Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at St Martins Practice on 24 November 2015. Overall the practice is rated as good for providing safe, effective, caring, responsive and well-led care for all of the population groups it serves.

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

• There was an open and transparent approach to safety and an effective system was in place for reporting and recording significant events.
• Risks to patients were assessed and well managed.
• Patients’ needs were assessed and care was planned and delivered following best practice guidance. Staff had the skills, knowledge and experience to deliver effective care and treatment.
• The practice held a register of the 2% of patients who were vulnerable or housebound and at risk of an unplanned hospital admission. These patients were given same day appointments when contacting the practice and longer appointment times were allocated.
• The practice had a process in place to follow up patients who had attended accident and emergency (A&E) and those patients who had unplanned hospital admission.
• Patients said they were treated with compassion, dignity and respect and were involved in care and decisions about their treatment.
• Patients were positive about access to the service. They said they found it easy to make an appointment, there was continuity of care and urgent appointments were available on the same day as requested.
• Patients registered with the practice had access to a heath trainer. Health trainers help their clients to assess their lifestyles and wellbeing, set goals for improving their health, agree action-plans, and provide practical support and information that will help people to change their behaviour.
• Information about services and how to complain was available and easy to understand.
• There was a clear leadership structure and staff were supported by management.
• The practice held two weekly clinical meetings to ensure information was communicated.
• The provider was aware of and complied with the requirements of the Duty of Candour.

We saw areas of outstanding practice:

• The leadership team in the practice had identified the specific needs of their patient group and proactively established services which were delivered to meet their needs and the needs of the local community.

• The practice had taken the lead on a number of innovative projects. For example; the Chapeltown Diabetes Service. St Martins Practice recruited a specialist nurse and seconded the nurse to work across six other practices in the locality. The specialist nurse provided support to manage more complex diabetes patients and provided training and support to GPs and practice nurses in order to manage these complex cases in the community.

• The practice also approached the CCG with the idea of a wellbeing service. This was aimed at supporting patients and signposting them to other health, social and third sector services as the practice acknowledged that clinicians did not always have adequate time during consultation to provide the best possible information for patients. The practice put together a plan for the role of a wellbeing co-ordinator, presented this to the CCG and were awarded funding. The social prescribing service was then commissioned at CCG level and rolled out to other practices.

• The practice had acknowledged a lower prevalence of some long term conditions such as hypertension and atrial fibrillation. At the time of our inspection the practice was in the process of undertaking work to confirm lower rates of the conditions in the area or improve detection of these conditions.

• The practice had a long history of looking after people with substance misuse and had developed additional services independent of the general practice to support these patients.

• The provider was a hub service for city wide substance misuse service and hosted a support service at the practice for black and minority ethnic (BME) family, friends and relatives affected by the alcohol use of an adult

• The practice was involved in the Leeds North Clinical Commissioning Group (CCG) Serious Untoward Incident (SUI) engagement scheme and had been identified as the highest reporting practice per 100 registered patients in the locality.

• The practice held a local contract to provide medical care to Care in Community (CIC) beds at a local care home. A CIC bed is a bed in a community setting for older people who do not need to be in hospital but cannot be supported at home. There were 20 beds located in the home, enabling patients to avoid hospital admission.

The practice had good links with the local community and had established the Chapeltown Practice Health Champions group. They had taken the lead on arranging activities for patients in the locality such as Zumba classes, coffee mornings and walking groups.

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice