dr pankaj srivastava 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? Requires improvement –––

DrDr PPankankajaj SrivSrivastastavavaaQuality Report

16-20 Holmlands DrivePrentonWirralMerseysideCH43 0TXTel: 0151 608 7750Website: www.holmlandsmc.nhs.uk

Date of inspection visit: 15 January 2015Date of publication: 26/03/2015

1 Dr Pankaj Srivastava Quality Report 26/03/2015

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 8

Areas for improvement 8

Detailed findings from this inspectionOur inspection team 9

Background to Dr Pankaj Srivastava 9

Why we carried out this inspection 9

How we carried out this inspection 9

Detailed findings 11

Action we have told the provider to take 22

Overall summaryLetter from the Chief Inspector of GeneralPractice

This is the report of findings from our inspection of DrPankaj Srivastava, also known as Holmlands MedicalCentre. Our inspection was a planned comprehensiveinspection which took place on 15 January 2015. DrPankaj Srivastava (“the practice”) delivers services undera Primary Medical Services (PMS) contract.

The service provided by Pankaj Srivastava is rated overallas good. We found care and treatment delivered topatients was safe, effective, caring and responsive topatients’ needs. Some improvements were required inthe area of well-led.

Our key findings were as follows:

• Patient safety was at the heart of the practice’s deliveryof services. Systems in place supported this and allstaff were clear about their responsibilities.

• Care and treatment of patients was effective. We foundthe ‘sit and wait’ system of seeing patients hadreduced the amount of time lost by GPs due topatients’ failure to attend appointments.

• All patients we spoke to on the day of our inspection,and in information from CQC comment cards,confirmed that the practice staff and clinicians werecaring and compassionate.

• The practice was responsive to patients’ needs. Accessto clinicians was very good and patient feedback hadbeen considered by the practice in the development ofits services.

• The practice was supportive of those patients whowere also carers and had offered those carers trainingin emergency first aid.

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

Importantly, the provider must:

Comply with regulation 21(b) and (c) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2010. Request and keep copies from locum supply

Summary of findings


agencies of all checks conducted on any locum supplied,confirmation of their entry on the NHS EnglandPerformers List and evidence of adequate indemnityinsurance.

In addition the provider should:

Address the non-attendance of district nurses at practicemulti-disciplinary team meetings for management of careof patients at end of life.

Make arrangements for the practice nurse to receiveannual appraisal with input from a clinician and havesystems in place to review the work of the practice nurse,for example by way of clinical audit.

Professor Steve Field CBE FRCP FFPH FRCGP

Chief Inspector of General Practice

Summary of findings


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

Are services safe?The practice is rated as good for providing safe services. Staffunderstood and fulfilled their responsibilities to raise concerns, andto report incidents and near misses. Lessons were learned andcommunicated to support improvement. Information about safetywas recorded, monitored, reviewed and addressed. Risks to patientswere assessed and well managed.GPs were committed to theprotection of children and vulnerable adults.

Good –––

Are services effective?The practice is rated as good for the provision of effective services.Patient’s needs were assessed and care was planned and deliveredin ways that met their needs. This included assessing capacity andpromoting good health. The practice kept lists of patients whorequired regular health checks, and these appointments weredelivered by the practice nurse. The practice GPs engaged with otherclinicians to ensure that patients discharged from hospital receivedthe follow-up care they needed. The practice worked withcommunity services to enhance efficiency. For example with localpharmacies who had conducted medicines reviews with patients.The practice recorded details of these medicine reviews withpatients and re-visited any points highlighted by the pharmacist, fordiscussion with the patient at their next consultation.

Good –––

Are services caring?The practice is rated as good for the provision of caring services. Wereceived 35 Care Quality Commission (CQC) comment cards, whichpatients had used to share their views about the practice and thecare and treatment they received. All comments were favourable.One comment was neutral and referred to the time waiting inreception areas to see a GP. We saw that patients were treated withdignity and respect and that staff responded compassionately topatients concerns.

Good –––

Are services responsive to people’s needs?The practice is rated as good for providing responsive services.Patients’ who needed to see a GP, arrived at the practice at 8.00amand would be seen by a GP before 1.00pm. Appointments werepre-bookable each day between 4.00pm – 6.00pm. The practice staffcould workflow messages to GPs about any patient they felt shouldbe seen quickly, allowing GP to make decisions on triage of patient

Good –––

Summary of findings


calls. The practice ensured GPs had the flexibility to deliver twohome visits a day. We saw how this was used to monitor morevulnerable patients during the first 24 hours following dischargefrom hospital.

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

The practice was supportive of its staff. We found recruitment checkswere in place for all staff. However, if a locum GP was used toprovide cover the practice manager verbally confirmed with thesupply agency that these checks had been done. The checks did notspecifically refer to the GPs last appraisal date and entry on the NHSperformers list. Copies of the recruitment checks had not beenrequested and retained by the practice.

Review of the management of serious incident reporting wasrequired to improve learning outcomes. Two examples we reviewedlacked detail and did not probe sufficiently into cause and effect. Wewere told that community nurses did not attend multi-disciplinarymeetings held by the practice to discuss and review patientsreceiving palliative and end of life care. The work of the practicenurse we spoke with was not subject to peer review or audit.Appraisal for the practice nurse was carried out by the practicemanager. However, there was no clinical input into the appraisal, bya clinician who had reviewed the outcomes for patients treated bythe nurse on a regular basis.

Requires improvement –––

Summary of findings


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

Older peopleAll older patients were assigned a named GP and given access to adirect line for that GP. If older patients were admitted to hospital inan unplanned way this was reviewed by the GP and if required,changes would be made to their treatment plan for example achange in medicines. Health promotional advice and support wasgiven to patients and their carers if appropriate and informationleaflets were freely available at the practice. These includedsignposting older patients and their carers to support servicesacross the local community. Older patients were offered vaccinessuch as the flu vaccine each year.

Good –––

People with long term conditionsThe practice had processes in place for the referral of patients withlong term conditions that had a sudden deterioration in health. TheGP reviewed all unplanned admissions to hospital. Registers ofpatients with long term conditions were kept and annual reviews ofpatients were carried out, including a review of medications. Ifneeded these patients were seen more regularly to monitor theirconditions. All patients with an unplanned admission to hospitalwere reviewed by the GP on discharge. We saw health promotionaladvice, information and referral to support services for examplesmoking cessation.

Good –––

Families, children and young peopleThe practice nurse delivered immunisations and vaccines tochildren and adult patients. We saw that a system of follow up wasin place to capture any patients, particularly child patients, who hadfailed to attend these appointments.There was a walk-in (sit & wait)system in place from 8.00am each morning between Monday andFriday. All patients arriving at the practice before 10.00am would beseen. Feedback from patients was that they valued this system andon the day of our inspection, we saw that it worked well, particularlyin meeting the needs of families with children.

Good –––

Working age people (including those recently retired andstudents)The facility for patients to pre-book appointments between 4.00pmand 6.00pm helped to meet the needs of those patients who hadwork commitments. Extended hours were available onThursdayevenings to see a nurse or doctor from between 6.30pm and 8.00pm.Clinicians at the practice routinely took patients’ blood pressure

Good –––

Summary of findings


readings and recorded these along with patients’ weights. GPs wereencouraged to ask questions about patients’ family history toincrease the consideration for referral of patients who may showearly signs of particular cancers, for example, bowel or lung cancers.

People whose circumstances may make them vulnerableThe deputy practice manager was responsible for maintaining aregister of all those patients who were carers. They had arrangedfirst aid and cardio-pulmonary resuscitation training for carers, to bedelivered by St Johns Ambulance, free of charge. All carers wereoffered a longer consultation time with the GP to ensure their ownhealth needs were not overlooked. Where any carer had notattended for a routine annual health check, the deputy practicemanager could demonstrate an effective system of follow-up toensure a further appointment was offered and attended by thecarer. When we reviewed the care plans of people who were morevulnerable to unplanned hospital admission, we saw the practicehad annotated care plans to show if a patient was living alone. Thisenabled other clinicians to assess the priority for a home visit, ifrequired.

Good –––

People experiencing poor mental health (including peoplewith dementia)The practice maintained a register of patients who experienced poormental health. The register supported clinical staff to offer patientsan annual appointment for a health check and a

medication review. Clinicians routinely referred patients tocounselling and talking therapy services, as well as psychiatricprovision. One of the salaried GPs at the practice had acted as thelead for dementia screening of patients, and for timely referral forformal diagnosis of those patients.

Good –––

Summary of findings


What people who use the service sayWe received 35 completed patient CQC comment cardsand spoke with seven patients who were attending thepractice on the day of our inspection. We spoke withpatients from across the population groups, includingparents with children, patients with different physicalconditions and long-term care needs. Patients werecomplimentary about the staff and GPs. Patients told usthat they had been consulted when Dr Srivastava hadtaken over the practice from the GP who had recentlyretired. One of the questions put to patients was whetherthey wished to keep the ‘sit and wait’ system of access.Patients told us that their opinions on this had beenlistened to and as a result, felt that they had a service thatdelivered care and treatment that met their needs.

Data we considered before our inspection included theresults of the last NHS England GP Patient Survey(2013-14). This showed that when patients were asked,91.4% described their overall experience of their GPpractice as good or very good, compared with an Englandaverage positive response of only 85.7%. 87.2% of thosepatients asked said they were involved in decisions abouttheir care and treatment, compared to an Englandaverage of just 81.8%. 90% of patients asked said theywere treated with care and concern when they were lastseen by a GP or nurse at the practice. 90.5% of patientssaid they were very satisfied or fairly satisfied with theopening hours of their GP practice; the England averagescore for this was just 79.8% of patients who weresatisfied with the opening hours of their practice.

Areas for improvementAction the service MUST take to improveThe provider must:

Comply with regulation 21(b) and (c) of the Health andSocial Care Act 2008 (Regulated Activities) Regulations2010. Request and keep copies from locum supplyagencies of all checks conducted on any locum supplied,confirmation of their entry on the NHS EnglandPerformers List and evidence of adequate indemnityinsurance.

Action the service SHOULD take to improveAddress the non-attendance of district nurses at practicemulti-disciplinary team meetings for management of careof patients at end of life.

Make arrangements for the practice nurse to receiveannual appraisal with input from a clinician and havesystems in place to review the work of the practice nurse,for example by way of clinical audit.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC inspector and theteam included a GP and a Practice Manager.

Background to Dr PankajSrivastavaDr Pankaj Srivastava is registered with the CQC to provideprimary care services, delivered under a Primary MedicalServices contract (PMS).

The practice GP Dr Srivastava retains the services of threesalaried GPs, one female and two males. There were threepractice nurses (all female) who provided diseasemanagement, health screening, immunisation and vaccineclinics and other health initiatives.

Practice opening hours were from 8.30am to 6.30pm.Extended hours appointments were available eachThursday, when the practice was open until 8.00pm in theevening.

The practice is located within an area rated as being at themid-point of social deprivation. Life expectancy for males is77.9 years of age and for females is 81.9 years of age. Interms of age, the population of males and females agedbetween 60 and 69 years, was higher than the Englandaverage, making up almost 19% of the practice register.

The CQC intelligent monitoring placed the practice in band6. The intelligent monitoring tool draws on existingnational data sources and includes indicators covering arange of GP practice activity and patient experienceincluding the Quality Outcomes Framework (QOF) and theNational Patient Survey. Based on the indicators, each GP

practice has been categorised into one of six priority bands,with band six representing the best performance band. Thisbanding is not a judgement on the quality of care beinggiven by the GP practice; this only comes after a CQCinspection has taken place.

Out of hours services were not provided by the practice,but by another, external provider.

Why we carried out thisinspectionWe inspected this service as part of our comprehensiveinspection programme. We carried out a comprehensiveinspection of this service under Section 60 of the Healthand Social Care Act 2008 as part of our regulatoryfunctions. This inspection was planned to check whetherthe provider is meeting the legal requirements andregulations associated with the Health and Social Care Act2008, to look at the overall quality of the service, and toprovide a rating for the service under the Care Act 2014.

How we carried out thisinspectionBefore visiting, we reviewed a range of information that wehold about the practice and asked other organisations toshare what they knew. We carried out an announced visiton 15 January 2015. During our visit we spoke with a rangeof staff including three GPs, a nurse, the practice managerand three other members of administrative support staff.We also spent time speaking with two members of thepatient participant group. We were able to speak to sevenpatients attending the practice on the day of ourinspection.

DrDr PPankankajaj SrivSrivastastavavaaDetailed findings


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

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

We also looked at how well services 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)

Detailed findings


Our findingsSafe track record

Reports from NHS England indicated the practice had agood track record for maintaining patient safety. During ourinspection we found good systems to monitor patientsafety. Staff were encouraged to share information whenincidents and untoward events occurred. The practicemanager told us that reports about incidents, significantevents and complaints were reported and discussed atregular practice meetings. Minutes kept of these meetingsconfirmed this information.

The practice manager kept records of accidents andincidents concerning staff members. We saw that thepractice followed guidance on the Reporting of Injuries,Diseases and Dangerous Occurrences (RIDDOR). Anyincidents or accidents involving staff were clearly describedand recorded on a reporting template. Incidents werediscussed at staff meetings with a view to raisingawareness on safety in the workplace, and any learningpoints identified.

Learning and improvement from safety incidents

The practice had a system in place for reporting, recordingand monitoring significant events. We reviewed recordskept of significant events that had occurred during the last12 months. Staff reported an open and transparent culturewhen accidents, incidents and complaints occurred. Staffwere trained in incident and accident reporting. Although aprocess for completing incident reports was in place, theywere not particularly detailed. Reports followed a setformat but those we reviewed did not prompt staff forlevels of detail that enabled conclusions to be drawn fromeach incident. The practice manager highlighted the use ofa specific template in the recording, reporting andinvestigation into serious incidents, which would providemore detail for use in learning from events. Examples ofthese were being considered by the practice to ensure thatall incident analysis followed a clearly defined pathway,which concluded with points for learning for all staff.

Reliable safety systems and processes includingsafeguarding

The practice had a policy for child and adult safeguarding.Staff demonstrated knowledge and understanding ofsafeguarding. They described what constituted abuse and

what they would do if they had concerns. Staff hadundertaken electronic learning regarding safeguarding ofchildren and adults as part of their essential (mandatory)training modules. GPs had undergone safeguardingtraining to the appropriate level and the date this was dueto be refreshed was recorded within a centrally held stafftraining record. The practice had a dedicated GP appointedas lead for safeguarding vulnerable adults and children,who was able to demonstrate good liaison with partneragencies such as the police and social services. GPsdemonstrated their commitment to safeguarding ofchildren and babies; where there were any concerns aboutyounger children and babies, GPs said they would removethe babies clothing to conduct a full examination, enablingthem to spot any unexplained marks or bruising.

There was a system to highlight vulnerable patients on thepractice’s electronic records system. This includedinformation so staff were aware of any relevant issues whenpatients attended appointments, for example childrensubject to child protection plans. The practice alsohighlighted the records of vulnerable patients who livedalone. This reminded staff and clinicians to be aware of anysign of neglect or potential abuse of that patient.

Patients’ records were written and managed in a way tohelp ensure safety. Records were kept on an electronicsystem which collated all communications about thepatient including scanned copies of communications fromhospitals.

There was a chaperone policy in place at the practice andthis was clearly advertised to patients in reception andwaiting areas. Staff were familiar with the policy. All staffthat were trained in providing this service had undergoneenhanced background checks.

Medicines management

The practice had clear systems in place for themanagement of medicines. Systems in place ensured amedicines review was recorded in all patients’ notes forpatients being prescribed four or more repeat medicines.The practice had developed it’s relationships withcommunity pharmacies, and recorded in patient notes if amedicines review had been carried out by the pharmacist.

We were told that the number of hours from requesting aprescription to availability for collection by the patient was48 hours or less (excluding weekends and bank/localholidays). The practice met on a regular basis with the local

Are services safe?

Good –––


area teams’ medicines manager and CCG pharmacists toreview prescribing trends and medication audits. Weobserved that prescribing practices were considered in linewith published guidance. Nurses and GPs we spoke to gaveinformation leaflets to patients relating to their medicines,which improved patients understanding of how theirmedicines worked, and contributed to the optimization ofmedicines performance.

Practice staff showed us how they ordered, stored andmaintained sufficient stocks of medicines, for example,vaccinations and immunisations. These were kept in adedicated fridge which was temperature controlled.Records were kept of checks made to ensure the fridgestayed within safe temperature limits. Stock within thefridge was rotated correctly to ensure that medicines wouldbe used in ‘best before’ date order. We also noted thatthose medicines with similar packaging where stored onseparate shelves. The nurses had printed off and taped tothe fridge, the time limits in place between courses ofvaccinations. This acted as a further check prompt fornurses delivering vaccines.

Emergency medicines were securely stored but availablequickly to all staff. We checked the medicines and foundthem to be in date and suitable for use.

Cleanliness and infection control

The practice had an infection control policy in place.Cleaning of the practice was managed and monitored bythe practice managers. Cleaning schedules were in placefor all parts of the building, treatment rooms andconsulting areas. Our visual inspection showed the practicewas clean, tidy and well maintained.

In treatment rooms we saw that appropriate segregation ofgeneral and clinical waste was in place. Bins were all footpedal operated and contracts were in place for the removalof clinical waste and sharps bins. We saw that all sinks inconsulting and treatment rooms had adequate handwashing materials and paper towels available for use. Wesaw that a cupboard for cleaning materials was wellstocked and all products were clearly labelled. The lastinfection control audit at the practice showed some (minor)areas for improvement. We reviewed the infection controlaudit of October 2013 and the report of January 2014. Wesaw that all improvements had been implemented.

Legionella checks were in place and an annual test wascarried out by an external contractor to confirm the safetyof water systems at the practice.

Equipment

When we checked equipment at the practice, we saw thiswas clean, well maintained and suitable for use. Recordsshowed that all equipment used for measurement, such asspirometry equipment, blood pressure cuffs and weighingscales had been recently tested and calibrated to ensureaccuracy. All electrical appliances had been tested. Furtherclinical items, such as syringes were for single use andthese were disposed of in the correct containers. All singleuse items were in plentiful supply in each consulting andtreatment room. The doctors and nurses consulting andtreatment rooms had been checked by the practicemanagers on a regular basis to ensure stocks of equipmentand cleaning standards were maintained.

Staffing and recruitment

The practice had a recruitment policy in place. Appropriatepre-employment checks were undertaken and completedbefore employment. All appropriate checks were in placefor permanent salaried GPs. On occasions when thepractice required holiday cover, or cover for unexpectedabsences of a GP, the practice used the services of a locumagency. The practice manager told us that the checksnamed above were confirmed by the supply agency.However additional checks, particularly those that refer tothe locum GPs last appraisal date and entry on the NHSperformers list, and level of indemnity cover were notautomatically confirmed by the supply agency. Thepractice manager did not keep copies of the checks carriedout by the supply agency.

From review of staffing rotas we could see that there weresufficient administrative and clinical staff available at alltimes to ensure the safety of patients. The practice hadrecently recruited an apprentice. We were able to confirmthat this staff member had received a full, comprehensiveinduction and was appropriately supported throughlearning and development opportunities.

The practice had procedures in place to manage expectedabsences, such as annual leave, and unexpected absencesthrough staff sickness. Staffing levels were set and reviewedto ensure patients were kept safe and their needs met.

Monitoring safety and responding to risk

Are services safe?

Good –––


We saw the practice had their own health and safety auditwhich included a walk around the practice looking for anyfaults or issues. Health and safety information wasdisplayed for staff to see and there was an identified healthand safety lead at the practice. Formal risk assessments forthe environment and premises were in place; this includeda fire risk assessment and a completed legionella test forthe building. We saw that regular fire alarm testing andmaintenance checks of fire extinguishers were in place.Health and safety visual inspections by the practicemanager included the waiting areas for patients. CCTV wasin place to ensure waiting areas out of immediate viewcould be monitored, for example, to maintain safety.Patients were aware that CCTV was in place and told usthey did not find it intrusive or that it breached theirprivacy.

We saw evidence that staff were able to identify andrespond to changing risks in patient’s conditions or duringa medical emergency. For example timely referrals weremade for all patients attending hospital as a referredpatient or as an emergency. All acutely ill children would beseen on the same day as they requested.

Arrangements to deal with emergencies and majorincidents

The practice had arrangements in place to manageemergencies. Records showed that all staff had receivedtraining in basic life support. Emergency equipment wasavailable including access to oxygen and an automatedexternal defibrillator (used to attempt to restart a person’sheart in an emergency). When we asked members of staff,they all knew the location of this equipment and recordsconfirmed that it was checked regularly.

A business continuity plan was in place to deal with a rangeof emergencies that may impact on the daily operation ofthe practice. Each risk was rated and mitigating actionsrecorded to reduce and manage the risk. Risks identifiedincluded power failure, adverse weather, unplannedsickness and access to the building. The document alsocontained relevant contact details for staff to refer to.

The practice had carried out a fire risk assessment thatincluded actions required to maintain fire safety. Recordsshowed that staff were up to date with fire training and thatthey practised regular fire drills.

Are services safe?

Good –––


Our findingsEffective needs assessment

The GPs and nursing staff we spoke with were familiar withcurrent best practice guidance. Patients received a fullhealth check assessment when registering at the practice.Any patient’s diagnosis of long term conditions wereconfirmed and checked; for example, in the cases ofchildren who had been recorded as having asthma, thisdiagnosis was checked through testing. All patients with ahistory of breathing difficulties underwent spirometrytesting. The practice screened patients for cardio-vasculardisease (CVD), chronic obstructive pulmonary disease(COPD), for asthma detection in children, for vitamin Ddeficiency in the Asian population and for vitamin B12deficiency in diabetics and the elderly population. Patientswhose condition made them more vulnerable to illnesssuch as flu were added to a register to trigger a reminder toattend annually for a flu vaccine. Those patients whosecondition merited it, were entered on a specific diseaseregister, enabling them to receive continuity of carethrough the practice nurses. The nurse who provided carefor patients with longer term conditions was able todescribe and show us the care pathways used for thosepatients, and instances of where patients had been referredto the GPs at the practice for overview, to ensure carecontinued to meet patients’ needs.

Management, monitoring and improving outcomes forpeople

The practice focused on screening for conditions thatbecame more prevalent in certain age groups, for example,by ordering annual blood tests for thyroid, liver and renalfunctions. The practice was able to demonstrate effectivescreening of patients aged 65 and over, who reported anymemory problems. This enabled the practice to referpeople to a memory clinic for correct, accurate and timelydiagnosis of dementia. At each appointment, GPs andnurses conducted a pulse and blood pressure check oneach patient and recorded each patients’ weight and BMI.This contributed to the early detection of heart disease, aswell as other common conditions. In data we reviewed wesaw that referral rates for common diseases were high,which related to the screening of patients at the practice,which clinicians considered as routine. The practice was

able to demonstrate how other conditions would bescreened for, where the family history of a patient indicatedthis would be of use, for example, testing for chronic kidneydisease, ovarian and breast cancers.

The practice GPs shared the results of audits recentlycarried out; one related to medicines prescribed to patientsand had been revisited to complete the audit cycle.Another audit related to minor surgery cases and had twoaims. The first was to monitor patient healing and recoverytimes and whether any infection followed the surgery. Thesecond was to check if biopsies of any tissue wereperformed and results followed up correctly. This auditshowed that no patients had reported any infectionfollowing surgery and that tissue samples had beenreferred appropriately for further testing.

Dr Srivastava employed a practice pharmacist for eighthours each month to work on reviews of medicines thatcould be substituted with other, more cost effectivealternatives. We saw that patients were given anexplanation of what the change in medication mightinvolve and whether it would impact on other aspects oftheir health. We noted that the practice nurse had reviewedpatients receiving a particular medicine for control of theirlong term health condition. When the pharmacist hadpresented alternative medicines that could be used tosimilar effect the nurse had considered other health factorsinvolved for particular patients. The nurse told us that inthis particular case, the issue had been discussed with thepatient. As a result the patient had expressed a wish not tohave their medicine changed. The practice supported thisand the patient remained on their prescribed medicines.This demonstrated the level of patient involvement, theopenness and transparency afforded to patients incommunication with their clinicians, and the widerapplication of patient consent to care and treatment.

Effective staffing

The practice had a mix of administration and receptionstaff working with a practice manager. We looked at theinduction programme which included mandatory training,role-specific training, risk assessments and health andsafety training. An apprentice had recently been taken onas an additional member of the administrative supportteam and we saw that they had been through a period of

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

Good –––


induction, which covered role specific training, with furthertraining planned throughout the year. This new member ofstaff had access to a mentor and was supported tocomplete national level qualifications.

All administrative support staff had been referenced andidentity checked. All staff had undergone basic levelsecurity checks. The practice manager followed bestpractice guidance of the Clinical Commissioning Group(CCG) by refreshing Disclosure and Barring Service (DBS)checks every three years. All staff had access to and hadcompleted what would be considered mandatory training,for example, in child and vulnerable adult safeguarding,infection control and emergency first aid.

The practice had recently taken on an additionalpermanent salaried GP. We saw the practice manager hadcarried out all appropriate checks on the new GP, andcopies of these were held at the practice. Records ofappraisal were held and notes of who the appointedappraiser was. References and enhanced backgroundchecks had been carried out and the practice hadconfirmed that the GP was on the GP Performers list, i.e.NHS England (Merseyside). All practicing GP’s must be onthe NHS England Performers list. The practice used locumGPs on occasion to cover for unplanned absences. Thepractice manager confirmed verbally that the locum supplyagency had conducted all required employment checks,but did not have copies of these. Also, the locum agencydid not appear to confirm that the indemnity cover of thelocum supplied, was sufficient i.e. how many locumsessions the GP could work.

The practice also retained the services of a female GP, whowas available for those patients that chose to be seen by afemale GP. This GP had lead responsibility for six week postnatal checks and the initial 6 week baby check-up. Adedicated health visitor visited the practice to deliver initialbaby vaccines and immunisations, as well as providing newparents with advice and support. A dedicated area midwifealso delivered antenatal care at the practice and providedadvice and support to new mothers.

The skills of the nursing team and GPs were sufficient tomeet the varied needs of the patient list. Nurses were ableto show evidence of annual appraisal. We did discuss themerits of the nurses being appraised with input by GPs togive full oversight and reflection on the nurse’s work. The

evidence of nurses presented at appraisal was sufficient toshow effective care of patients, but overview by the GPswould present greater opportunity of identifying areas fordevelopment and furthering their practice qualifications.

Working with colleagues and other services

All staff at the practice were aware of their duties. Incomingcorrespondence was dealt with by designated staff anddistributed to the team to scan onto patients records, oncereturned from GP scrutiny. We saw that this system workedwell and that there was no significant delay in addingblood test results or medical reports from hospitalspecialists to patients’ notes. We reviewed one incidentthat was recorded as a significant event, which involved adelay in a GP seeing the correspondence from a consultant.We saw how some lessons had been learned from this andshared amongst all staff. The practice used the Choose andBook system of referring patients to secondary care. At thetime of this inspection, 100% of referrals were through thissystem. The system presents choices where available, topatients on where they can be seen by a specialist forfurther tests, surgery or follow-up care.

The practice hosted a number of services at its site, whichprovided easy access to secondary care for patients. Theseservices included physiotherapy, counselling, ultrasoundscanning, phlebotomy, warfarin clinic and advice fromcommunity services such as Citizens Advice Bureau.

Information sharing

The practice used several electronic systems tocommunicate with other providers. For example, there wasa shared system with the local out of hour’s provider toenable patient data to be shared in a secure and timelymanner. Information was shared in this way with hospitaland other healthcare providers. We saw that all newpatients were assessed and patients’ records were set up.This routinely included paper and electronic records withassessments, case notes and blood test results. We sawthat all letters relating to blood results and patient hospitaldischarge letters were reviewed on a daily basis by doctorsin the practice. We found that when patients movedbetween teams and services, including at referral stage,this was done in a prompt and timely way.

We found that staff had all the information they needed todeliver effective care and treatment to patients. Foremergency patients, patient summary records were inplace. This electronic record was stored at a central


Good –––


location. The records could be accessed by other servicesto ensure patients could receive healthcare faster, forinstance in an emergency situation or when the practicewas closed.

Consent to care and treatment

Staff were aware of the Mental Capacity Act 2005, theChildren Acts 1989 and 2004 and their duties in fulfillingthis. All the clinical staff we spoke to understood the keyparts of the legislation and were able to describe how theyimplemented it in their practice. They gave examples intheir practice of when best interest decisions were madeand mental capacity was assessed prior to consent beingobtained for an invasive procedure. All clinical staffdemonstrated a clear understanding of Gillickcompetencies. (These help clinicians to identify childrenaged under 16 who have the legal capacity to consent tomedical examination and treatment).

There was a practice policy for documenting consent forspecific interventions. We also saw how consent wasconsidered when reviewing patient medicines; we foundthe needs of the patient and their understanding of theirtreatment was confirmed as part of the consent process.

Health promotion and prevention

We saw how staff used each intervention to supportpatients in taking control of their health and well-being.The practice manager showed us how information noticeboards were kept up to date. Literature was available totake home and read, which covered initiatives to helppatients stop smoking, manage alcohol consumption andsupport for patients suffering from anxiety and depression.Details on support available included information fromWirral advocacy services and a self-help group that gavepatients access to structured exercise activities, aimed atreducing anxiety levels.

GPs screened patients for a number of common healthconditions with a view to early diagnosis and effective earlyintervention. The practice also considered the familyhistory of patients when considering referral for furtherclinical investigations. The practice GPs conducteddischarge reviews. When patients had been dischargedfrom hospital, they received a telephone call from the GP. Ifa house call was needed this was carried out on the day ofdischarge wherever possible. We saw several examples ofhow discharge follow-up had been used to ensure patientswell-being. This early intervention had prevented patientsreturning to hospital due to insufficient support being inplace for the patient.


Good –––


Our findingsRespect, dignity, compassion and empathy

Staff we spoke with were aware of the importance ofproviding patients with privacy and of confidentiality. Therewas a separate room available if patients wanted to speakin private when they presented at reception. We observedstaff were discreet and respectful to patients.

We reviewed the most recent data available for the practiceon patient satisfaction. These included data sources suchas the national patient survey, the practice survey and theCQC comments cards completed during our inspection.Overall patients reported being treated by staff with dignityand respect and in general they were satisfied with the carethey received. Most commented on the friendly and caringapproach of staff. 91.4% of patients asked in the last NHSEngland GP Patient Survey described their overallexperience of their GP surgery as good or very good. Thisresult is higher than the England score of 85.7%.

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.

The practice offered patients a chaperone prior to anyexamination or procedure. Information about having achaperone was seen displayed in the reception area.Patients we spoke with told us they were always treatedwith dignity and respect and that staff were caring and

compassionate. We found that staff knew the majority oftheir patients well and patients told us the practice had afamily feel to it, the staff were all welcoming, caring andcompassionate.

Care planning and involvement in decisions aboutcare and treatment

Patients we spoke with felt confident they had beeninvolved in any decisions about their treatment and care.We looked at the Quality and Outcomes Framework (QOF)information and this showed adequate results for patientsreporting that the nurse of doctor was good or very good atinvolving patients in decisions about their care.

We found that staff were at clear about how to ensurepatients were involved in making decisions and therequirements of the Mental Capacity Act 2005 and theChildren’s Act 1989 and 2005.

The practice had an ‘access to records’ policy that informedpatients how their information was used, who may haveaccess to that information, and their own rights to see andobtain copies of their records.

Patient/carer support to cope emotionally with careand treatment

Patients were positive about the care they received fromthe practice. They commented that they were treated withrespect and dignity. Patients we spoke with told us theyhad enough time to discuss things fully with the GP.

Clinical staff used a number of methods to supportbereaved patients. Some would contact them personally.The reception staff were knowledgeable in supportprocesses for bereaved patients. They were familiar withsupport services and knew how to direct patients to these.Information was available to patients in leaflet form thatthey could take away with them. Staff described how theywould explain to patients how services could be accessed,if there was a referral pathway in place.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needs

The practice considered the needs of its patients whenplanning resource. The practice had recently recruited afurther permanent salaried GP. The practice also retainedthe services of a female GP to ensure access to femaleclinicians was available to patients. The practice had anactive patient participant group, who assisted the practicein the gathering of patient views. The practice manager toldus how recently they had consulted with patients on howthe premises could be improved.

The practice worked with the local clinical commissioninggroup to host or provide a range of services in-house.These included but were not limited to physiotherapyservices, phlebotomy, counselling and ultrasoundscanning. As part of our inspection, patients were left CQCcomment cards to share their views of the service. Patientsparticularly commented on the ease of access to theservice, not only through appointments with GPs but alsotheir access to additional services and how much theyappreciated this.

Tackling inequity and promoting equality

The practice operated a ‘sit and wait’ surgery for patientseach morning. If a patient came to the practice before10.00am, they would be seen that morning or by 1.30pmthat day. The afternoon surgery which ran between 4.00pmand 6.00pm was run on an appointment system. We askedpatients how this worked in practice. Patients we spoke totold us they had been given the option to move to anappointment only system when the lead GP took over thepractice two years ago. Patients fed back to the practicethat they wanted to remain on the ‘sit and wait’ system,and this had been facilitated. Patients told us they valuedthe system; we were told by parents with very youngchildren that if their child was particularly unwell, theywould phone the practice to say they would be attendingthat morning, and the child would be seen ahead of otherpatients if required. Other patients told us they may wait fora considerable time, but valued being seen on the sameday.

We conducted an analysis of the previous week’s patientattendance figures. The total number of available patientappointments for the previous week was audited. Therewere no instances of patients failing to attend during the

morning surgeries but there were instances of failure toattend during the later afternoon surgeries. This indicatedthat pre bookable appointments had a higher rate of non-attendance by patients.

The appointment availability, measured by number ofpatients seen each morning, well exceeded the requiredaverage of 75 appointments per 1000 registered patients,per week. We asked patients about the amount of timeafforded to them within the appointment. Of the sevenpatients we spoke with, none of them complained that theyfelt rushed or that the GP did not give them sufficient timeto discuss their healthcare needs.

Access to the service

Access to the practice building is via an automateddoorway and there is a ramp for ease of access for disabledpatients. There is a chair lift to the second floor for disabledand elderly patients. We observed staff were aware of theneed for patient confidentiality when speaking withpatients and assessing their needs. The seating area inreception was set back from the immediate reception deskto facilitate this.

The practice manager and clinicians ensured that patients’access to care and treatment was considered in line withtheir physical and cultural needs. The practice kept specificpatient registers, and those GP’s with a lead interest wouldsee them for annual health checks and wherever possible,for routine appointments. For example, there was a lead GPfor patients with a learning disability. The practice also hada GP who took the lead in the care and treatment ofteenagers. The needs of patients who experienced othersocial problems were also considered, for example, thosepatients with alcohol dependency who had other clinicalillnesses. These patients were classed as more vulnerableand care plans were in place to ensure they received theclinical care they needed at the time it was needed.

We looked at systems in place for referral of patients tospecialists and other secondary care. The staff involvedunderstood the importance of the timeliness of referralsand followed procedures in place to ensure nounnecessary delays were caused. Where any delay hadoccurred, the referral was reviewed and lessons learnt.Communications with patients regarding referrals wasprompt. The referral of patients often provided choice andthe options available were discussed with patients.Wherever possible, patients’ needs were considered, for

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

Good –––


example in referring a patient to a facility outside of theimmediate area. Patients we spoke with told us they hadused the Choose and Book system and any choicesavailable had been explained to them fully.

Listening and learning from concerns and complaints

The practice has a system in place for handling complaintsand concerns. Its complaints policy was in line withrecognised guidance and contractual obligations for GPs inEngland and there was a designated responsible personwho handled all complaints in the practice.

Staff were knowledgeable regarding the complaintsprocess. We saw posters advising patients how they couldmake a complaint. We looked at a number of complaintsthat had been made. We considered that the practiceresponse to complaints was appropriate and actions hadbeen taken to make improvements as required.

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

Good –––


Our findingsVision and strategy

The practice GPs, nurses and practice staff were aware oftheir duties and how their role contributed to the overallaims, objectives and achievements of the practice. Thepractice development plans had been carefully consideredby the lead GP, following a period of absence due toill-health. This included the recruitment of a further,permanent salaried GP with additional areas of specialism,who could help deliver a wide range of services to patients.The accessibility of GPs to patients had beenconsidered. This had resulted in the services of a female GPbeing retained to offer health and care to those patientswishing to be seen by a female GP. The practice missionstatement is “to provide people registered with the practicewith personal health care of high quality and to seekcontinuous improvement on the health status of thepractice population overall.” Staff we spoke withthroughout the day referred to this; support staff weobserved through the day dealt with patientscompassionately and treated them with dignity andrespect. We found that all patients we spoke with wereappreciative of staff at the practice. Staff acknowledgedthat in being compassionate and caring towards patients,patients treated staff with courtesy and respect.

Governance arrangements

The practice had policies and procedures in place tosupport the safe, effective delivery of services and thesewere available to staff via the desktop on any computerwithin the practice. Policies were up to date and hadregular review dates. The practice held monthly practicemeetings during which time governance and riskmanagement issues were discussed. Risks that had beenidentified were discussed and actions taken. Patientcomplaints were also discussed so that learning could bedisseminated to all staff. We looked at minutes from thelast three meetings and found that performance, qualityand risks had been discussed.

The GPs attended a meeting with neighbouring GPs toreview performance and best and updated clinicalguidance. The practice used the Quality and OutcomesFramework (QOF) to measure their performance. The QOFdata for this practice showed it was performing in line or at

times above average with national standards. We saw thatQOF data was regularly discussed at practice teammeetings and action plans were produced to maintain orimprove outcomes.

Investigation of significant events was completed but wefound the forms to record these did not pose openquestions to draw out pertinent details, for examplequestions on what, why, who when, where and how werenot asked. Examples of significant event analysis wereviewed lacked detail and as a result of this, learningpoints were limited. Incident reports did not follow aconsistent order; details around what was happening onthe day were present in the incident recording, but did notadd value. As a result, any learning that could be drawnfrom an incident was limited.

The practice nurses received annual appraisal from thepractice manager, rather than a clinician. Systems were notin place to review the work of the practice nurse, forexample by way of clinical audit. Although the achievementof targets (evidenced by QOF) could be checked on atappraisal, the significance of these, or the confirmedeffectiveness of treatment of patients by the nurses, waslimited due to the lack of clinical oversight.

The practice relied on one locum agency for supply oflocum GPs in the event of unplanned absence of one of thepractice GPs. When we reviewed records kept ofrecruitment checks undertaken by the agency, we foundthe practice did not ask for copies of these. The practicemanager told us they had accepted that pre-recruitmentchecks would have been completed by the agency and didnot ask for copies of these each time a locum GP was used.We pointed out that separate legislation applicable tosupply agencies, did not exempt the practice from theprovisions of regulation 21 of the Health and Social CareAct 2008 (Regulated Activities) Regulations 2010.

Leadership, openness and transparency

The management model in place was supportive of staff.Staff we spoke with said they enjoyed working at thepractice, many had worked there for a long period of time.Annual and more regular team events took place, staffspoke positively of these events and how valued andsupported they felt working there. The practice had a

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



strong team who worked together in the best interest of thepatient. All staff were aware of the practice whistleblowingpolicy and they were sufficiently confident to use thisshould the need arise.

The lack of attendance by district nurses at practicemulti-disciplinary team meetings for management of careof patients at end of life had not been addressed by theGPs. Although the lead GP had been absent from thepractice due to ill-health, in his absence, this had not beenaddressed. We understand that following our inspection,this matter had been raised with the CCG, and attendanceof the community nurses at practice led multi- disciplinaryteam meetings, particularly in respect of patients receivingpalliative care or end of life care had been arranged.

Practice seeks and acts on feedback from its patients,the public and staff

Staff reported a culture where their views were listened toand if needed action would be taken. We saw how staffinteracted and found there was care and compassion notonly between patients and staff but also amongst staffthemselves. We were told that regular clinical andnon-clinical meetings took place. At these meetings anynew changes or developments were discussed giving staffthe opportunity to be involved. All incidents, complaintsand positive feedback from surveys were discussed.

We found the practice proactively engaged with the generalpublic, patients and staff to gain feedback. An annualpatient survey had been carried out and appropriate actionplans were in place. The practice had an active Patient

Participation Group (PPG) and during our inspection withmet with two of their members. They spoke positively onhow the practice engaged with them at meetings and howthey took account of any recommendations or changesthey asked them to consider.

Management lead through learning and improvement

Staff had access to a programme of induction and trainingand development. Mandatory training was undertaken andmonitored to ensure staff were equipped with theknowledge and skills needed for their specific individualroles. Staff told us the practice supported them to maintaintheir clinical professional development through trainingand mentoring. We looked at a number of staff files andsaw that regular appraisals took place. However, we notedthat nurses were not appraised by a GP but by the practicemanager, which limited the insight that GPs had into thepossible areas for development for nursing staff.

The practice held regular staff meetings and clinicalmeetings. Minutes of meetings were kept and available forreview by staff that may have recently been on leave. Theall staff meetings were used to discuss any complaints, howthese were responded to and any changes to the practiceway of working. Performance was also discussed atmeetings, for example, the latest QOF results or otherinformation made available for example, through the localCCG. Staff we spoke with told us they received positiveleadership from the clinicians and practice managers andfelt part of a team, which contributed to their level ofcommitment to the practice.

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



Action we have told the provider to takeThe table below shows the essential standards of quality and safety that were not being met. The provider must send CQCa report that says what action they are going to take to meet these essential standards.

Regulated activityDiagnostic and screening procedures

Family planning services

Maternity and midwifery services

Surgical procedures

Treatment of disease, disorder or injury

Regulation 21 HSCA 2008 (Regulated Activities) Regulations2010 Requirements relating to workers

Regulation 21(b) and (c) of the Health and Social CareAct 2008 (Regulated Activities) Regulations 2010.

The practice must ensure that copies of checks carriedout by locum supply agencies are kept. This shouldinclude copies of indemnity cover, entry on the NHSEperformers list, GMC registration (and any conditions)and all other items covered by this regulation andSchedule 3.

Regulation

This section is primarily information for the provider

Compliance actions


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