Letter from the Chief Inspector of General Practice

We carried out an announced comprehensive inspection at The Greenhouse Practice on 15 June 2017. Overall the practice is rated as outstanding.

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

• There was a strong, open and embedded culture at the practice in respect of patient safety and the practice used every opportunity to learn from incidents. We observed a genuine open culture in which all safety concerns raised by staff were highly valued and integral to learning and improvement. All staff were encouraged to participate in learning and to improve safety as much as possible. We saw evidence that incidents were shared externally to enhance learning on a wider basis.
• Comprehensive systems were in place to keep people safe, which took account of current best practice. For example, there was an effective system in place to review patients on high risk medicines which included a nominated lead, an alert on the clinical system, a recall system and regular patient audits to ensure prescribing was in line with safe and best practice.
• Staff were aware of current evidence based guidance. Staff had been trained to provide them with the skills and knowledge to deliver effective care and treatment.
• There was evidence of quality improvement including clinical audit. We saw that the practice had put in place a comprehensive audit programme which was driven by the needs of the practice population in order to improve patient outcomes. There had been 11 clinical audits commenced in the last two years, four of these were completed audits where the improvements made were implemented and monitored.
• Feedback from patients about their care was consistently positive. Data from the national GP patient survey showed patients rated the practice higher than others for almost all aspects of care. Information about services and how to complain was available. Improvements were made to the quality of care as a result of complaints and concerns.
• Patients we spoke with said they found it easy to make an appointment with a named GP and there was continuity of care, with urgent appointments available the same day.
• The practice had good facilities and was well equipped to treat patients and meet their needs.
• The practice worked closely with co-located housing officers and homelessness case workers to support patients transitioning into more secure accommodation.
• The practice worked with other care providers to reduce inequality and improve access to secondary and specialised care.
• Leaders had an inspiring shared purpose and a clear vision which had reducing inequality and access to high quality, safe care as its top priority. The strategy to deliver this vision had been produced with stakeholders and was regularly reviewed and discussed with staff and the Patient Association. There was a high level of constructive engagement with staff and a high level of staff satisfaction.
• The provider was aware of the requirements of the duty of candour. Examples we reviewed showed the practice complied with these requirements.

The areas where the provider should make improvements:

• Continue to monitor practice performance in relation to outcomes for patients with long term conditions.
• Review and improve how patients with caring responsibilities are identified and recorded on the clinical system to ensure that information, advice and support is made available to them.
• The practice should review arrangements in place to ensure a patient has access to a female GP if this is requested.

We saw several areas of outstanding practice:

• The practice did not place a limit on the number of walk-in appointments available on any day so that patients who found it difficult to book appointments in advance or who struggled to adhere to scheduled appointments, could access GP services in a way that suited them.
• A specialist substance and alcohol misuse clinician at the practice offered and delivered alcohol and substance reduction programmes. The substance misuse clinician and the lead GP had a meeting before every clinical session and would discuss the care plan for each patient with an appointment. Patients attending this clinic who had not recently seen a GP were encouraged to see the doctor and would be accommodated on the same day where possible. This meant that GPs were able to undertake opportunistic health and medicine reviews.
• The practice had reviewed the practice list within the previous year and had identified an increasing number of Polish and Vietnamese speaking patients registering. The practice had arranged for a Vietnamese speaking interpreter from a local hospital to attend the practice weekly and had employed its own Polish speaking translator who also attended the practice one day per week. Patients we spoke with told us this had significantly improved their access to health services.

Professor Steve Field CBE FRCP FFPH FRCGP 

Chief Inspector of General Practice