Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at Saxon Cross Surgery on 29 September 2015. Overall the practice is rated as good.

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

• There was a clear leadership structure and staff felt supported by management.

• High standards were promoted and owned by an enthusiastic and motivated practice team with evidence of highly effective team working.

• The practice had excellent facilities and was well equipped to treat patients and meet their needs.

• Results from the national GP survey, and responses to our conversations with patients, showed that patients were treated with compassion, dignity and respect, and that they were involved in their care and decisions about their treatment.

• Staff understood and fulfilled their responsibilities to raise concerns and report incidents. We found evidence of learning being applied from incidents to enhance future service delivery. People affected by significant events received a sincere apology and were told about the actions taken to improve care.

• High quality patient care was paramount to what the practice did. Patients’ needs were assessed and care was planned and delivered following best practice guidance.

• Staff training was up to date and individual staff were supported to continually develop in their roles – for example, a nurse had commenced training to become the second advanced nurse practitioner (ANP) within the practice. An ANP would be able to see a broader range of patients and have a greater degree of autonomy to make decisions.

• Risks to patients were assessed and well managed. Regular liaison meetings were held with the wider multi-disciplinary team to co-ordinate the delivery of effective and responsive care.

• We saw excellent examples that demonstrated the practice’s commitment to working with the Clinical Commissioning Group (CCG), other GP practices in Nottinghamshire, and local health and social care providers to achieve the best outcomes for patients and share best practice.

• The practice implemented suggestions for improvements and made changes to the way it delivered services as a consequence of feedback from patients and from the Patient Participation Group (PPG). For example, the PPG organised a session to raise awareness of dementia, leading to some practice staff being awarded ‘Dementia Friends’ status.

We saw several areas of outstanding practice including:

• The practice proactively used data to review their performance and to make changes to continuously improve outcomes for patient care. For example, by analysingunplanned hospital admissions to provide additional support, such as referral to community and voluntary services, that would enable patients to remain in their home.

• A GP partner had led on the implementation of a shared intranet system across local CCGs to facilitate learning by the sharing of data and access to a range of documents including best practice guidance. This innovation had led to the introduction of a performance tool called eHealthscope which had been rolled out to all practices across Nottinghamshire.

• Opportunities for learning from incidents were maximised by working collaboratively with the Clinical Commissioning Group (CCG), other GP practices, and community and secondary care service providers.

• The practice had increased the flexibility of access to appointments and could demonstrate the impact of this by reduced patient attendance at A&E compared against the national average, and also by positive patient survey results. This flexibility was facilitated by a good skill mix which included an advanced nurse practitioner (ANP) who led a triage service. A practice nurse had been supported to maintain her skills from a previous role by seeing patients with minor injuries to assist access and help relieve pressure on GP appointments. There were three independent nurse prescribers in the practice offering greater flexibility in offering patient consultations.

• Nurses rotated on a weekly basis to be assigned to a different doctor to discuss patients and access mentorship. This facilitated a thorough understanding of working with each other and helped to share expertise across the practice.

• Management of end of life care was planned effectively in conjunction with the multi-disciplinary team and this had resulted in only 18% of patient deaths in hospitals in the last year. This was a significant improvement to the previous 12 months in which 42% of the practice’s end of life patients had died in hospital. This reflected the achievement of the practice and community based teams to engage in difficult conversations with patients, families and carers to respect the patient’s wishes.

• The practice held a daily meeting for clinicians to discuss challenging cases and referrals. This meeting was observed during our inspection and was observed to be an effective approach in supporting the team, sharing ideas and focussing on patient care.

However, there were areas of practice where the provider should make improvements:

• The practice had attempted to obtain information on the environmental risks overseen by the landlord on a number of occasions with limited success, but should negotiate a more formal mechanism to discuss and record the premise related issues which impact directly upon the practice.

• The practice policy for chaperones should outline a clear procedure for acting as a chaperone and reflect recent guidance for where the chaperone should stand during the examination

• The practice should complete the infection control audit action plan from March 2014 and ensure all clinical rooms are included within any future infection control audit

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Letter from the Chief Inspector of General Practice

This practice is rated as Outstanding overall. (Previous inspection 29/09/2015 – Good)

The key questions are rated as:

Are services safe? – Good

Are services effective? – Outstanding

Are services caring? – Good

Are services responsive? – Good

Are services well-led? - Outstanding

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 – Outstanding

People with long-term conditions – Outstanding

Families, children and young people – Good

Working age people (including those recently retired and students – Good

People whose circumstances may make them vulnerable – Good

People experiencing poor mental health (including people with dementia) - Good

We carried out an announced inspection at Saxon Cross Surgery on 14 November 2017 as part of our inspection programme.

At this inspection we found:

• The practice had clear systems to manage risk so that safety incidents were less likely to happen. When incidents did happen, the practice learned from them and improved their processes.

• The practice routinely reviewed the effectiveness and appropriateness of the care it provided. It ensured that care and treatment was delivered according to evidence- based guidelines.

• At our last inspection, we found that a GP partner had led on the implementation of eHealthscope, a shared intranet system across the local CCG to facilitate learning by the sharing of data and access to a range of documents including best practice guidance. This innovation had led to eHealthscope being rolled out to all practices across Nottinghamshire. At this inspection, we found the practice had continued to develop this system to review and improve patient care by creating information sharing platforms with other practices and healthcare providers.

• The practice used information about care and treatment to make improvements. For example, they initiated opportunistic pulse rhythm checks to improve their identification of people with atrial fibrillation, resulting in 78% of eligible people having checks for the condition and two people being diagnosed with the condition.

• Staff involved and treated patients with compassion, kindness, dignity and respect.

• Staff had the skills, knowledge and experience to carry out their roles. Mentorship of the nursing staff was shared amongst all GPs in the practice, enabling them to learn different skills from the clinicians.

• The practice understood the needs of its population and tailored services in response to those needs. Patients were able to access care and treatment from the practice within an acceptable timescale for their needs through a variety of methods.

• There was a strong focus on continuous learning and improvement at all levels of the organisation. This included the sharing of policies, significant events and clinical audits with other practices within the CCG using the shared eHealthscope system and practice group meetings. As a result, some practices implemented the audits and adopted the same approach to improving the quality of care across the whole CCG.

We saw some areas of outstanding practice:

• The practice continued to promote innovation by developing a workflow system within the eHealthscope which enabled holistic care of registered patients with complex needs by identifying community teams that were involved or needed to be involved in their care.

• Clinicians initiated opportunistic pulse rhythm checks to improve their identification of people with atrial fibrillation, resulting in 78% of eligible people over 64 years old having checks for the condition and two people being diagnosed with the condition.

• Leaders at all levels were visible within the practice as well as the CCG where they held various positions, enabling them to influence improvements across the group of practices. Mentorship for the nursing team was rotated amongst all the GP partners to share skills and build resilience within the team.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice