Neasham Road Surgery
186 Neasham Road Darlington County Durham DL1 4YL
Tel: 01325 461128
Fax: 01325 469123
Out of Hours: 111

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Date of inspection 25.03.2015

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.
Overall rating for this service                     Good

Are services safe?                                            Good

Are services effective?                                        Good

Are services caring?                                           Good

Are services responsive to people’s needs?     Good

Are services well-led?                                     Good

 

Letter from the Chief Inspector of General Practice

We carried out this comprehensive inspection on 25 March 2015.

Overall, we rated this practice as good.

Our key findings were as follows:

• The practice provided a good standard of care, led by current best practice guidelines.

• The practice had a good understanding of the patient population and their needs.

• Patients told us they were treated with dignity and respect.

• Staff told us they felt confident and well supported in their roles.

• The practice performed well in the management of long term conditions.

• The practice had developed good continuity of care for patients in nursing homes.

• The practice promoted shared learning from incidents.

• The building was safe for patients to access, with sufficient facilities and equipment to provide safe effective services.

We saw some areas of outstanding practice including:

• Enhanced care plans and communication/education with care homes including weekly ward rounds.

• The practice provided an additional voluntary service to hospice patients who did not already have their own GP.

• Newly registered patients with visual impairments were invited to the practice for a walk through induction.

However, there were also areas of practice where the provider needs to make improvements.

The provider should:

• Ensure that documented action points arising from risk assessments are carried out.

• Explore options to improve patient privacy in the reception area.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

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 good for providing safe services. Staff understood their roles and responsibilities in raising concerns, and reporting incidents. Lessons were learned from incidents, and were communicated widely throughout the practice to allow additional learning opportunities. The practice had assessed risks to those using or working at the practice and kept these under review, although it was not clear whether some documented action points had been completed. There were sufficient emergency procedures in place to keep people safe. There were sufficient numbers of staff with an appropriate skill mix to keep people safe.

Are services effective?

The practice is rated as good for providing effective services. Quality data showed patient outcomes were at or above average for the locality. Guidance from the National Institute for Health and Care Excellence (NICE) was referred to routinely, and people’s needs were assessed and care planned in line with current legislation. This included promotion of good health and assessment of capacity where appropriate. Staff had received training appropriate to their roles. Clinical staff undertook audits of care and reflected on patient outcomes. The practice worked with other services to improve patient outcomes and shared information appropriately.

Are services caring?

The practice is rated as good for providing caring services. Patients gave us positive feedback. They said they were treated with compassion, dignity and respect, and involved in their treatment and care. The practice was accessible for people with mobility issues. In patient surveys, the practice scored highly for satisfaction with the care and treatment provided. Patient survey views aligned with what patients told us on the day of the inspection.

Are services responsive to people’s needs?

The practice is rated as good for providing responsive services. The practice had a good overview of the needs of their local population, and was proactive in engaging with the Clinical Commissioning Group (CCG) to secure service improvements. The practice had good facilities and was well equipped to meet patient need. Information was provided to help people make a complaint, and there was evidence of shared learning with staff. Patients told us it was generally easy to get an appointment, although there was some negative feedback around getting appointments the same day.

Saturday morning appointments were available at another practice as part of a CCG wide initiative.

Are services well-led?

The practice is rated as good for being well-led. There was a long standing visible management team, with a clear leadership structure. Staff felt supported by management. The practice had published values to work to with clear aims and objectives. There were systems in place to monitor quality and identify risk. The practice had an active Patient Participation Group (PPG) and was able to evidence where changes had been made as a result of PPG and staff feedback.

x 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. The practice participated in a nursing home pilot where a named nurse practitioner carried out a ‘ward round’ each week in designated nursing homes, supported by a GP. The practice held monthly palliative care and multi-disciplinary meetings to discuss those with chronic conditions or approaching end of life care. Enhanced care plans had been produced for those patients deemed at most risk of an unplanned admission to hospital. Any admissions from these patients, or from patients in nursing homes were analysed monthly to identify any learning points. However the practice was not able to provide practice specific information on this to demonstrate positive outcomes for patients, such as a fall in unplanned admissions. Information was shared with other services, such as out of hours services and district nurses. Nationally reported data showed the practice had good outcomes for conditions commonly found in older people. The over 75’s had a named GP.

People with long term conditions

The practice is rated as good for the care of people with long term conditions. People with long term conditions were monitored and discussed at multi-disciplinary clinical meetings so the practice was able to respond to their changing needs. Information was made available to out of hours providers for those on end of life care to ensure appropriate care and support was offered. People with conditions such as diabetes and asthma attended regular nurse clinics to ensure their conditions were appropriately monitored, and were involved in making decisions about their care. Nurses communicated with a clinical lead GP for each condition. Attempts were made to contact non-attenders to ensure they had required routine health checks.

Families, children and young people

The practice is rated as good for the care of families, children and young people. Systems were in place to identify children who may be at risk. For instance, the practice monitored levels of children’s vaccinations and attendances at A&E. There was a named children’s safeguarding lead. The practice held bi-monthly safeguarding meetings attended by health visitors and social services.

Immunisation rates were high for all standard childhood immunisations. Patients could access weekly midwife-led clinics at the practice, which were supported by the on-call GP. Full post natal and six week baby checks were carried out by GP’s. There was a policy to see sick children the same day, and a minor illness clinic after school hours. There were dedicated areas on the practice website and in reception for young people. These gave information on services available, such as contraception and counselling.

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). The needs of the working population had been identified, and services adjusted and reviewed accordingly. The practice continued to monitor access to the service on an ongoing basis. Routine appointments could be booked up to four weeks in advance, or on the day. Appointments could be made online. Repeat prescriptions could be ordered online. Saturday morning appointments were available weekly at another practice as part of a CCG wide initiative. Some early morning and evening appointments were available.

People whose circumstances may make them vulnerable

The practice is rated as good for the care of people living in vulnerable circumstances. The practice had a register of those who may be vulnerable, including those with learning disabilities, who were offered annual health checks. Patients or their carers were able to request longer appointments if needed. The practice had a register for looked after or otherwise vulnerable children and also discussed any cases where there was potential risk or where people may become vulnerable. The computerised patient plans were used to flag up issues where a patient may be vulnerable or require extra support, for instance if they were a carer. Staff were aware of their responsibilities in reporting and documenting safeguarding concerns

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). Nationally returned data showed the practice performed well in carrying out additional health checks and monitoring for those experiencing a mental health problem. The practice made referrals to other local mental health services as required. The practice had a register of patients with a learning disability and these patients were invited for an annual health check-up. Daily emergency appointments could be accessed for patients having a mental health crisis. A Primary Care Link Worker worked from the practice weekly. The practice referred as required to counselling and support services. Counselling services worked from the practice building on a weekly basis, allowing patients to be easily referred and seen.

In the most recent NHS England GP patient survey,

88.41% reported their overall experience as good or very good (above the national average of 85.7%). 88.5% of patients said the GP was good at involving them in decisions about their care (above the national average of 81.8%), and 86.2% said the GP was good or very good at treating them with care and concern (above the national average of 85.3%). 34.73% of patients said they could usually see their preferred doctor, the national average being 37.6%.

Patients were less satisfied with the access to the service, with 65.96% saying it was easy to get through on the phone, below the national average of 75.4%, and 71.59% of patients said they were fairly or very satisfied with GP opening hours (below the national average of 79.8%). A higher than average number of patients said they could be overheard in reception, which we confirmed through our observations during the inspection.

We spoke to a member of the Patient Participation Group (PPG) and six patients during the inspection. We also collected 26 CQC comment cards which were sent to the practice before the inspection for patients to complete.

The majority of patients we spoke to and the comment cards indicated they were satisfied with the service provided, that they were treated with dignity, respect and care, and that staff were thorough, professional and approachable. Patients said they were confident with the care provided, and would recommend the practice to friends and family.

Area improvement

Action the service SHOULD take to improve

• Ensure that documented action points arising from risk assessments are carried out.

• Explore options to improve patient privacy in the reception area.Otstanding practice

• Enhanced care plans and communication/education with care homes including weekly ward rounds.

• The practice provided an additional voluntary service to hospice patients who did not already have their own GP.

• Newly registered patients with visual impairments were invited to the practice for a walk through induction.

Our inspection team

Our inspection team was led by:

Our inspection team was led by a CQC Lead Inspector.

The team included a second CQC inspector, a specialist advisor GP, and a Practice Manager.

Background to Neasham Road Surgery

Neasham Road Surgery provides primary medical services to approximately 11,200 patients in an urban catchment area of Darlington, within the NHS Darlington Clinical Commissioning Group (CCG) area.

There are three GP partners and three salaried GPs, and patients can be seen by a male or female GP as they choose. There is a team of four nursing staff, and two healthcare assistants. They are supported by a team of management, reception and administrative staff.

The practice is registered with the Care Quality Commission (CQC) to provide the regulated activities of diagnostic and screening procedures; family planning; maternity and midwifery services; and treatment of disease, disorder and injury. The practice slightly higher levels of deprivation compared to the England average. There are higher levels of people with a long term health condition, claiming disability allowance, and slightly higher levels of unemployment than the CCG average.

The practice has opted out of providing Out of Hours services, which patients access through the 111 service.

The practice has recently formed a federation with the ten other practices in the CCG area, which is known as Primary Healthcare Darlington. This federation successfully applied for funding under the Prime Ministers Challenge Fund to provide greater flexibility for patients to access appointments, and to provide additional care planning and support for frail elderly patients.

Why we carried out this inspection

We carried out the inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions. This inspection was planned to check whether the provider is meeting the legal 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. 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.

How we carried out this inspection

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

• Is it safe?

• Is it effective?

• Is it caring?

• Is it responsive to people’s needs?

• Is it well-led?

We also looked at how well services are provided for specific groups of people and what good care looks like for 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 living in vulnerable circumstances

• People experiencing poor mental health (including people with dementia)

Before our inspection we carried out an analysis of data from our Intelligent Monitoring system. We also reviewed information we held and asked other organisations and key stakeholders to share what they knew about the service.

We reviewed the practice’s policies, procedures and other information the practice provided before the inspection.

We also spoke with a member of the Patient Participation Group. The information reviewed did not highlight any significant areas of risk across the five key question areas.

We carried out an announced inspection on 25 March 2015.

We reviewed all areas of the surgery, including the administrative areas. We sought views from patients both face-to-face and via comment cards. We spoke with the practice manager, GP’s, nursing staff, healthcare assistants, and administrative and reception staff.

We observed how staff handled patient information received from the out-of-hour’s team and patients ringing the practice. We reviewed how GPs made clinical decisions.

We reviewed a variety of documents used by the practice to run the service.

 

Our findings

Safe Track Record

The practice used a range of information to identify risks and improve quality in relation to patient safety. This included reported incidents, national patient safety alerts, and complaints, some of which were then investigated as significant events. Prior to inspection the practice gave us a summary of significant events from the previous 12 months.

The practice had a system in place for reporting, recording and monitoring significant events, incidents and accidents.

Staff we spoke to were aware of incident reporting procedures. They knew how to access the forms, and felt encouraged to report incidents. Staff described a clear chain of command which helped them identify who to speak to about an incident and what actions needed to be taken. GPs told us they completed incident reports and carried out significant event analysis as part of their ongoing professional development. The practice worked with the Clinical Commissioning Group (CCG) in reporting incidents as necessary.

The practice had systems in place to record and circulate safety and medication alerts. GP’s and nurses were aware of the latest best practice guidelines and incorporated this into their day-to-day practice. Information from the quality and outcomes framework (QOF), which is a national performance measurement tool, showed the provider was appropriately identifying and reporting significant events.

We reviewed safety records, incident reports and minutes of meetings where these were discussed for the previous year. This showed the practice had managed these consistently over time and so could evidence a safe track record over the long term.

Learning and improvement from safety incidents

We saw where incidents had been discussed and reviewed, and learning points documented. Incidents were discussed during staff meetings, and the findings communicated to staff. The practice also held annual significant event meetings, where they analysed themes and trends. This information was then disseminated to all staff to enable wider learning within the practice.

Staff could be given feedback about incidents they had involvement in directly either verbally or via email. They could also access minutes of meetings they had not attended, which helped staff had a broad overview of safety within the practice. Staff were able to give examples of were procedures had been changed or reviewed following an incident, for instance a refresher on procedures to summon help if a patient became violent. We could see from a summary of significant events that where necessary the practice had communicated with patients affected to offer a full explanation and apology.

Patients were told what actions would be taken as a result. National patient safety alerts were disseminated by email or via the intranet, and staff were able to give recent examples of alerts relevant to them and how they had actioned them, such as a recall of equipment.

Reliable safety systems and processes including safeguarding

The practice had up to date child protection and vulnerable adult policies and procedures in place, which staff accessed via the computer system. They contained contact details for organisations such as social services and the police. These provided staff with information about identifying, reporting and dealing with suspected abuse.

The practice had a named GP safeguarding lead, who staff were able to identify. Staff had been trained in safeguarding at a level appropriate to their role, and were able to describe types of abuse and how to report these.

The practice was able to raise safeguarding alerts through a multi-agency computer hub, which meant information they sent was seen immediately by social services and the police. Staff were able to demonstrate how they had made referrals and then followed these up to make sure they had been received and actioned. Multi-disciplinary safeguarding meetings were held every three months, which were attended by health visitors, social services and district nurses.

The computerised patient plans were used to enter codes to flag up issues where a patient may be vulnerable or require extra support, for instance if they were a carer. The practice had systems to monitor children who failed to attend for childhood immunisations, or who had high levels of attendances at A&E.

The practice had chaperone guidelines and a policy, and there was information on this service

Medicines Management

We checked medicines in the fridges and found these were stored appropriately. Daily checks took place to make sure refrigerated medicines were kept at the correct temperature. Refrigerated and emergency medicines we checked were in date and there was a process for checking this. Expiry dates of medicines were logged on the computer system which sent a reminder to staff a fortnight before. There was a cold chain policy and incident protocol in case of fridge breakdown. We checked medicines in the treatment rooms and found they were stored securely and were only accessible to authorised staff.

Vaccines were administered by nurses or in some cases healthcare assistants using specific directions that had been produced in line with legal requirements and national guidance. Expired and unwanted medicines were disposed of in line with waste regulations.

The practice had a GP prescribing lead. There were prescribing and repeat prescribing protocols which had been reviewed and updated. The practice reviewed its prescribing data through clinical audits and communication with the CCG, and had audited, for example, antibiotic use.

There was a process to regularly review patients’ repeat prescriptions to ensure they were still appropriate and necessary. For instance, there was a process to review and check medicines after a patient was discharged from hospital. GPs reviewed their prescribing practices regularly.

The frequency was governed by factors such as the age of the patients, and number and type of medicines. Reviews were at least annually, or more frequently for some patients.

Any changes in medication guidance were communicated to clinical staff, and staff were able to describe an example of a recent alert. This ensured staff were aware of any changes and patients received the best treatment for their condition.

Prescriptions were stored securely, and there was a system in place for GP’s to double check repeat prescriptions before they were generated. Any errors were logged as incidents and investigated.

Cleanliness & Infection Control

Patients we spoke with told us they found the practice to be clean and had no concerns about cleanliness. The practice had infection prevention and control (IPC) and waste disposal policies, and these were reviewed and updated regularly. We saw that cleaning schedules for all areas of the practice were in place, with daily, monthly and six monthly tasks. The operations manager carried out a weekly walk-round to check for issues. There was also an identified IPC lead, who carried out full yearly audits.

We saw evidence that staff had training in IPC to ensure they were up to date in all relevant areas. Aprons, gloves and other personal protective equipment (PPE) were available in all treatment areas as was hand sanitizer and safe hand washing guidance. Sharps bins were appropriately located, labelled, closed and stored after use.

The practice employed its own cleaners. While on the whole we observed areas of the practice to be clean, tidy and well maintained, we did find some minor cleanliness issues in one room, which had not been identified through cleaning and audit checks.

Staff said they were given sufficient PPE to allow then to do their jobs safely, and were able to discuss their responsibilities for cleaning and reporting any issues. Staff we spoke with told us that all equipment used for invasive procedures and for minor surgery were disposable. Staff therefore were not required to clean or sterilise any instruments, which reduced the risk of infection for patients. We saw that other equipment such as blood pressure monitors used in the practice were clean.

We saw evidence that staff had their immunisation status for Hepatitis B checked which meant the risk of staff transmitting infection to patients was reduced. They told us how they would respond to needle stick injuries and blood or body fluid spillages and this met with current guidance.

Equipment

We found that equipment such as spirometers, ECG machines (used to detect heart rhythms) and fridges were checked and calibrated yearly by an external company.

Contracts were in place for checks of equipment such as fire extinguishers and fire alarms. Weekly and monthly checks were carried out by practice staff to ensure fire equipment was operational. Portable appliance testing was carried out annually. Review dates for all equipment were overseen by management staff. The operations manager carried out regular checks of each room including the equipment to ensure it was working.

Staff could also report faults using a form or via team meetings. Staff told us they had sufficient equipment to enable them to carry out diagnostic examinations, assessments and treatments. Staff told us they were trained and knowledgeable in the use of equipment for their daily jobs, and knew how to report faults with equipment.

Staffing & Recruitment

Records we looked at contained evidence that appropriate recruitment checks had been undertaken prior to employment. For example, proof of identification, references, qualifications, registration with the appropriate professional body and criminal records checks via the Disclosure and Barring Service. The practice had a recruitment policy that set out the standards it followed when recruiting clinical and non-clinical staff.
Staff told us about the arrangements for planning and monitoring the number of staff and mix of staff needed to meet patients’ needs. We saw there was a rota system and protocols in place for all the different staffing groups to ensure there was enough staff on duty. There was also anarrangement in place for members of staff, including nursing and administrative staff to cover each other’s annual leave. Some staff were able to operate in dual roles, for instance administration/reception, therefore this  allowed some flexibility in cover and planning. Staff said there were generally sufficient staff numbers for the effective operation of the practice, although they could be stretched at times. The practice was actively recruiting for a practice nurse and a salaried GP, as well as training a nurse practitioner, to ensure they could continue to meet demand in the future.

Monitoring Safety & Responding to Risk

There were procedures in place to assess, manage and monitor risks to patient and staff safety. These included annual, monthly and weekly checks and risk assessments of the building, the  environment, equipment and medicines management, so patients using the service were not exposed to undue risk. Each room had an individual risk assessment which was kept under review. There was an identified health and safety lead. Health and safety was a standing agenda item at practice meetings.

There were health and safety policies in place covering subjects such as fire safety, manual handling and equipment, and risk assessments for the running of the practice. These were all kept under review to monitor changing risk. We did find however, one instance where a risk of combustibles stored in a boiler room had been identified in three separate audits over a period of time but this had not been actioned.

We found that staff recognised changing risks within the service, either for patients using the service or for staff, and were able to respond appropriately. Patients with a change in their condition or new diagnoses were reviewed appropriately and discussed at clinical meetings, which allowed clinicians to monitor treatment and adjust according to risk. Therefore the practice was positively managing risk for patients. Information on such patients was made available electronically to out of hours providers so they would be aware of changing risk.

Arrangements to deal with emergencies and major incidents

Staff we spoke with were able to describe what action they would take in the event of a medical emergency situation.

We saw records confirming staff had received Cardio Pulmonary Resuscitation training. Staff who would use the defibrillator were regularly trained to ensure they remained competent in its use, which ensured they could respond appropriately if patients experienced a cardiac arrest. Staff could describe the roles of accountability in the practice and what actions they needed to take if an incident or concern arose.

A business continuity plan and emergency procedures were in place which had been recently updated. This included details of scenarios they may be needed in, such as loss of data or utilities. Weekly fire alarm checks took place and fire drills every six months.

Emergency medicines, such as for the treatment of cardiac arrest and anaphylaxis, were available and staff knew their location. There was also a defibrillator and oxygen available. Processes were in place to check emergency medicines were within their expiry date. Medicines were separated into pouches for different emergencies, for instance convulsions or anaphylaxis, to help with locating them quickly and easily.

Effective needs assessment

Treatment was considered in line with evidence based best practice, and we saw minutes of fortnightly clinical staff meetings for GPs and nurses where new guidelines and protocols were discussed. GPs also had a weekly meeting where they could review case notes, discuss the assessment of patients, and discuss new guidance. All clinical staff we interviewed were able to describe how they accessed guidelines from the National Institute for Health and Care Excellence (NICE) and from local health commissioners. They were able to demonstrate how these were received into their practice and disseminated via computer system as assigned tasks, or via email.

All the GP’s interviewed were aware of their professional responsibilities to maintain their knowledge. Nurses attended regular updates and implemented changes as appropriate to ensure best practice. The nurses were supported by the GPs and attended clinical meetings. One nurse was being mentored and supported to become a nurse practitioner. There was a GP lead for each chronic disease area who worked with the nursing team. If a patient had more than one condition they could see the same nurse within a longer appointment.

Patients with long term conditions such as diabetes were having regular health checks, and were being referred to other services or discussed at multi-disciplinary meetings when required. Feedback from patients confirmed they were referred to other services or hospital when required.

National data showed the practice was in line with referral rates to hospitals and other community care services for all conditions. All GP’s we spoke with used national standards for referral, for instance two weeks for patients with suspected cancer to be referred and seen.
Staff were able to demonstrate how care was planned to meet identified needs using best practice templates which were kept under review, and how patients were reviewed at required intervals to ensure their treatment remained effective. The practice kept up to date disease registers for patients with long term conditions such as asthma and chronic heart disease which were used to arrange annual, or as required, health reviews. They also provided annual health reviews for patients with learning disabilities and mental illness. The practice could produce a list of those who were in need of palliative care and support, and held end of life planning discussions.

The practice had identified their 2% of most vulnerable patients, who were at risk of an unplanned admission to hospital, and had produced enhanced care plans for these.

These were regularly reviewed and discussed, for instance after an admission, to ensure they were accurate and addressed the needs of those patients. Patients requiring palliative care or with new cancer diagnoses were discussed at monthly multi-disciplinary care meetings to ensure their needs assessment remained up to date.

We saw no evidence of discrimination when making care or treatment choices, with patients referred on need alone.

Management, monitoring and improving outcomes for people

The practice routinely collected information about people’s care and outcomes. It used the Quality and Outcome Framework (QOF) to assess its performance and undertook regular clinical audits. Latest QOF data from 2013-14 showed the practice had an overall rating of 97.4%, above the England average. The data showed the practice supported patients with long term conditions such as diabetes, asthma, and chronic heart disease.

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