMedicalal PrPracticacticeeDetailed findings


How we carried out thisinspectionBefore visiting, we reviewed a range of information we holdabout the practice and asked other organisations to sharewhat they knew. We carried out an announced visit on11February 2016. During our visit we spoke with a range ofstaff including the deputy practice manager, thegovernance and quality manager, members of the centralcorporate administration team as well the practicereception staff. The practice/operations manager was onleave at the time of our inspection. The clinical staffmembers we spoke with included the lead GP partner atthe practice, as well as a salaried GP. Other members of theteam included Healthcare assistants and nurses. We alsospoke with members of other services that were locatedwithin the building such as the drug workers assigned tothe practice.

To get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

We also looked at how well services were provided forspecific groups of people and what good care looked likefor them. The population groups are:

• Older people• People with long-term conditions• Families, children and young people• Working age people (including those recently retired

and students)• People whose circumstances may make them

vulnerable• People experiencing poor mental health (including

people with dementia)

Please note that when referring to information throughoutthis report, for example any reference to the Quality andOutcomes Framework (QOF) data, this relates to the mostrecent information available to the CQC at that time.

Detailed findings


Our findingsSafe track record and learning

There was a system in place for reporting and recordingsignificant events. A staff member we spoke with told usabout a specific incident that had occurred recently. Theytold us that they had completed an incident form and haddiscussed the incident at the reception team meeting. Wesaw that the practice had a significant event monitoringpolicy with a template. The practice had recorded eightincidents from June 2015 and where appropriate learninghad been discussed and change in practice implemented.For example, an incident from November 2015 showed thatthere was a mix-up with a vaccination of a patient. Thepractice took steps to contact the patient and their familyand explained the incident and apologised to them.Changes to the way patients were booked forappointments were also made.

The practice also shared many of the incidents at thepractice with the Clinical Commissioning Group (CCG) usingan electronic system. CCGs are groups of general practicesthat work together to plan and design local health servicesin England. They do this by 'commissioning' or buyinghealth and care services.

Overview of safety systems and processes

Arrangements were in place to safeguard children andvulnerable adults from abuse that reflected relevantlegislation and local requirements. All staff had access topolicies and protocols. For example, reception staff showedus two folders for safeguarding children and adults withrelevant policies. The policies clearly outlined who tocontact for further guidance if staff had concerns about apatient’s welfare. There was a lead member of staff forsafeguarding and all staff we spoke with were aware of whoit was. Staff demonstrated they understood theirresponsibilities and all had received training relevant totheir role. GPs were trained to Safeguarding level 3. We sawan example where appropriate advice was sought.

Notices in the reception areas and consultation rooms welooked at advised patients that chaperones were availableif required. All staff who acted as chaperones were trainedfor the role and had received a Disclosure and Barring

Service (DBS) check. DBS checks identify whether a personhas a criminal record or is on an official list of peoplebarred from working in roles where they may have contactwith children or adults who may be vulnerable.

The practice maintained appropriate standards ofcleanliness and hygiene. We observed the premises to beclean and tidy. One of the healthcare assistants (HCA) wasthe practice infection control lead. The practice was unableto provide us with evidence of their training and suitabilityto the role on the day of the inspection. However, after theinspection we were sent a training certificate but wereunable to determine the date of the training. The local CCGheld regular IPC link worker training but we were told bythe practice that the HCA did not attend as they did notmeet the criteria set by the CCG. However, we were told bystaff that the CCG had changed its criteria and the HCAwould now be attending meeting with other local infectionprevention leads. We were also told that another nurse at anearby practice that was part of the corporate partnershipacted as a ‘buddy’ for the HCA to lead on IPC issues.

We saw that the IPC lead undertook monthly checks of thepractice premises such as consultation rooms andreception areas to identify any issues. We saw that thechecks had identified a treatment rooms as beingcarpeted. We spoke with one of the GP partners who toldus that they planned to change the carpeting of thepractice including the treatment room and consultationrooms. We saw that some treatment rooms had adequateflooring that would facilitate effective cleaning. Although,these IPC checks were being undertaken regularly they hadnot identified all issues. For example, we saw that theflooring in one of the patient toilets needed to be repairedas it compromised effective cleaning and this was notidentified in the audits.

Patient Group Directions (PGDs) had been adopted by thepractice to allow nurses to administer medicines in linewith legislation. PGDs are written instructions for thesupply or administration of medicines to groups of patientswho may not be individually identified before presentationfor treatment. However, we saw six PGDs that had not beenby appropriately signed by management. After theinspection the practice had sent us copies of signed PGDs.

We reviewed four personnel files to check if appropriaterecruitment checks had been undertaken prior toemployment. For example, proof of identification,references, qualifications, registration with the appropriate

Are services safe?



professional body and the appropriate checks through theDisclosure and Barring Service. Although most recruitmentinformation was available some was missing. For example,the practice could not confirm if medical indemnity for a GPwas in place.

Monitoring risks to patients

There was a health and safety policy available with a posterin the reception office which identified local health andsafety representatives. The practice had up to date fire riskassessments and carried out regular fire drills. All electricalequipment was checked to ensure the equipment was safeto use and clinical equipment was checked to ensure it wasworking properly. The practice had a variety of other riskassessments in place to monitor safety of the premisessuch as control of substances hazardous to health (COSHH)and legionella. Legionella is a term for a particularbacterium which can contaminate water systems inbuildings.

Arrangements were in place for planning and monitoringthe number of staff and mix of staff needed to meetpatients’ needs. There was a rota system in place for all thedifferent staffing groups to ensure that enough staff wereon duty. Within the corporate provider each location had anearby ‘buddy’ practice. In the event of unplanned absenceother staff members could cover. The practice also hadaccess to locum clinical staff. We were told that one of staffmembers from the practice was helping out at the ‘buddy’site currently.

Arrangements to deal with emergencies and majorincidents

The practice had arrangements in place to respond tosome emergencies and major incidents.

Staff members we spoke with told us that there was analert system on all computers which when activated willinform all computers in the practice of an emergency.

The practice did not stock any emergency medicines apartfrom adrenaline which could be used for anaphylacticshock. We spoke with a GP partner who told us that theyhad conducted a risk assessment to identify a list ofmedicines that werenotsuitable for a practice to stock.However, the practice was unable to present the riskassessment to us when asked on the day of the inspection.The GP partner also told us that because there was achemist located in the same building they could acquireemergency medicines when needed. As part of theemergency medicines kit the practice held a portablemedical oxygen cylinder and an Automated ExternalDefibrillator (AED). An AED is a portable electronic devicethat analyses life threatening irregularities of the heartincluding ventricular fibrillation and is able to deliver anelectrical shock to attempt to restore a normal heartrhythm. We saw records that showed they were checked toensure they were in good working order and were in date.However, these checks were not regular because recordsshowed that checks were undertaken in June 2015, andthen checked again in December 2015 and January 2016.Emergency medicines and equipment should be checkedregularly. Furthermore, these checks were not robustbecause we found two syringe needles in the emergencydrugs kit that had expired in June 2014.

Are services safe?



Our findingsEffective needs assessment

The practice assessed needs and delivered care in line withrelevant and current evidence based guidance andstandards, including National Institute for Health and CareExcellence (NICE) best practice guidelines. We spoke withone of the GPs who demonstrated how they accessed andused guidance including NICE. The practice was part of acorporate GP partnership that operated across 13 differentlocations in Sandwell and Birmingham and the use of NICEguidance was monitored centrally by relevant lead GPswithin the partnership.

The practice had systems in place to identify and assesspatients who were at high risk of admission to hospital.This included reviewing discharge summaries followinghospital admission to establish the reason for admission. Ahealthcare assistant called patients following discharge sothat arrangements could be made to review and developcare plans. This was to ensure patient needs were beingmet which assisted in reducing the need for them to go intohospital.

Data we looked at showed the number of emergencyadmissions with cancer was lower than the national andCCG average. We saw also that the practice referral forcancer which resulted in detection and treatment wassignificantly higher than the Clinical Commissioning Group(CCG) and national averages. CCGs are groups of generalpractices that work together to plan and design localhealth services in England. They do this by 'commissioning'or buying health and care services CCG and nationalaverages.

Management, monitoring and improving outcomes forpeople

The practice used the information collected for the Qualityand Outcomes Framework (QOF) and performance againstnational screening programmes to monitor outcomes forpatients. QOF is a system intended to improve the qualityof general practice and reward good practice. The mostrecent published data showed that the practice achieved98% of the total number of points available, with 9%exception reporting. Exception reporting is the removal ofpatients from QOF calculations where, for example, thepatients are unable to attend a review meeting or certain

medicines cannot be prescribed because of side effects.The exception reporting was in line with local and nationalaverages. This practice was not an outlier for any QOF (orother national) clinical targets. Data from 2014/15 showed;

• Performance for diabetes related indicators was bettercompared to the CCG and national average. The practiceachieved 94% of the available points for all diabetesindicators. This was 9% better than the local and 8%better than the national average.

• The percentage of patients with hypertension havingregular blood pressure tests was better to the CCG andnational average. The practice achievement was 85%;this was 3% above local and 2% above national average.

• Performance for mental health related indicators wasworse compared to the CCG and national average. Thepractice value was 80%; this was 8% below local and12% below national average.

The practice found it difficult to engage with every patientand had recently instigated a ‘meeter and greeter’receptionist who had access to mobile care records (usinga laptop) and was able to proactively invite patients forreviews as well as other interventions such as vaccinations.The practice hoped to further increase their QOFachievement through this pilot scheme. We spoke with thestaff member who told us that they would look at theappointment system for the next day and check if anypatients were due any QOF related reviews. They were thentaken off their normal responsibilities to engage withpatients whilst they waited for their appointments. Thisallowed for any follow up to be undertaken or scheduled asappropriate.

The practice had completed a number of clinical auditswith evidence to confirm that these were positivelyinfluencing and improving practice and outcomes forpatients. We saw evidence of completed audits whereimprovements were implemented and monitored. Forexample, the practice had conducted an antibiotic audit inJanuary 2015. This audit looked at whether patientsprescribed antibiotics met the criteria. The audit showedthat the practice had made improvement since theprevious audit.

The practice had also conducted audits on certain types ofmedicine prescribed for substance misuse patients. Theidea was to reduce the dose of these medicines for thosepatients who were taking more than the recommendeddose. Also, there were a number of patients who were

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

Good –––


thought to be on reducing doses but did not seem to beconsistently maintaining their reductions. The first auditwas conducted on May 2015 and following the audit, ameeting was held with all prescribing clinical staff in May2015 to discuss the findings. A re-audit was conducted inAugust 2015 which identified some improvements as wellas other identifying other actions to make furtherreductions such as more support for patients to facilitatereduction.

Effective staffing

The practice had an induction programme for all newlyappointed staff. It covered such topics as safeguarding,infection prevention and control, fire safety, health andsafety and confidentiality. We spoke with a staff memberwho confirmed that they had received an induction whenthey first started working at the practice.

The practice had a training matrix to ensure mandatorytraining was up to date for all staff. However, this was noteffective as there were gaps and it did not demonstratecurrent training completed by all staff. Following theinspection, the provider sent us certificates to confirmtraining which were identified as gaps in the trainingmatrix.

The learning needs of staff were identified through asystem of appraisals. Staff received training that includedsafeguarding, fire procedures, basic life support, chaperonetraining as well as equality and diversity. Staff had access toand made use of eLearning training modules and in-housetraining.

Regular staff meetings provided the opportunity to shareimportant information with staff. The minutes showed thatthese meetings were detailed and covered a number ofareas including significant events and complaints.

Coordinating patient care and information sharing

The information needed to plan and deliver care andtreatment was available to relevant staff in a timely andaccessible way through the practice’s patient recordsystem, their intranet and an integrated pathology anddischarge summaries system linked to the local acutehospital. This included care plans, risk assessments,medical records and results of tests and investigations. Allrelevant information was shared with other services in atimely way, for example when people were referred to otherservices. The practice had a system of a ‘duty’ GP or on call

GP. One of their roles was to review and action clinicalletters received from other providers. The lead GP also toldus that they reviewed all referral made by locum GPs toensure they were appropriate.

There was some evidence that staff worked with otherhealth and social care services to understand and meet therange and complexity of people’s needs and to assess andplan ongoing care and treatment. This included whenpeople moved between services, including when they werereferred, or after they were discharged from hospital. Thelead GP and a practice nurse we spoke with told us thatthey met frequently to discuss patients as they found thiseasier and more effective to do than to organise regularformal multidisciplinary meetings as attendance at thesecould be variable. Hever, we were told after the inspectionthat multidisciplinary were held submitted minutes ofmeetings as evidence.

The practice used a dashboard system (governance datapack) from the central management team from thecorporate partnership. The data pack was RAG (Red, Amberand Green) rated with actions points. For example, lookingat the practice performance for reviews of patients withspecific conditions or on long term medicines. Theseallowed the practice to further monitor and improvepatient outcomes.

Consent to care and treatment

Staff sought patients’ consent to care and treatment in linewith legislation and guidance. Staff understood therelevant consent and decision-making requirements oflegislation and guidance, including the Mental Capacity Act2005. A GP we spoke with confirmed that they had receivedtraining in mental capacity and told us that they advisedearly dementia patients to consider lasting power ofattorney.

The GPs we spoke with demonstrated an understanding ofthe importance of determining if a child was Gillickcompetent especially when providing contraceptive adviceand treatment. A Gillick competent child is a child under 16who has the legal capacity to consent to care andtreatment. They are capable of understanding theimplications of the proposed treatment, including the risksand alternative options. A GP we spoke with told us thatconsent was recorded on the patient notes and an alert puton the screen if relevant.

Supporting patients to live healthier lives


Good –––


Patients who may be in need of extra support wereidentified by the practice. These included patients in thelast 12 months of their lives, carers, those at risk ofdeveloping a long-term condition, those requiring adviceon their diet, smoking cessation and sexual health advice.

The GP partners told us that they had one of the largestlists (130, at the time of inspection) of patients withSubstance Misuse problems along with other social andpsychological problems within the CCG area. There werethree drug workers that were assigned to the practice. Wespoke to one of the drug workers on the day of theinspection and they told us that they worked well with thepractice and had a close working relationship with them tomeet patient needs. One of the salaried GP was trained insubstance misuse.The lead GP and one of the ANPs werealso trained were trained to an enhanced level frosubstance misuse.

The Community Mental Health Team was also located inthe same building which facilitated better management ofthese patients, especially as many of the substance misusepatients had other complex physical and psychologicalissues. The lead GP had also completed a certificate inPrimary Mental Health Care.

Many of the patients registered at the practice were ofsouth Asian heritage who were known to have a higherprevalence for diabetes. The practice offered regular weeklydiabetes clinic run by one of the practice nurses and theHealthcare Assistant (HCA). They were supported by a GPand an Advanced Nurse Practitioner (ANP). Patients werealso signposted to other organisations such as the XPERTdiabetes education programme.

The practice had an electronic screen with healthpromotion information such as the benefits of exercise.There were also posters and practice leaflets with details ofservices for patients to access including a range ofself-referral service such as sexual health, smokingcessation and mental health services.

The practice had a comprehensive screening programme.Data showed that the practice’s uptake for the cervicalscreening test over the last five years was 81.4% which wasbetter than the CCG average and in line with the nationalaverage. There was a system in place to recall and followup patients who did not attend for their cervical screeningtest. Findings were audited to ensure good practice wasbeing followed.

Childhood immunisation rates were mostly in line with CCGaverages. For example, childhood immunisation rates forthe vaccinations given to under one year olds was 89%, twoyear olds ranged from 80% to 89%. Vaccinations for fiveyear olds ranged from 86% to 91%. These values werecomparable to the CCG values.

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


Good –––


Our findingsKindness, dignity, respect and compassion

We observed members of staff were courteous and veryhelpful to patients and treated them with dignity andrespect. We saw that many of the patients knew the staffwell and vice versa. Patients we spoke with also werepositive about the staff and told us they were helpful andcourteous.

Curtains were provided in consulting rooms to maintainpatients’ privacy and dignity during examinations,investigations and treatments. We noted that consultationand treatment room doors were closed duringconsultations; conversations taking place in these roomscould not be overheard. Reception staff we spoke withwhere aware when patients wanted to discuss sensitiveissues or appeared distressed they could offer them aprivate room to discuss their needs.

All of the 17 patient Care Quality Commission commentcards we received were positive about the serviceexperienced. Patients said the service offered was excellentand staff were helpful, caring and treated them with dignityand respect.

We spoke with six patients including a member of thepatient participation group (PPG). They also told us theywere satisfied with the care provided by the practice andsaid their dignity and privacy was respected. Commentcards highlighted that staff responded compassionatelywhen they needed help and provided support whenrequired. A PPG is a group of patients registered with apractice who work with the practice to improve servicesand the quality of care.

Results from the national GP patient survey showedpatients felt they were treated with compassion, dignityand respect. The practice was above average for itssatisfaction scores on consultations with GPs and nurses.For example:

• 91% said the GP was good at listening to themcompared to the CCG average of 83% and nationalaverage of 89%.

• 87% said the GP gave them enough time (CCG average81%, national average 87%).

• 97% said they had confidence and trust in the last GPthey saw (CCG average 93%, national average 95%)

• 90% said the last GP they spoke to was good at treatingthem with care and concern (CCG average 80%, nationalaverage 85%).

• 90% said the last nurse they spoke to was good attreating them with care and concern (CCG average 86%,national average 91%).

• 87% said they found the receptionists at the practicehelpful (CCG average 81%, national average 87%)

Care planning and involvement in decisions aboutcare and treatment

Patients told us they felt involved in decision making aboutthe care and treatment they received. They also told usthey felt listened to and supported by staff and hadsufficient time during consultations to make an informeddecision about the choice of treatment available to them.Patient feedback on the comment cards we received wasalso positive and aligned with these views.

Results from the national GP patient survey showedpatients responded positively to questions about theirinvolvement in planning and making decisions about theircare and treatment. Results were in line with local andnational averages. For example:

• 84% said the last GP they saw was good at explainingtests and treatments compared to the CCG average of81% and national average of 86%.

• 88% said the last GP they saw was good at involvingthem in decisions about their care (CCG average 76%,national average 82%)

• 85% said the last nurse they saw was good at involvingthem in decisions about their care (CCG average 82%,national average 85%)

The practice was located in a very deprived area and thelead GP told us that a significant number of their patientpopulation were transient. For example, they told us that in2013 they had received the most requests for polishtranslators. However, for 2016 Arabic translators were mostrequested while the request for Polish translators haddecreased to the sixth most requested. To further emphasisthis, the lead GP pointed out that in 2013 the request forArabic translators was very minimal. Some of the staffincluding the GPs also spoke some of the languagesspoken by patients. They included Punjabi, Urdu andBengali. The practice website could also be translated intovarious languages so that it was more responsive to theneeds of its patient population.

Are services caring?

Good –––


Patient and carer support to cope emotionally withcare and treatment

Notices in the patient waiting room told patients how toaccess a number of support groups and organisations. Thepractice’s computer system alerted GPs if a patient wasalso a carer. The practice had identified 1% of the practicelist as carers. Written information was available to directcarers to the various avenues of support available to them.

Staff told us that if families had suffered bereavement, theirusual GP contacted them referred them to other servicessuch as Cruse. A GP we spoke with told us of anotherservice (Edward’s Trust) which they felt provided a usefulservice for patients who had lost children.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needs

The practice worked with the local Clinical CommissioningGroup (CCG) to plan services and to improve outcomes forpatients in the area. A CCG is an NHS organisation thatbrings together local GPs and experienced healthprofessionals to take on commissioning responsibilities forlocal health services. For example, the practice was part ofa corporate provider and patients had access to specialistGPs in Dermatology, Rheumatology, Musculoskeletal andGynaecology. One of the GPs at the practice had aspecialist interest in Cardiology. The corporate partnershipwas looking to develop a cardiology service within practiceand was currently offering an in house Electrocardiogram(ECG) service. ECG equipment helps to record electricalactivity of the heart to detect abnormal rhythms and thecause of chest pain. Patients also had access to on-sitespirometry services for patients with respiratory conditionsand phlebotomy services (blood taking) which allowedcare closer to home.

There were three drug workers based at the practice andalthough the practice did not provide the service, thepractice hosted the drug workers who provided a service tomany of the patients registered with the practice. Otherservices were also based in the same building such as thecommunity mental health service.

The practice offered extended hours on a Thursday until8pm for working patients who could not attend duringnormal opening hours. There were longer appointmentsavailable for people with a learning disability. Onlinebooking was available as well as home visits for olderpatients or patients who would benefit from these. Thecorporate provider had also developed a smartphoneapplication to help book appointments as well as toprovide further information on services.

The practice building was located in a purpose builtbuilding with disabled facilities as well as a hearing loop.All consultation rooms were on the ground floor and thereception area was large and spacious making access witha push chair or a wheel chair easier.

Access to the service

The practice was open between 8am and 6pm Tuesdays,Thursdays and Fridays. On Mondays the practice opened at9am and closed at 6pm. On Wednesdays the practiceopened at 8am but closed at 1pm.

Patients were able to have consultations in person or takeadvantage of a range of other ways to seek advice includingonline, telephone and by skype.

Results from the national GP patient survey showed thatpatient’s satisfaction with how they could access care andtreatment was comparable to local and national averages.

• 85% of patients were satisfied with the practice’sopening hours compared to the CCG average of 71%and national average of 75%.

• 52% patients said they could get through easily to thesurgery by phone (CCG average 62%, national average73%).

• 55% patients said they always or almost always see orspeak to the GP they prefer (CCG average 47%, nationalaverage 59%).

People told us on the day of the inspection that they wereable to get appointments when they needed them.However, some patients also told us that they found itdifficult to get through to the practice on the telephone.Some patients also stated that they found the telephonesystem confusing. This aligned with the GP patient surveyabove where the practice performed worse than the localand national averages.

The practice told us that they had a dedicated call centrebased at the practice that triaged all calls. We saw thatthere was a dedicated call centre with 13 call handlers onthe day of the inspection. We were also told that thepractice was a hub for four other practices within thecorporate partnership. We saw work was underway toincrease the size of the call centre so that calls for otherpractices within the corporate partnership could also behandled. However, the practice had received feedback frompatients that the process of getting through to the practicevia the call centre was confusing. In response the practicehad simplified the process by minimising the number ofoptions on the system. Some of the patients we spoke withon the day acknowledged that the system had becomemore user-friendly. One of the GP partners we spoke withexplained that the purpose of the call centre was to offerbetter access and flexibility but this was a period transitionfor patients as they were getting used to the new system.

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

Good –––


Listening and learning from concerns and complaints

The practice had a policy in place for handling complaintsand concerns. Its complaints policy and procedures were inline with recognised guidance and contractual obligationsfor GPs in England. The practice manager received andresponded to all complaints. In the absence of the practicemanager the deputy practice manager was responsible forresponding to complaints. The responsibility forinvestigating and responding to complaints was the lead

GP partner and the practice manager. We saw thatinformation was available to help patients understand thecomplaints system and staff we spoke with knew theprocess to follow when a patient wanted to make acomplaint. The practice investigated complaints anddiscussed learning through staff meetings.

The practice had received 17 complaints for 2015 andwhere appropriate action was taken and learning shared.

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

Good –––


Our findingsVision and strategy

The practice had a clear vision to deliver excellent careevery time in a variety of ways. A poster of the visionstatement was displayed in the reception waiting area.Staff members we spoke with told us that they had beenconsulted on the mission statement when it wasdeveloped.

The practice had a robust strategy and processes were inplace that reflected its vision. For example, the practicevison was able to deliver healthcare advice in a range ofways including online, telephone and by skype. Systemswere in place for the practice to deliver that vision.

Governance arrangements

The practice had a governance framework whichsupported the delivery of the strategy and good qualitycare. The operational management team for the corporateprovider met regularly to discuss issues affecting all thepractices. This team included practice managers, thegovernance and quality manager from the centraloperations team as well as other members from the sameteam. The clinical management team for the corporateprovider met regularly and the practice also held its ownclinical meetings as well as practice meetings to discussissues related specifically to the practice.

The practice had a comprehensive understanding of theperformance of the practice because the corporateprovider team released a RAG (red, amber and green) rateddashboard identifying areas for improvement. This allowedthe practice to focus on areas of weakness.

There was a clear staffing structure and that staff wereaware of their own roles and responsibilities. The lead GPwas responsible for clinical issues and the practicemanager was responsible for day to day running of thepractice. There was an assistant practice manager and thegovernance team for the corporate partnership were alsobased in the same building.

A programme of continuous clinical audits and internalchecks were used to monitor quality and to makeimprovements.

Although there was a governance structure in place therewere gaps in the process. For example, checks such as the

infection prevention needed to be more robust. Adequatechecks were not in place for emergency medicalequipment. There were also some gaps in recruitment andstaffing processes. For example, the practice could notconfirm the indemnity status of a GP.

Leadership and culture

The partners in the practice had the experience, capacityand capability to deliver high quality care. The practice hada corporate team to support its aim of delivering its visionof care. Staff told us and records we looked at showed thatregular team meetings were held. Staff also told us thatthere was an open culture within the practice and they hadthe opportunity to raise any issues at team meetings. Staffsaid they were confident in raising any issues and feltsupported if they did. There were protected learning eventsheld in house six monthly as well as those held by theClinical Commissioning Group (CCG) to support stafflearning and development.

Staff said they felt respected, valued and supported. Allstaff were involved in discussions about how to run anddevelop the practice and this was encouraged so thatopportunities for improvement could be identified.

Seeking and acting on feedback from patients, thepublic and staff

The practice encouraged and valued feedback frompatients, the public and staff. It proactively sought patients’feedback and engaged patients in the delivery of theservice.

Feedback from patients was gathered through the PatientParticipation Group (PPG) and through surveys andcomplaints received. The practice PPG also met with otherPPGs within the corporate partnership. We spoke with aPPG member on the day of the inspection and they told usthat the practice listened to any suggestions made by thePPG. The last PPG meeting at the practice was held inFebruary 2016 where issues regarding telephone accesswas highlighted and discussed. A PPG is a group of patientsregistered with a practice who work with the practice toimprove services and the quality of care.

The practice also monitored the national GP patient surveyas well as feedback from the NHS friends and family test.We saw that the practice displayed its performance of thefriends and family test from November 2015 to January

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



2016. We saw that 515 patients were extremely likely torecommend the practice to their friends and family. Also,284 were likely to recommend, 51 were neither likely norunlikely, and 68 were unlikely.

Continuous improvement

There was a strong focus on continuous learning andimprovement at all levels within the practice. One of the GPhad an interest in Cardiology and was due to complete adiploma in June 2016. They supported and answeredqueries from other colleagues within the partnership.

Furthermore, the practice planned to develop and offer aspecialist cardiology clinic in the future. The practice teamwas forward thinking and was undertaking pilot schemesto improve outcomes for patients in the area. For example,they had instigated a ‘meeter and greeter’ receptionist whohad access to mobile care records (using a laptop) and wasable to proactively invite patients for reviews, vaccinationsnear patient testing etc. The practice hoped to implementthis in other practices within the corporate partnershipafter trialling at this practice.

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



Action we have told the provider to takeThe table below shows the legal requirements that were not being met. The provider must send CQC a report that sayswhat action they are going to take to meet these requirements.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Treatment of disease, disorder or injury

Regulation 12 HSCA (RA) Regulations 2014 Safe care andtreatment

How the regulation was not being met:

The registered person must ensure persons providingcare or treatment to service users have the competenceto deliver care. The registered person must ensureappropriate emergency medicines are kept in thepractice through adequate risk assessments. Risks to thespread of infections are detected and prevented orcontrolled.

This was in breach of regulation 12 (2) (c) (g) (h)

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Treatment of disease, disorder or injury

Regulation 17 HSCA (RA) Regulations 2014 Goodgovernance

How the regulation was not being met:

Systems or processes must be operated effectively toenable the registered person to keep all current andrelevant records of persons employed in the carrying onof the regulated activities.

This was in breach of regulation 17 (d) (I)

Regulation

Regulation

This section is primarily information for the provider

Requirement notices


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