Letter from the Chief Inspector of General Practice

East Norfolk Medical Practice has a practice population of approximately 12200 patients.

We carried out a comprehensive inspection at Newtown Surgery on 7 October 2014.

We have rated each section of our findings for each key area. We found that the practice provided a safe, effective, caring, responsive and well led service for the population it served. The overall rating was good and this was because improvements had been made that had a positive impact on patient care.

Our key findings were as follows:

• We found evidence that the practice staff worked together to make on-going improvements for the benefit of patients.

• Each day there was an assigned duty doctor and a doctor on call to respond to any unexpected peaks in patient’s requests to be seen. The feedback we received from patients informed us they could get appointments when they needed to.

• The practice was able to demonstrate a good track record for safety. Effective systems were in place for reporting safety incidents. Untoward incidents were investigated and where possible improvements made to prevent similar occurrences.

• We found that patients were treated with respect and their privacy was maintained. Patients informed us they were satisfied with the care they received.

We saw several areas of outstanding practice including:

• In April 2014 practice staff established the ‘Service Development Group’ Committee. The group consists of staff from each grade within the practice and external professionals. The purpose of the group was to implement changes that affect more than one staff grade. The meetings take place monthly and we saw they had investigated and made changes to the way that patients obtain their repeat prescriptions and how patients were informed about urine test results.

• The nurse practitioner offered open access by mobile phone to teenagers who were insulin dependent diabetics. They were able to text their blood test results if they had any concerns about management of their diabetes and the nurse practitioner would respond.

• A recent restructuring of management and administration staff resulted in more clinical time to invest in patient care. The staff skill mix was closely monitored. Clinical staff roles were analysed to ensure work and responsibilities were evenly distributed. If clinic sessions run late the cause is investigated and changes made to prevent future delays for patients.

Professor Steve Field (CBE FRCP FFPH FRCGP)

Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Newtown Surgery on 4 March 2019 as part of our inspection programme. Our inspection team was led by a CQC inspector and included a GP specialist advisor and a practice manager specialist advisor.

We previously inspected the practice in October 2014 and rated the practice as good overall and outstanding for providing well-led services.

Our judgement of the quality of care at this service is based 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.

I have rated this practice as good overall and requires improvement for providing safe services.

This means that:

• People were generally protected from avoidable harm and abuse and that legal requirements were met.
• Patients had good outcomes because they received effective care and treatment that met their needs.
• The practice was fully engaged with reviewing and monitoring the clinical service they offered and used this information to make changes and improvements in care. For example, the practice regularly reviewed data from the Clinical Commissioning Group and used this to drive improvement within the practice.
• Patients were supported, treated with dignity and respect and were involved as partners in their care.
• People’s needs were met by the way in which services were organised and delivered. For example, the practice had engaged with the local food bank charity and completed several health events.
• The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.
• The practice encouraged continuous improvement and innovation. For example, the practice had a diverse skill mix within the practice and encouraged staff to undertake further education such as nurses undertaking prescribing courses and phlebotomists training to become a Health Care Assistant.
• Staff reported they were proud to work within the practice.

We rated the practice as requires improvement for providing safe services because:

We found out of date medicines in the emergency medicine kit. The practice did not stock atropine, an emergency medicine recommended for practices that fit coils. At all sites, the practice kept glucogon in the emergency kit; it was not refrigerated, and the date of when it was taken out of the fridge was not recorded, nor was the new expiry date. After the inspection, the practice sent an updated protocol for the management of the emergency kit.

We rated the practice as outstanding for providing effective services for older people because:

• The practice had led a pilot to identify and care for older patients at risk of rapid decline or crisis. A multidisciplinary team meeting (MDT) was held weekly to discuss patients and support required and included a lead GP, a community matron, social services care co-ordinator and a social isolation link worker. In the first four months, 37 patients were referred, 14 received support, 13 were still receiving support, nine were being assessed and one patient was declined. The pilot had been extended to another local practice.
• Each care home had a named GP who was supported by a paramedic which had enabled to the practice to respond to urgent need in a timely manner and the practice told us this had helped reduce admissions to hospital from 64 in 2017/18 to 33 in 2018/19.

We rated the practice as outstanding for providing responsive care for people whose circumstances make them vulnerable because:

• The practice had a Homeless Care Service, which included an outreach service at the Salvation Army, street work and multidisciplinary team working based from the local housing trust. Services included immediate access for homeless patients. The practice had 81 homeless patients on their practice list. The practice had helped to find housing for 20 patients and were working with agencies to get a further 18 re-housed. Some of these patients were in prison, however the practice kept them on their list to actively follow up once released. The practice held regular events to gain money for ‘kip bags’ which included items such as sleeping bags and a toothbrush and had purchased 22 of these for the Salvation Army. The practice had a system whereby if a patient presented as homeless, a member of staff was allocated to fully assess their needs and signpost them to a clinician if required, offer food vouchers and assist with emergency accommodation and housing needs.
• The practice had established in-house Hepatitis C clinics and TB clinics which were also open to patients outside of the practice list. For the Hepatitis C clinic, 28 patients had attended, 18 of which had been discussed at a specialist meeting, ten had been started on treatment and six had finished treatment. The remaining patients were awaiting starting treatment or had not engaged.
• The practice held a Christmas Stocking campaign where patients and staff brought toys for children and essential items for people in need. The practice originally donated 200 stockings and due to the success, were able to fill another 250.
• The practice held a ‘start my week’ campaign which identified 12 people over the age of 50 who did not belong to an activity or group to make friends and become more active. The outcomes were positive for patients recently bereaved, carers and visually impaired patients joining groups. The practice facilitated this by visiting the local library with the group to identify groups in the local areas, such as walking football, crafts, singing groups and others.

We saw another area of outstanding practice:

• The practice had life connectors at each site who were able to refer patients to local charities, groups and external agencies. The practice had 140 agencies they could refer to. The practice had run a pilot for this role which was successful and had been rolled out across the CCG and recognised nationally. The practice were able to give examples where this had been positive in securing housing, reducing emergency calls and reducing social isolation for patients.

We found the provider must:

• Establish effective systems and processes to ensure good governance in accordance with the fundamental standards of care.

We found the provider should:

• Review the system for coding carers and the support provided to them.
• Continue to embed the plan to improve outcomes relating to the Quality and Outcomes Framework, particularly for outcomes relating to diabetes, COPD and mental health.
• Embed the action plan to improve the uptake of health checks for patients with a learning disability.

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

Dr Rosie Benneyworth BS BM BMedSci MRCGP

Chief Inspector of General Practice