We carried out an announced comprehensive inspection at Harleston Medical Practice on 1 February 2019 as part of our inspection programme. Our inspection team was led by a CQC inspector and included a GP specialist advisor and a member of the medicines team.

We previously inspected the practice in April 2016 we rated the practice outstanding, and outstanding for providing safe and well led services. At the last inspection in November 2017, we rated the practice as requires improvement for providing responsive services because

• The practice did not have clear oversight of the Hepatitis B immunity of all staff.
• The practice did not have complete oversight of the clinical and non-clinical governance within the practice to ensure good patient outcomes were delivered. For example, the system for recording when children did not attend their hospital appointments was not well maintained to ensure future monitoring.
• The practice did not evidence that they had effective systems to monitor all exception reporting.

At this inspection, we found that the provider had addressed these areas and showed evidence of improved outcomes for patients as a result.

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 outstanding overall.

This means that:

• The practice demonstrated outstanding leadership as senior clinicians and management team overcame previous difficult circumstances and the disappointment of the requires improvement rating of our previous inspection. They had reflected and planned and ensured they and the practice staff were motivated to make, further improve and sustain the improvements needed.
• People were protected by a strong comprehensive safety system, and a focus on openness, transparency and learning when things go wrong.
• The practice had taken significant steps to improve patient access to GPs. They had installed a new telephone and appointment system. Patient surveys they had undertaken showed a significant improvement in positive patient’s experiences.
• There was a truly holistic approach to assessing, planning and delivering care and treatment to all people who use services.
• The practice had identified areas where there were gaps in provision locally and had taken steps to address them.
• There was a strong person-centred and open culture in which all safety concerns raised by staff and patients was highly valued as being integral to learning and improvement. Learning was based on a thorough analysis and investigation of things that went wrong. Opportunities for learning from external safety events was also identified and used.
• 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.
• The leadership, governance and culture of the practice promoted the delivery of high quality person-centred care.

We rated the practice as outstanding for providing safe services because:

• The systems to manage and share information that is needed to deliver safe and effective care, treatment and support were co-ordinated, provided real time information across the practice and supported integrated care for patients who use the services. We saw evidence where the provider had used external information to safeguard patients.
• All staff were proactively involved in developing and embedding systems and processes to protect patient safety. All staff we spoke with had an in-depth knowledge of safety systems including safeguarding, infection prevention and control and health and safety.
• Staff ensured safe care was delivered in line with local and national guidance and in addition they also contributed, as a team, to development of local guidance. For example, the practice had invested in a clinical system and designed a search criterion which enabled them to use and develop a system to ensure patients with high risk of developing sepsis were proactively managed. Patients who presented with symptoms of an infection were screened using the National Early Warning Score (NEWS). The practice encouraged this data collection with the use of a league table on clinician’s performance, since June 2018, the practice had completed 664 NEWS scores. Learning from this work was shared with the CCG and the Royal College of General Practice.
• Compliance with medicines policy and procedure was routinely monitored and action plans were always implemented promptly. We saw evidence where the monitoring of medicines obtained from other sources such as online websites had resulted in appropriate actions taken to safeguard the patient and other health professionals.
• There was an open culture in which all safety concerns raised by staff and patients were highly valued as being integral to learning and improvement. Learning was based on a thorough analysis and investigation of things that went wrong. Opportunities for learning from external safety events was also identified, used and shared within the practice and with external stakeholders.

We rated the practice as outstanding for providing effective services because the rating for the populations groups of working age people (including those recently retired and students) and people experiencing poor mental health (including dementia) were rated as outstanding. This was because;

• Over the past 12 months the practice had a programme of education and engagement for patients to understand the benefits of screening, to attend their appointment and to return screening kits for the national cancer screening programme. The practice had been proactive in following up patients who had declined their appointments or had not returned their screening kit and been able to show an additional 99 patients had completed the screening process as a result of this work.
• Practice staff were consistent in supporting patients to live healthier lives by using every contact with patients to do so and ensuring face to face reviews were undertaken even if this involved multiple home visits. This had resulted in 100% performance in some outcomes for patients with poor mental health or dementia.

In addition:

• There was a truly holistic approach to assessing, planning and delivering care and treatment to patients. Patients had good outcomes because they received effective care and treatment that met their needs. They used every contact with patients as an opportunity to do so. We saw examples of this proactive approach resulting in early diagnosis and treatment.
• The continuing development of staff’s competence and knowledge was recognised as being integral to ensure high quality care. Staff were proactively supported and encouraged to acquire new skills and share best practice. GPs gave weekly education sessions to the nursing team and joint appointments with patients were routinely undertaken.
• Systems and processes around consent were actively monitored and reviewed to ensure patients are involved in making decisions about their care and treatment.

We rated the practice as good for providing caring services.

We rated the practice as good for providing responsive services.

We rated the practice as outstanding for providing well-led services because:

• The clinically driven leadership, governance and culture was used to drive and improve the delivery of high quality person-centred care. There was inclusive and effective leadership at all levels. Leaders at all levels demonstrated the high levels of experience capacity and capability needed to deliver excellent and sustainable care.
• The practice ensured clinical leadership and gave staff including nurses protected time to ensure they proactively managed patients, systems and processes.
• There was clear joint working between the clinical team members with GPs supporting and leading education and development with the nursing team.
• The leaders had a deep understanding of issues, challenges and priorities in their practice and in the wider health system.
• There was a systematic and integrated approach to monitoring, reviewing and providing evidence of progress against strategy and plans.
• Staff were proud of the practice as a place to work and spoke highly of the culture. There was a strong team-working and support across all areas and a common focus on improving the quality and sustainability of care and patient’s experience.
• There was a demonstrated commitment to best practice performance and risk management of systems and processes.
• The practice processes and systems to ensure patients and staff were kept safe from harm were robust and demonstrated good practice.
• There was demonstrated commitment at all levels to sharing data and information safely to drive and support decision making including system wide working and improvement.

We saw several areas of outstanding practice including:

• We saw a comprehensive, innovative and proactive approach to managing sepsis by minimising delays in the practice. The practice was in a rural location where there could be delays in patients getting to hospital quickly. The practice had undertaken a National Early Warning Score (NEWS) on 644 patients who had presented with an infection during the past 12 months. Daily searches identified the patients at high risk and staff, including out of hours staff, were made aware in case the patient contacted them. Prior to the Christmas closure and as part of their winter pressures management of vulnerable patients, the practice telephoned all patients identified at risk (score of three or above) to ensure they were well and gave advice should they develop symptoms. We were given evidence to show this proactive work had led to patients receiving preventative/in case prescriptions for antibiotics to obtain medicine to use if their symptoms worsened. The GPs followed up these patients when the practice re opened.

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

Professor Steve Field CBE FRCP FFPH FRCGPChief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as require improvement overall. (Previous inspection in April 2016 – Outstanding)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Good

Are services caring? – Good

Are services responsive? – Requires Improvement

Are services well-led? – Requires Improvement

As part of our inspection process, we also look at the quality of care for specific population groups. The population groups are rated as:

Older People – Requires Improvement

People with long-term conditions – Requires Improvement

Families, children and young people – Requires Improvement

Working age people (including those recently retired and students – Requires Improvement People whose circumstances may make them vulnerable – Requires Improvement

People experiencing poor mental health (including people with dementia) – Requires Improvement

We carried out an announced comprehensive inspection at Harleston Medical Practice on 28 November 2017. We carried out this comprehensive inspection under Section 60 of the Health and Social Care Act 2008 as part of our regulatory functions.

At this inspection we found:

• The practice had clear systems to manage risk in relation to safety incidents so that these were less likely to happen. When incidents did occur, the practice learned from them, improved their processes and was proactive in sharing this experience with others when relevant.
• The systems and processes used by the practice to mitigate risk required strengthening in some areas.
• The practice reviewed the effectiveness and appropriateness of the care it provided. This was supported by a wide range of focused audits and through reviewing their clinical work. It ensured that care and treatment was delivered according to evidence- based guidelines.
• Staff had the skills, knowledge and experience to carry out their roles and there was a strong focus on continuous learning and improvement at all levels of the organisation.
• The practice was above average for Quality Outcomes Framework scores compared to local and national averages. The practice was also above average for childhood immunisations and cervical screening rates.
• The practice had higher than average exception reporting for mental health indicators for the Quality Outcomes Framework. Following the inspection, the practice shared an audit they had completed which had identified a coding error. They told us patients had received relevant health monitoring.
• The facilities and premises were appropriate for the services delivered.
• Staff involved and treated patients with compassion, kindness, dignity and respect. However, the national GP patient survey July 2017 showed mixed responses from patients about the way staff treated them with compassion, dignity and respect.
• The practice had a proactive approach to supporting carers.
• Not all patients found it easy to access care and treatment at the practice although they were able to get appointments when their need was urgent.
• Staff demonstrated leadership within the practice; however there was incomplete oversight of practice performance.

We saw one area of outstanding practice:

• The practice had taken a proactive approach to seek patient consent to share information with the wider multidisciplinary team. The practice wrote to patients who were particularly frail or vulnerable as part of the enhanced summary care record (ESCR) and as a result doubled the number of patients with an ESCR to a total of 507.

The areas where the provider must make improvements are:

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

The areas where the provider should make improvements are:

• Review and update the procedures for monitoring uncollected medicines and any actions that are required.

• Review and continue to build upon patient feedback and ensure that the issues within the annual GP patient survey are considered as part of an action plan to improve patient experience.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Harleston Medical Practice on 5 April 2016. Overall the practice is rated as outstanding.

Our key findings across all the areas we inspected were as follows:

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents and near misses. All opportunities for learning from internal and external incidents were maximised.
• Patients said they sometimes found it difficult to get an appointment at a time convenient for them. The practice had identified that this was an area to be improved upon and proactively sought patient feedback to gain a better understanding of the issue.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice actively reviewed patients’ complaints and how they were managed and responded to, and made improvements as a result. A patient had joined the Patient Participation Group following the effective handling of a complaint.
• The practice used innovative and proactive methods to improve patient outcomes, working with other local providers to share best practice. For example, the practice was in the process of opening a community hub in the previous branch’s surgery premises. This was planned to house both local public and third sector organisations. This was aimed to improve collaborative care and provide greater convenience for patients, with a ‘no wrong door’ ethos and to facilitate integration of health and social care services to support the aims of the Five Year Forward View for the NHS. The practice had led a scoping exercise of local service providers to inform the community hub plan, to identify need and seek commitment to the proposal.
• The practice had a clear vision which had quality and safety as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff.
• The practice had strong and visible clinical and managerial leadership and governance arrangements.

We saw several areas of outstanding practice:

• Information about safety was highly valued and was used to promote learning and improvement. For example, the practice manager was accredited to provide training on female genital mutilation (FGM) to practice staff. A member of staff had raised a safeguarding concern identifying a FGM risk following in house training presented to the team.
• The practice worked alongside the patient participation group (PPG) to develop health promotion events for patients, including topics such as dementia, medicines’ management, common childhood illnesses and prostate cancer. This resulted in patients presenting themselves for screening, and in one instance a diagnosis being made.
• The practice carried out non-clinical audits on third party consent and Lasting Power of Attorney following a significant event. This had been shared throughout the practice and had improved staff awareness of data protection and the Caldicott principles. Furthermore, the audit and resources developed had been shared with local practices to develop learning and best practice in the area. The practice raised concerns in relation to Lasting Power of Attorneys with the Office of the Public Guardian when required.
• The practice recognised the barriers to engaging with younger patients, and was keen to build positive relationships and promote good health. The practice had a plan in place to present health education sessions at the local secondary school. Topics for discussion included diet, acne, mental health and mindfulness.

The area where the provider should make an improvement is:

• Ensure that patient feedback continues to be monitored to identify further areas for improvement.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

We spoke with four people who said they were involved in decisions about their care and treatment. One person said, “I feel very much involved in decisions about my care.” We found that people's privacy and dignity were maintained during clinical consultations.

We looked at the records of five people. We saw evidence that verbal consent had been obtained before an intimate examination or procedure or minor surgical procedure had occurred. This showed that before people received any care or treatment, they were asked for their consent.

We saw that people's care was planned, delivered and reviewed. One person we spoke with said, “They are busy but when you get to see a GP, they look at your notes, see your history and you are dealt with by a professional medical person.”

We saw that a patient survey had been undertaken in 2012-2013 and that the results had been analysed and an action plan completed. We saw that there was a process for learning from significant events that occurred at the surgery.

We saw a copy of the surgery complaints and comments patient information leaflet. These were available in the waiting area. We saw that there was an effective complaints system in place.