dr alan m campion 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 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 –––

DrDr AlanAlan MM CampionCampionQuality Report

New Mill Street Surgery1 Wolseley StreetLondonSE1 2BPTel: 020 7252 1817Website: www.newmillstreet.com/Practice

Date of inspection visit: 28 April 2015Date of publication: 25/06/2015

1 Dr Alan M Campion Quality Report 25/06/2015

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 4

The six population groups and what we found 6

What people who use the service say 9

Areas for improvement 9

Detailed findings from this inspectionOur inspection team 10

Background to Dr Alan M Campion 10

Why we carried out this inspection 10

How we carried out this inspection 10

Detailed findings 12

Overall summaryLetter from the Chief Inspector of GeneralPracticeWe carried out an announced comprehensive inspectionat Dr Alan Campion on 28 April 2015. Overall the practiceis rated as good.

Specifically, we found the practice to be good forproviding, safe, effective, caring, and responsive and wellled services.

It was also good for providing services for older people,people with long term conditions; mothers, babies,children and young people; the working age populationand those recently retired.; people in vulnerablecircumstances and people experiencing poor mentalhealth

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

• Staff understood and fulfilled their responsibilities toraise concerns, and to report incidents and near misses.Information about safety was recorded, monitored,appropriately reviewed and addressed.

• Risks to patients were assessed and well managed.

• Patients’ needs were assessed and care was plannedand delivered following best practice guidance. Somestaff had received training appropriate to their roles andany further training needs had been identified andplanned.

• Patients said they were treated with compassion, dignityand respect and they were involved in their care anddecisions about their treatment.

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

• 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.

However there were areas of practice where theprovider needs to make improvements.

Action the provider Should take to improve:

Summary of findings


• Ensure all staff who undertake chaperone activities aresuitably trained.

• Ensure availability of an automated externaldefibrillator (AED) or undertake a risk assessment if adecision is made to not have an AED on-site.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Professor Steve Field (CBE FRCP FFPH FRCGP)Chief Inspector of General Practice

Summary of findings


The five questions we ask and what we foundWe always ask the following five questions of services.

Are services safe?The practice is rated as good for providing safe care. Reception staffacting as chaperones did not have Disclosure and Barring Service(DBS) checks and appropriate training. However staff understoodand fulfilled their responsibilities to raise concerns, and reportincidents and near misses. Lessons were learned andcommunicated widely to support improvement. Information aboutsafety was recorded, monitored, appropriately reviewed andaddressed. Risks to patients were assessed and well managed.There were enough staff to keep people safe.

Good –––

Are services effective?The practice is rated as good for providing effective services. Datashowed patient outcomes were at or above average for the locality.National Institute for Health and Care Excellence (NICE) guidancewas referenced by clinical staff and used routinely. The practice usedthe data from the Quality Outcomes

Framework (QOF) to assess how the practice was performing. QOF isa voluntary incentive scheme for GP practices in the UK. The schemefinancially rewards practices for managing some of the mostcommon long-term conditions and implementing preventativemeasures. The results are published annually. For the year ending 31March 2014, the practice achieved an overall QOF score of 92%.People’s needs were assessed and care was planned and deliveredin line with current legislation. This included assessment of mentalcapacity and the promotion of good health. Staff had receivedtraining appropriate to their roles and further training needs havebeen identified and planned. The practice had completed appraisalsand personal development plans for all staff. There was evidence ofmultidisciplinary working with other health and social careprofessionals.

Good –––

Are services caring?The practice is rated as good for providing caring services. Datashowed patients rated the practice higher than others for severalaspects of care. Both these results were above average compared tothe local area and national averages. Patients we spoke with duringour inspection told us they were treated with compassion, dignityand respect and they were involved in care and treatment decisions.Accessible information was provided to help patients understandthe care available to them. We also saw that staff treated patientswith kindness and respect, and ensured their confidentiality wasmaintained.

Good –––

Summary of findings


Are services responsive to people’s needs?The practice is rated as good for providing responsive services. Thepractice reviewed the needs of their local population and engagedwith their NHS England Local Area Team and Clinical CommissioningGroup (CCG) to secure service improvements where these wereidentified. Patients reported good access to the practice, having anamed GP for those with long term conditions and continuity ofcare, with urgent appointments available the same day. The practicehad good facilities and was well equipped to treat patients andmeet their needs. There was an accessible complaints system withevidence demonstrating that the practice responded quickly toissues raised. There was evidence of shared learning fromcomplaints with staff and other stakeholders.

Good –––

Are services well-led?The practice is rated as good for being well-led. It had a clear visionand strategy. Staff were clear about the vision and theirresponsibilities in relation to this. There was a clear leadershipstructure and staff felt supported by management. The practice hada number of policies and procedures to govern activity. There weresystems in place to monitor and improve quality and identify risk.The practice proactively sought feedback from staff and patients,which it acted on. The patient participation group (PPG) was active.Staff had received inductions, regular performance reviews andattended staff meetings.

Good –––

Summary of findings


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

Older peopleThe practice is rated as good for the care of people with long-termconditions.

Nationally reported data showed that outcomes for patients weregood for conditions commonly found in older people such asdementia. The practice offered proactive, personalised care to meetthe needs of the older people in its population and had a range ofenhanced services, for example, in dementia and end of life care. Aspart of the unplanned admissions Direct Enhanced Service (DES),care plans had been put in place for two percent of the practicepatients who met the criteria to avoid unplanned admissions tohospital. The practice was responsive to the needs of older people,and offered home visits and rapid access appointments for thosewith enhanced needs.

Good –––

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

Longer appointments and home visits were available when needed.All patients with long-term conditions had a named GP and astructured annual review to check that their health and medicationneeds were being met. For those people with the most complexneeds, the named GP worked with relevant health and careprofessionals to deliver a multidisciplinary package of care.

Good –––

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

There were suitable safeguarding policies and procedures in place,and staff we spoke with were aware of how to report any concernsthey had. Staff had received training on child protection whichincluded Level 3 for GPs and level 2 for nurses. There was evidenceof joint working with other professionals including midwives andhealth visitors to provide good antenatal and postnatal care.Systems were in place for identifying and following-up children whowere considered to be at-risk of harm or neglect. Childhoodimmunisations were administered in line with national guidelinesand the coverage for all standard childhood immunisations wasrelatively high compared with local figures. Appointments wereavailable outside of school hours and the premises were suitable forchildren and babies.

Good –––

Summary of findings


Working age people (including those recently retired andstudents)The practice is rated as good for the care of working-age people(including those recently retired and students).

The needs of the working age population, those recently retired andstudents had been identified and there were a variety ofappointment options available to patients such as on-line bookingand extended hours. The practice offered health checks, travelvaccinations and health promotion advice including on smokingcessation.

The practice offered NHS health as required and worked with localhospitals in following up patients who failed to attend the identifiednational screening programmes.

Good –––

People whose circumstances may make them vulnerableThe practice is rated as good for the care of people experiencingpoor mental health (including people with dementia.

The practice held a register of patients living in vulnerablecircumstances including homeless people, travellers and those witha learning disability. It had carried out annual health checks forpatients with a learning disability and 100% of these patients hadreceived a follow-up. Longer appointments were offered to patientswith a learning disability.

The practice regularly worked with multi-disciplinary teams in thecase management of vulnerable people. It had told vulnerablepatients about how to access various support groups and voluntaryorganisations. Staff knew how to recognise signs of abuse invulnerable 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.

Good –––

People experiencing poor mental health (including peoplewith dementia)The practice is rated as good for the care of people experiencingpoor mental health (including people with dementia

All patients registered at the practice experiencing poor mentalhealth had received an annual physical health check. The practiceregularly worked with multi-disciplinary teams in the casemanagement of people experiencing poor mental health, includingthose with dementia. It carried out advance care planning forpatients with dementia.

The practice had told patients experiencing poor mental healthabout how to access various support groups and voluntary

Good –––

Summary of findings


organisations. It had a system in place to follow up patients who hadattended accident and emergency (A&E) where they may have beenexperiencing poor mental health. Staff had received training on howto care for patients with mental health needs and dementia.

Summary of findings


What people who use the service sayThe six patients we spoke with on the day of our visit toldus that they were treated with kindness and respect by allthe practice staff. We received eight comment cards frompatients who attended the practice during the two weeksbefore our inspection and almost all were complimentaryabout the care they received from the surgery staff.

The 2013/14 GP survey results (latest results published inJan 2015; 405 surveys were sent out, with 105 returnedgiving a 27% completion rate.) Ninety one percent ofrespondents said the last GP they saw or spoke to wasgood at listening to them compared to the nationalaverage of 85%, and 87% of respondents said the last GPthey saw or spoke to was good at treating them with care

and concern, compared to the national average of 85%.Seventy seven percent of the respondents said the lastappointment they got was convenient and 63% found thereceptionists at the surgery helpful which was slightlylower that the local and national average.

The patients we spoke with had never needed to make acomplaint. However they were aware of the process andsaid they would speak with staff and felt confident thattheir issues would be addressed.Patients told us theywere treated appropriately and staff maintained theirprivacy and dignity. We saw staff spoke politely topatients. Patients said they were involved in decisionsabout their care and treatment.

Areas for improvementAction the service SHOULD take to improve

• Ensure all staff who undertake chaperone activities aresuitably trained.

• Ensure availability of an automated externaldefibrillator (AED) or undertake a risk assessment if adecision is made to not have an AED on-site.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC Lead Inspector, aGP specialist advisor and a nurse advisor. They aregranted the same authority to enter registered persons’premises as the CQC inspector.

Background to Dr Alan MCampionThe surgery is located in London Bridge in the LondonBorough of Southwark, and provides a general practiceservice to around 5000 patients. NHS Southwark ClinicalCommissioning Group (CCG) is made up of 44 GP practicesacross Southwark. Southwark is a densely populated,geographically small inner London borough, estimated at285,600 people. Southwark is London's second largestinner borough. Its population has increased by 37,700 overthe last 10 years and is estimated to increase by 37,500between 2010 and 2020.The practice population isrelatively young, ethnically diverse, with significant wealthinequality.

The practice is registered with the Care Quality Commission(CQC) to provide the regulated activities of: treatment ofdisease, disorder or injury; family planning; and maternityand midwifery services at one location.

The practice has a PMS contract and provides a full range ofessential, additional and enhanced services includingmaternity services, child and adult immunisations, familyplanning clinic, contraception services and minor surgery.

PMS is a locally-agreed alternative to General MedicalService (GMS) for providers of general practice. This is alocal contract agreed between NHS England and thepractice, together with its funding arrangements.

The practice is currently open five days a week from 7:30am to 6:30 pm. In addition, as part of their contract practiceoffers enhanced opening hours up to 8:00 pm on Mondaysand Tuesdays. Consultation times are 08:00am until13:00pm and 16:00am until 18:30pm. When the practicewas closed, the telephone answering service directedpatients to contact the out of hours provider.

The practice has opted out of providing out of hours (OOH)services to their patients and directs patients to anout-of-hours provider. The practice was also taking part in alocal initiative for the Clinical Commissioning Group (CCG)where extended hours were being offered daily at onepractice in the locality and all patient records registered inthe CCG were available through the electronic system.

The practice has a full time GP male, two part time nurses,and uses occasional female locum GPs. Both nurses werenot working due to leave and sickness at the time of ourinspection. The administrative team comprised ofreception staff and a patient services manager. No practicemanager was in post at the time of our inspection.However the outgoing practice manager was available onthe day of our inspection. We were told by the GP and theoutgoing practice manager that Southwark CCG hadreduced the funding for practice manager posts in 2012. Asa result most practices had formed alliances locally toemploy a practice manager that worked across differentsites. The practice was considering this arrangement forcover.

There were no previous performance issues or concernsabout this practice prior to our inspection.

DrDr AlanAlan MM CampionCampionDetailed findings


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

Why we carried out thisinspectionWe carried out a comprehensive inspection of this serviceunder Section 60 of the Health and Social Care Act 2008 aspart of our regulatory functions. This inspection wasplanned to check whether the 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.

This provider had not been inspected before and that waswhy we included them.

How we carried out thisinspectionTo get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?• Is it effective?

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

We also looked at how well services are provided forspecific groups of people and what good care looks like forthem. The population groups are:

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

and students)• People whose circumstances may make them

vulnerable• People experiencing poor mental health (including

people with dementia)Before visiting, we reviewed arange of information we hold about the practice andasked other organisations to share what they knew. Wereceived information from Southwark Healthwatch,which represents the patient voice. We carried out anannounced visit on 28 April 2015. During our visit wespoke with a range of staff (GP, the administrative andreception staff)) and six patients who used the service.We observed interaction between staff and patients inthe waiting room. We reviewed eight comment cardswhere patients shared their views and experiences ofthe service. We looked at a range of records, documentsand policies and observed staff interactions withpatients in the waiting area.

Detailed findings


Our findingsSafe Track Record

The practice had a good track record for maintainingpatient safety. Staff told us of the arrangements they hadfor receiving and sharing safety alerts from otherorganisations such as the Medicines and HealthcareProducts Regulatory Authority (MHRA) and NHS England.Alerts were received via a practice generic email to ensurethey were accessible to all staff with the GP having overallresponsibility on all actions required. The practice had apolicy that required the alerts to be printed, circulated andadded to the practice meetings to ensure they were sharedwith all staff.

The practice had a policy and a significant event toolkit toreport the incidents. Staff showed us the processes aroundreporting and discussions of incidents. Significant eventswere reviewed regularly and staff we spoke with wereaware of identifying concerns and issues and reportingthem appropriately.

Learning and improvement from safety incidents

The practice had an effective system in place for reporting,recording and monitoring incidents and significant events.There was evidence of learning and actions taken toprevent similar incidents happening in the future. Forexample, an incident had occurred that resulted in a childbeing given the wrong vaccinations. We followed thisincident through and noted that the practice had taken allappropriate action of reporting the incident to the ClinicalCommissioning Group (CCG) and had followed guidanceissued by the Department of Health when such an erroroccurred. The practice had also strengthened their systemsof ensuring the appropriate and due schedules forvaccinations were accurate and appropriately followed bymatching the child parent held record (Red Book) and theelectronic system.

Reliable safety systems and processes includingsafeguarding

The practice had policies in place relating to thesafeguarding of vulnerable adults, child protection andwhistleblowing. The GP was the designated lead forsafeguarding at the practice. Staff we spoke with wereaware of their duty to report any potential abuse or neglectissues. The GP had completed Level 3 training and the

nurses had completed level 2 training in child protection.Reception staff had received Level 1 child protectiontraining. Staff had also received training in safeguarding ofvulnerable adults. All clinical staff had received criminalrecords checks through the Disclosure and Barring Service(DBS). The contact details of the local area’s childprotection and adults safeguarding departments wereaccessible to staff if they needed to contact someone toshare their concerns about children or adults at risk.

There was a chaperone policy, which was visible on thewaiting room noticeboard and in consulting rooms. (Achaperone is a person who acts as a safeguard and witnessfor a patient and health care professional during a medicalexamination or procedure). All nursing staff had beentrained to be chaperones. Reception staff told us that theyhad been asked to chaperone in the absences of nurses.Though they understood their responsibilities when actingas chaperones, including where to stand to be able toobserve the examination, no training had been provided tothem, and they had not received DBS checks. However thepractice had risk assessed that the reception staff wouldnever be left unsupervised with patients.

Medicines Management

The practice had procedures in place to support the safemanagement of medicines. Medicines and vaccines weresafely stored, suitably recorded and disposed of inaccordance with recommended guidelines. We checkedthe emergency medicines kit and found that all medicineswere in date. The vaccines were stored in suitable fridges atthe practice and the practice maintained a log oftemperature checks on the fridge. Records showed allrecorded temperatures were within the correct range andall vaccines were within their expiry dates. Staff were awareof protocols to follow if the fridge temperature was notmaintained suitably. No Controlled Drugs were kept on site.

GPs followed national guidelines and accepted protocolsfor repeat prescribing. All scripts were reviewed and signedby GPs and our GP specialist adviser found theseacceptable. Medication reviews were undertaken regularlyand the GPs ensured appropriate checks had been madebefore prescribing medicines with potential for serious sideeffects, such as Methotrexate.

Are services safe?

Good –––


The nurses administered vaccines using directions that hadbeen produced in line with legal requirements and nationalguidance. We saw up-to-date copies of sets of directionsthat were in use and evidence that nurses had receivedappropriate training to administer vaccines.

Cleanliness and Infection Control

Effective systems were in place to reduce the risk andspread of infection. One of the nurses was the designatedinfection prevention and control (IPC) lead in the practice.Staff had received IPC training in were aware of IPCguidelines. All staff received yearly IPC updates. There wasa cleaning schedule in place to ensure each area wascleaned on a regular basis. The area around the receptiondesk and all communal areas were clean and in goodrepair. Hand washing sinks, hand cleaning gel and papertowels were available in the consultation and treatmentrooms. Equipment such as blood pressure monitors,examination couches and weighing scales were clean andcleaning checks were undertaken regularly.

Clinical waste, including sharps was collected by anexternal company and consignment notes were availableto demonstrate this.

The practice had a policy for the management, testing andinvestigation of Legionella (a germ found in theenvironment which can contaminate water systems inbuildings). We saw records that confirmed the practice wascarrying out regular checks in line with this policy in orderto reduce the risk of infection to staff and patients.

Equipment

There were appropriate arrangements in place to ensureequipment was properly maintained. These includedannual checks of equipment such as portable appliancetesting (PAT) and calibration, where applicable. These testshad been undertaken in December 2014.

Staffing and Recruitment

A staff recruitment policy was available and the practicewas aware of the various requirements including obtainingproof of identity, proof of address, references andundertaking criminal records checks through theDisclosure and Barring Service before employing staffthough they had not undertaken DBS checks fornon-clinical staff. We looked at a sample of staff files andfound evidence of some checks having been undertaken aspart of the recruitment process.

Rotas showed safe staffing levels were maintained andprocedures were in place to manage planned andunexpected absences.

Monitoring Safety and Responding to Risk

Staff explained the systems that were in place to ensure thesafety and welfare of staff and the people using the service.Risk assessments of the premises including trips and falls,Control of Substances Hazardous to Health (COSHH),security, and fire had been undertaken. The fire alarmswere tested monthly. Regular maintenance of equipmentwas undertaken and records showing annual testing ofequipment and calibration were available. The receptionarea could only be accessed via locked doors to ensuresecurity of patient documents and the computers. Thepractice had recognised the risk of having staff working parttime and of being a small location. Therefore to ensure thatall messages were appropriately dealt with they had set upand made use of a generic email account that could beaccessed by all.

Arrangements to Deal with Emergencies andMajor Incidents

The practice had some arrangements in place to manageemergencies. We saw records showing all staff had receivedannual training in basic life support. Emergency equipmentwas available including access to oxygen. All staff we askedknew the location of this equipment, and records we sawconfirmed these were checked regularly. No externaldefibrillator was on site. The GP explained the process theyhad used to assess risk. They had concluded that thepractice was located near two major hospitals and theemergency response would have been adequate .Howeverthis had not been formally documented.

Emergency medicines were available in a secure area of thepractice and all staff knew of their location. These includedthose for the treatment of cardiac emergencies,anaphylaxis and hypoglycaemia. Processes were also inplace to check emergency medicines were within theirexpiry date and suitable for use. All the medicines wechecked were in date and fit for use.

A business continuity plan was in place and had beenreviewed in April 2015.It dealt with a range of emergenciesthat may impact on the daily operation of the practice.Each risk was rated and mitigating actions recorded toreduce and manage the risk. Risks identified includedpower failure, adverse weather, unplanned sickness and

Are services safe?

Good –––


access to the building. The document also containedrelevant contact details for staff to refer to such as thecontact details of a heating company to contact in theevent of failure of the heating system. The practice had alsopartnered with other practices in the local area to supporteach other in times of such event should there be the need.

A fire risk assessment had been undertaken that includedactions required maintaining fire safety. We saw records

that showed staff were up to date with fire training and thatregular fire drills were undertaken. The practice had anappointed fire lead who took responsibility in sharingguidance and undertook mock testing to ensure all staffwere aware of the policies and procedures.

Risks associated with service and staffing changes (bothplanned and unplanned) were noted on the practice risklog and possible action identified beforehand.

Are services safe?

Good –––


Our findingsEffective needs assessment

The GPs reviewed incoming guidelines such as those fromthe National Institute for Health and Care Excellence (NICE)and if considered relevant they were discussed in practiceclinical meetings and by e-mails. There was evidence of agood working relationship between the professionals toensure information was cascaded suitably and adaptedaccordingly. We viewed eight patient records and there wasevidence that patients with dementia, learning disabilitiesand those with mental health disorders received suitablecare with an annual review of their health and care plan.

There was evidence that staff shared best practice viainternal arrangements and meetings. The practice was partof an external peer reviewed referral management systemSouthwark CCG whereby all referrals were reviewed by anexperienced doctor to decide the best option forassessment and treatment.

As part of the unplanned admissions Direct EnhancedService (DES), care plans had been put in place for twopercent of the practice patients who met the criteria toavoid unplanned admissions to hospital. [GPs arecontracted to provide core (essential and additional)services to their patients. The extra services they canprovide on top of these are called Enhanced Services. Oneof the types of enhanced service is Directed EnhancedService (DES) where it must be ensured that a particularservice is provided for the population.]

Management, monitoring and improvingoutcomes for people

The practice had systems in place to monitor and manageoutcomes to help provide improved care. The GP and thepractice nurses were actively involved in ensuringimportant aspects of care delivery such as significantincidents recording, child protection alerts management,referrals and medicines management were beingundertaken suitably.

Regular clinical meetings or information sharing took placewith multi-disciplinary attendance to ensure learning andto share information.

The practice had completed a number of clinical audits.The audits completed included one for diabetes care andanother on oral vitamin supplements. The first audit

carried out in December 2014 looked at patients at thepractice with diabetes. The purpose was to ensure theywere receiving all nine care processes as per NICErecommendations. NICE recommends that all people withdiabetes should receive nine key tests at their annualdiabetes review. These important markers ensure diabetesis well controlled and are designed to prevent long-termcomplications. The nine key tests are: weight, bloodpressure, smoking status, HbA1c, urinary albumin, serumcreatinine, cholesterol, eye examinations and footexaminations. The practice reviewed the records of all theirpatients registered at the practice and with diabetes. Theaudit checked if care was being delivered asrecommended. The practice noted that 62% for theirregistered patients had the nine stages completed whichwas 2% above the CCG required achievement. The practiceidentified patients who had not had the nine careprocesses fully completed and invited them for checks. Thepractice carried out a re -audit in March 2015 and foundthat all the registered patients who had been invited forchecks had the full care process fully completed Thepractice had set this up as a rolling audit to ensure care wasbeing delivered as recommended.

Effective staffing

We reviewed staff training records and saw that all staffwere up to date with attending mandatory courses such assafeguarding training and information governance. The GPwas up to date with their yearly continuing professionaldevelopment requirements and was due to be revalidatedin 2016. (Every GP is appraised annually, and undertakes afuller assessment called revalidation every five years. Onlywhen revalidation has been confirmed by the GeneralMedical Council can the GP continue to practise andremain on the performers list with NHS England).

The practice had records showing the practice nurses’registrations with the Nursing and Midwifery Council (NMC)were current. The practice had also verified these records.

All staff undertook annual appraisals which identifiedlearning needs from which action plans were documented.The CCG had introduced a system for all practice nurses tobe appraised by a senior clinical lead for the CCG. This wasstill to be arranged for the nurses at the practice.

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

Good –––


Staff interviews confirmed that the practice was proactivein providing training and funding for relevant courses, suchas travel vaccines and customer service training. They heldtraining days together with other practices in the locality.

The practice nurses had defined duties they were expectedto perform working alongside the GP. Their training recordsdemonstrated they were trained to fulfil these duties. Forexample, they had received training in administration ofvaccines, and in performing cervical cytology.

Working with colleagues and other services

The practice worked with other service providers to meetpeople’s needs and manage complex cases. Blood results,X ray results, letters from the local hospital includingdischarge summaries, and communications from the out ofhours providers and the 111 service were received bothelectronically and by post. The practice had a policyoutlining the responsibilities of all relevant staff in reading,passing on and actioning any issues arising fromcommunications with other care providers on the day theywere received. The GP was fully responsible for all theaction required. All staff we spoke with understood theirroles and felt the system in place worked well. There wereno instances within the last year of any results or dischargesummaries which were not followed up appropriately.

The practice held multidisciplinary team meetings everythree months to discuss patient’s needs. For example,mental health problems, people from vulnerable groupsand children on the at risk register. These meetings wereattended by district nurses, social workers and decisionsabout care planning were documented in a shared carerecord. Staff felt this system worked well. Care plans were inplace for patients with complex needs and shared withother health and social care workers as appropriate.

Information Sharing

The practice used several electronic systems tocommunicate with other providers. For example, there wasa shared system with the local GP out-of-hours provider toenable patient data to be shared in a secure and timelymanner. Electronic systems were also in place for makingreferrals.

For emergency patients, there was a policy of providing aprinted copy of a summary record for the patient to takewith them to A&E. The GP showed us how straightforwardthis task was using the electronic patient record system,

and highlighted the importance of this communicationwith A&E. The practice had also signed up to the electronicSummary Care Record and planned to have this fullyoperational by end of 2015. (Summary Care Recordsprovide faster access to key clinical information forhealthcare staff treating patients in an emergency or out ofnormal hours).

The practice had systems to provide staff with theinformation they needed. Staff used an electronic patientrecords) to coordinate, document and manage patients’care. All staff were fully trained on the system, andcommented positively about the system’s safety and easeof use. This software enabled scanned papercommunications, such as those from hospital, to be savedin the system for future reference. We saw evidence thataudits had been carried out to assess the completeness ofthese records and that action had been taken to addressany shortcomings identified.

Consent to care and treatment

We found that clinical staff were aware of the requirementsof the Mental Capacity Act 2005 and the Children’s andFamilies Act 2014 and their duties in fulfilling it. The GPunderstood the key parts of the legislation and was able todescribe how they implemented it in their practice.

Patients with learning disabilities and those with dementiawere supported to make decisions through the use of careplans which they were involved in agreeing. These careplans were reviewed annually or more frequently if changesin clinical circumstances dictated it and had a sectionstating the patient’s preferences for treatment anddecisions. Eight clinical notes we reviewed confirmed this.When interviewed, staff gave examples of how a patient’sbest interests were taken into account if a patient did nothave capacity. All clinical staff demonstrated a clearunderstanding of Gillick competencies. (The Gillickcompetency test is used to help assess whether a child hasthe maturity to make their own decisions and tounderstand the implications of those decisions.)

Health Promotion & Prevention

The practice had met with the Public Health team from thelocal authority and the CCG to discuss the implications andshare information about the needs of the practicepopulation identified by the Joint Strategic NeedsAssessment (JSNA). The JSNA pulls together informationabout the health and social care needs of the local area.


Good –––


The GP told us that a healthy weight campaign had beenidentified as a key area. They ensured they offered alleligible patients a weight check and this was followed by adiscussion of their BMI and referrals were made accordingto the agreed pathway.

It was practice policy to offer all new patients registeringwith the practice a health check with the practice nurse.The GP was informed of all health concerns detected andthese were followed-up in a timely manner. We noted aculture amongst the GP to use their contact with patientsto help maintain or improve mental, physical health andwellbeing. For example, by offering opportunisticchlamydia screening to patients aged 18-25 and offeringsmoking cessation advice to smokers. The practiceundertook various health checks, such as the NHS healthchecks for patients between 40 and 74 years old.

The practice had numerous ways of identifying patientswho needed additional support, and it was pro-active inoffering additional help. For example, the practice kept aregister of all patients with a learning disability and 100%had a completed physical health check in the past year.

The practice’s performance for cervical screening uptakewas 76% for the year ending 31 March 2014, which wasabove other practices in the CCG. There was a policy tooffer telephone reminders for patients who did not attendfor cervical screening and the practice audited patientswho do not attend annually. The nurse was responsible forfollowing-up patients who did not attend screening.

The percentage of patient at the practice aged over 6months to under 65 years in the defined influenza clinical

risk groups that received the seasonal influenzavaccination was low at 37% compared to a nationalaverage of 57%. The GP explained that the practice hadtaken all necessary steps to invite patients for the fluvaccine but they attributed the low response to the loweffective rates of flu vaccinations that were being reported.We saw records to confirm that the practice had systems inplace to follow up on patients that had failed to attend thevaccinations and the nurses had continually followedthese.

National screening for bowel cancer and breast cancer wasmanaged by the local hospitals. The practice worked withthe hospitals to send reminder letters to patients whofailed to attend screening appointments andnon-responders.

The practice offered a full range of immunisations forchildren, adults and travel, in line with current nationalguidance. The practice’s performance on childhoodimmunisations during the year ending 31 March 2014, forchildren aged three months to 12 months were as follows;Dtap/IPV/Hib (Diphtheria, Tetanus, acellular pertussis(whooping cough), poliomyelitis and Hemophilus influenzatype b) 97%, Meningitis C and PCV (Pneumococcalconjugate vaccine) 90% and MMR (measles, mumps, andrubella) 92%; all were above the CCG average. The practicehad a clear policy for following up non-attenders by thepractice nurse and GP. We saw records that confirmed thiswas being followed. The practice were also aware that anumber of their patients with children were highly mobilewith others moving from abroad and as such some of theirrates were lower due to this.


Good –––


Our findingsRespect, Dignity, Compassion & Empathy

The 2013/14 GP survey results (latest results published inJan 2015; 405 surveys were sent out, with105 returnedgiving a 27% completion rate.) Ninety one percent ofrespondents said the last GP they saw or spoke to wasgood at listening to them compared to the nationalaverage of 85%, and 87% of respondents said the last GPthey saw or spoke to was good at treating them with careand concern, compared to the national average of 85%.Seventy seven percent of the respondents said the lastappointment they got was convenient and 63% found thereceptionists at the surgery helpful which was slightly lowerthat the local and national average.

Patients completed CQC comment cards to tell us whatthey thought about the practice. We received eightcompleted cards and all were positive about the serviceexperienced. Patients said they felt the practice offered anexcellent service and staff were efficient, helpful and caring.They said staff treated them with dignity and respect. Wealso spoke with six patients on the day of our inspection. Alltold us they were satisfied with the care provided by thepractice and said their dignity and privacy was respected.Staff and patients told us that all consultations andtreatments were carried out in the privacy of a consultingroom. Disposable curtains were provided in consultingrooms and treatment rooms so that patients’ privacy anddignity was maintained during examinations, investigationsand treatments. We noted that consultation / treatmentroom doors were closed during consultations and thatconversations taking place in these rooms could not beoverheard.

We saw that staff were careful to follow the practice’sconfidentiality policy when discussing patients’ treatmentsso that confidential information was kept private. Thepractice switchboard was located away from the receptiondesk which helped keep patient information private. Stafftold us that if they had any concerns or observed anyinstances of discriminatory behaviour or where patients’privacy and dignity was not being respected, they wouldraise these with the GP. The GP told us she wouldinvestigate these and any learning identified would beshared with staff.

There was a clearly visible notice in the patient receptionarea stating the practice’s zero tolerance for abusivebehaviour. Receptionists told us that referring to this hadhelped them diffuse potentially difficult situations.

Care planning and involvement in decisionsabout care and treatment.

The GP patient survey information we reviewed showedpatients responded positively to questions about theirinvolvement in planning and making decisions about theircare and treatment and generally rated the practice well inthese areas. For example, data from the national patientsurvey showed 81% of practice respondents said the GPinvolved them in care decisions and 85% felt the GP wasgood at explaining treatment and results. Both theseresults were above average compared to CCG area/national.

Patients we spoke with on the day of our inspection told usthat health issues were discussed with them and they feltinvolved in decision making about the care and treatmentthey received. They also told us they felt listened to andsupported by staff and had sufficient time duringconsultations to make an informed decision about thechoice of treatment they wished to receive. Patientfeedback on the comment cards we received was alsopositive and aligned with these views.

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

Patient/carer support to cope emotionally withcare and treatment

The survey information we reviewed showed patients werepositive about the emotional support provided by thepractice and rated it well in this area. For example, 76% ofrespondents to the Patient Participant Group survey saidthey had received help to access support services to helpthem manage their treatment and care when it had beenneeded. The patients we spoke with on the day of ourinspection and the comment cards we received were alsoconsistent with this survey information. For example, thesehighlighted that staff responded compassionately whenthey needed help and provided support when required.

Notices in the patient waiting room, on the TV screen andpatient website also told patients how to access a number

Are services caring?

Good –––


of support groups and organisations. During patientregistrations the practice sought information relating tocarers support to ensure support was offered werenecessary. The practice’s computer system also alerted GPsif a patient was also a carer. We were shown the writteninformation available for carers to ensure they understoodthe various avenues of support available to them.

Staff told us that if families had suffered bereavement, theirusual GP contacted them. This call was either followed by a

patient consultation at a flexible time and location to meetthe family’s needs and/or by giving them advice on how tofind a support service. Patients we spoke with who had hada bereavement confirmed they had received this type ofsupport and said they had found it helpful.

The practice had the services of a counsellor who wasemployed by the CCG .Sessions were held once a week atthe practice and the GP was able to directly refer patientsand reduce waiting times.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needs

We found the practice was responsive to patient’s needsand had systems in place to maintain the level of serviceprovided. The needs of the practice population wereunderstood and systems were in place to addressidentified needs in the way services were delivered. The GPexplained that currently weight management was anidentified as a target. Therefore they offered all patients anopportunity to be weighed at the practice with a referral toa keep fit programme when needed.

The practice engaged regularly with the NHS England AreaTeam and Clinical Commissioning Group (CCG) and otherpractices to discuss local needs and service improvementsthat needed to be prioritised. We saw minutes of meetingsand communications where this had been discussed andactions agreed to implement service improvements andmanage delivery challenges to its population such asdeveloping a new healthy weight service for patients whostruggled with losing and keeping a healthy weight.

The practice had also implemented suggestions forimprovements and made changes to the way it deliveredservices in response to feedback from the patientparticipation group (PPG). The practice had continued tocarry out surveys together with the PPG to determine howthe appointments suited patients. We saw that the practicehad continued to improve the appointments system basedon the patient survey results.

Tackling inequity and promoting equality

The practice had recognised the needs of different groupsin the planning of its services .The practice offered patientregistrations and opportunistic appointments to homelesspatients. They also had a system in place for flagging thesepatients. Staff told us that they prioritised appointments forvulnerable patients to reduce the likelihood of a missedopportunity in providing them access to healthcare. Staffwe spoke with was aware of the need to ensure the GP wasaware of such patients and it was practice policy for themto be prioritised.

The practice had access to online and telephonetranslation services for patients who required this service.

The practice provided equality and diversity trainingthrough e-learning. Staff we spoke with confirmed that theyhad completed the equality and diversity training in the last12 months and that equality and diversity was regularlydiscussed at team events.

The premises and services had been adapted to meet theneeds of patient with disabilities. The practice was on theground floor. We saw that the waiting area was largeenough to accommodate patients with wheelchairs orprams, and allowed for easy access to the treatment andconsultation rooms. Accessible toilet facilities wereavailable for all patients attending the practice includingbaby changing facilities.

Access to the service

Appointments were available from 7:30 am to 6:30 pm.Consultation times were 07:30:00am until 13:00pm and16:00am until 18:30pm as part of their contract the practiceoffered enhanced opening hours up to 8:00 pm onMondays and Tuesdays. These appointments wereavailable to book via telephone and online access andpatients could walk into the practice to book appointmentsas well.

Comprehensive information was available to patientsabout appointments on the practice website. This includedhow to arrange urgent appointments and home visits andhow to book appointments through the website. Therewere also arrangements to ensure patients received urgentmedical assistance when the practice was closed. Ifpatients called the practice when it was closed, ananswerphone message gave the telephone number theyshould ring depending on the circumstances. Informationon the out-of-hours service was provided to patients.

Longer appointments were also available for patients whoneeded them. This included appointments with the GP ornurse. Home visits were made to those patients who weretoo ill to attend the practice or those with mobilitydifficulties. The GP told us that they carried out one to twohome visits per week or as needed. For those patients whowere too ill to attend the practice for flu vaccinations theGP ensured they were referred to the district nurses whooffered this at home.

Patients were generally satisfied with the appointmentssystem. They confirmed that they could see a doctor on thesame day if they needed to. They also said they could seeanother locum doctor if there was a wait to see the doctor

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

Good –––


of their choice. Comments received from patients showedthat patients in urgent need of treatment had often beenable to make appointments on the same day of contactingthe practice.

Listening and learning from concerns and complaints

The practice had a system in place for handling complaintsand concerns. Its complaints policy and procedures were inline with recognised guidance and contractual obligationsfor GPs in England. There was a designated responsibleperson who handled all complaints in the practice who wasthe practice nurse.

We saw that information was available to help patientsunderstand the complaints system. This was included inthe practice information leaflet and displayed in thereception area and on the practice website. Patients we

spoke with were aware of the process to follow should theywish to make a complaint. None of the patients we spokewith had ever needed to make a complaint about thepractice.

We looked at three complaints received in the last 12months and found these were satisfactorily handled, dealtwith in a timely way, openness and transparency withdealing with the complaints.

The practice reviewed complaints annually to detectthemes or trends. We looked at the report for the lastreview and no themes had been identified. However,lessons learned from individual complaints had been actedon. Minutes of team meetings demonstrated thatcomplaints were discussed to ensure all staff were able tolearn and contribute to determining any improvementaction that might be required.

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

Good –––


Our findingsVision and Strategy

The practice did not have a strategy or business plan inplace to detail its vision, but the practice vision wasdetailed in their statement of purpose. The practice visionwas to deliver high quality care and promote goodoutcomes for patients. We did not see the vision displayedin staff rooms but all four members of staff we spoke withunderstood the vision and values and knew what theirresponsibilities were in relation to these.

Governance arrangements

The practice had a number of policies and procedures inplace to govern activity and these were available to staff onthe desktop on any computer within the practice. Welooked at eight of these policies and procedures and moststaff had completed a cover sheet to confirm that they hadread the policy and when. All eight policies and procedureswe looked at had been reviewed annually and were up todate.

The GP was the overall lead for the practice, includinggovernance, but they delegated certain responsibilities. Forexample, the practice nurses were responsible for infectioncontrol and complaints. All staff we spoke with knew whothe lead people were. However we found that it had notbeen made clear at the practice that the practice managerhad left the practice. Some staff we spoke with stillreported that they had a practice manager in post, thoughthey would speak to the GP for any support during thepractice manager’s absence.

On the day of our inspection the former practice managerattended the inspection. They told us that they had left thepractice but were still assisting with other administrativeroles such as payroll. We were told by both the GP andpractice manager that due to changes with the CCG fundingin Southwark, most practices had not been able to employpractice managers working on a more full time basis.Instead a group of practices had teamed up and shared apractice manager working across sites. The GP told us theywere in discussions with another local practice to work outthe possibilities of sharing a manager.

The practice used the Quality and Outcomes Framework(QOF) to measure their performance. The QOF data for thepractice showed it was performing in line with nationalstandards. For the period 2013/2014 the practice hadachieved 832 points out of 900; score of 92%.

The practice had an ongoing programme of clinical auditswhich it used to monitor quality and systems to identifywhere action should be taken. We saw an example ofcompleted clinical audit in relation to diabetesmanagement.

The practice had arrangements for identifying, recordingand managing risks. The staff showed us the risk log, whichaddressed a wide range of potential issues such as staffillness and risks of the building. We saw that the risk logwas regularly discussed within the practice and updated ina timely way. Some risk assessments had been carried outwhere risks were identified and action plans had beenproduced and implemented. However we found that thepractice had not formally documented a risk assessment tomitigate the lack of AED on-site.

The practice held regular governance meetings. We lookedat minutes from the last two meetings and found thatperformance, quality and risks had been discussed.

Leadership, openness and transparency

We saw from minutes that team meetings were heldregularly, at least quarterly. Staff told us that there was anopen culture within the practice and they had theopportunity and were happy to raise issues at teammeetings.

The practice nurse and GP were responsible for humanresource policies and procedures. We reviewed a numberof policies such as disciplinary procedures, inductionpolicy, management of sickness, which were in place tosupport staff. We were shown the electronic staff handbookthat was available to all staff, which included sections onequality and harassment and bullying at work. Staff wespoke with knew where to find these policies if required.

Seeking and acting on feedback from patients, publicand staff

The practice had gathered feedback from patients throughpatient surveys, comment cards and complaints received.

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

Good –––


We looked at the results of the annual patient survey and30% of patients agreed telephone consultations would beuseful. We saw as a result of this the practice hadintroduced telephone consultation appointments.

The practice had an active patient participation group(PPG) which had steadily increased in size. The PPGincluded representatives from various population groupsincluding the elderly and working age. The PPG had carriedout quarterly surveys and met every quarter. Staff showedus the analysis of the last patient survey, which wasconsidered in conjunction with the PPG. The results andactions agreed from these surveys were available on thepractice website.

The practice had gathered feedback from staff throughmeetings, appraisals and discussions. Staff told us theywould not hesitate to give feedback and discuss anyconcerns or issues with colleagues and management.

The practice had a whistleblowing policy which wasavailable to all staff in the staff handbook and electronicallyon any computer within the practice.

Management lead through learning and improvement.

We looked at four staff files and saw that regular appraisalstook place which included a personal development plan.Staff told us that the practice was very supportive oftraining.

The practice had an effective system to incident reportingthat encouraged reporting and the review of all incidents.Team meetings were held to discuss significant incidentsthat had occurred. The practice had completed reviews ofsignificant events and other incidents and shared thesewith staff and the CCG as required.

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

Good –––


dr alan m campion newapproachcomprehensive report ... ·...

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