We carried out an announced comprehensive inspection at Haxby Group Practice on 22 November 2018 as part of our inspection programme.

We based our judgement of the quality of care at this service on a combination of:

• what we found when we inspected
• information from our ongoing monitoring of data about services and
• information from the provider, patients, the public and other organisations.

We have rated this practice as outstanding overall. We rated the older people and families, children and young people population groups as outstanding and the other population groups as good. We rated the practice as outstanding for providing effective, caring and well-led services.

We found that:

• The practice provided care in a way that kept patients safe and protected them from avoidable harm.
• Patients received effective care and treatment that met their needs.
• Staff dealt with patients with kindness and respect and involved them in decisions about their care.
• The practice scored consistently highly in questions from staff and patients regarding care and culture.
• The practice organised and delivered services to meet patients’ needs. The practice had developed a new access model and was one of the first to introduce new roles into general practice. This meant that patients could access care and treatment in a timely way, with the most appropriate healthcare professional.
• The way the practice was led promoted the delivery of high-quality, person-centred care.
• Haxby Group Practice were part of a federation that provided care to 130,000 patients and were committed to working at scale with other providers to meet the needs of the population of York. The practice followed the Primary care home model which was developed by the National Association of Primary Care (NAPC), the model brought together a range of health and social care professionals to work together to provide enhanced personalised and preventative care for their local community.

We rated the practice as outstanding for providing effective, caring and well-led services because:

• The Group had implemented effective services for their patients including evidence of interventions that had avoided hospital admissions and effective approaches to childhood immunisations. They could demonstrate the positive impact this had for patient outcomes.
• The practice offered patients the opportunity to self-administer an injectable contraceptive that was a suitably licensed preparation for patient self-administration. The practice nursing team provided education and support to patients. The service gave patients choice and increased the availability of nurse appointments.
• The Group were an Advanced Training Practice (ATP) hub and had been instrumental in supporting pre- registration student nurses to have clinical placement experience to encourage them to consider practice nursing at the point of qualification. They were able to demonstrate the numbers of newly qualified nurses who had chosen to follow a career in primary care.
• The Group had developed up to date templates. This reduced variability in coding as well as improving the safety of work carried out by new members of staff, clinical trainees and locums. The templates also promoted patient safety through prompts for clinicians during and after consultations to ensure referrals and investigations were completed.
• The practice was part of a scheme as part of the federation Nimbuscare Ltd whereby patients who were deemed as at risk of hospital admissions were offered a service by York Integrated Care Team (YICT). The team reviewed all hospital admissions and discharges each day for patients in the federation practices and another rural practice. They worked with patients to review reasons for admissions and to plan care and support to minimise the risk of readmission. They also reviewed discharges to ensure that the patient had the care and support they needed to enable them to remain independent for longer. We saw evidence that 122 patients avoided admittance to hospital with this support (April 2018 – October 2018).

• The Group had recognised that the number of carers they had identified was low and had introduced measures to increase the numbers identified. The number of carers identified in York had increased from 773 in 2017 to 1055 because of these measures.

• Haxby Group had made improvements to their services for palliative care patients. Palliative care Champions had been established at the ‘centrepoint’ sites (in the call centres), the Champions had been given extended training in how to deal with bereavement, how to prioritise palliative care issues and how to liaise with specialist services such as the hospice and Macmillan nurses.

• We were shown evidence that GPs were now twice as likely to add a palliative care patient to the palliative care register (22% of palliative care patients identified by a GP in 2015 and 42% of palliative care patients identified by a GP in 2018).

• Staff and patient feedback was consistently positive regarding the caring culture of the practice.

The areas where the provider should make improvements are:

• Where patients are prescribed medicines not in line with National Institute for Clinical Excellence guidance provide a rationale as to why another medicine was prescribed within the patient record. This should include patients who had not been prescribed a high intensity statin as recommended by National Institute for Clinical Excellence guidance.
• Improve the system in place to physically check the contents of bags that hold medicines to be used on home visits.
• Review and improve awareness of quality improvement programmes within the practice.

Details of our findings and the evidence supporting our ratings are set out in the evidence tables.

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