Dr N Pillai and Dr L Nair NewApproachComprehensive Report...

This report describes our judgement of the quality of care at this service. It is based on a combination of what we foundwhen we inspected, information from our ongoing monitoring of data about services and information given to us fromthe provider, patients, the public and other organisations.

Ratings

Overall rating for this service Good –––Are services safe? Good –––

Are services effective? Good –––

Are services caring? Good –––

Are services responsive to people’s needs? Good –––

Are services well-led? Good –––

DrDr NN PillaiPillai andand DrDr LL NairNairQuality Report

St Lukes Surgery,Pinfold Health CentreField Road,BloxwichWalsallWS3 3JPTel: 01922 775136Website: www.stlukesurgery.co.uk

Date of inspection visit: 15 October 2015Date of publication: 28/01/2016

1 Dr N Pillai and Dr L Nair Quality Report 28/01/2016

Contents

PageSummary of this inspectionOverall summary 2

The five questions we ask and what we found 4

The six population groups and what we found 6

What people who use the service say 8

Areas for improvement 8

Outstanding practice 8

Detailed findings from this inspectionOur inspection team 10

Background to Dr N Pillai and Dr L Nair 10

Why we carried out this inspection 10

How we carried out this inspection 10

Detailed findings 12

Overall summaryLetter from the Chief Inspector of GeneralPracticeWe carried out an announced comprehensive inspectionat Dr N Pillai and Dr L Nair on15 October 2015. Overall thepractice is rated as good.

Specifically, we rated the practice as good for providingsafe, effective, caring, responsive and well led services.The service provided to the following population groupswas rated as good:

• Older people

• People with long-term conditions

• Families, children and young people

• Working age people (including those recently retiredand students)

• People whose circumstances may make themvulnerable

• People experiencing poor mental health (includingpeople with dementia).

Our key findings across all the areas we inspected were asfollows:

• Staff understood and fulfilled their responsibilities toraise concerns, and to report incidents and nearmisses. Information about safety was recorded,monitored, appropriately reviewed and addressed.

• Patients’ needs were assessed and care was plannedand delivered following best practice guidance. Staffhad received training appropriate to their roles andany further training needs had been identified andplanned.

• Patients said they were treated with compassion,dignity and respect and they were involved in theircare and decisions about their treatment.

• Patients said they found it easy to make anappointment with a named GP and that there wascontinuity of care, with urgent appointments availablethe same day.

• There was a clear leadership structure and staff feltsupported by management. The practice proactivelysought feedback from staff and patients, which it actedon.

Summary of findings


We saw areas of outstanding practice, these were:

• There were examples of how the practice hadresponded to the needs of vulnerable patients withcompassion and empathy. The practice told us thatthey had supplied a stair lift for a patient from theirdonation funds when other services were unable to.We saw a letter from the patients carer thanking thepractice for their support and that it had made apositive impact on their life.

• The practice was proactive in completing clinicalaudits that demonstrated quality improvement.There was evidence that clinical audits were effectivein improving outcomes for patients. For example, an

audit identifying patients who were at risk of highcholesterol due to family history, asthma diagnosisin children, minor surgery audits and an audit onspirometry rates.

However, there was an area of practice where theprovider needs to make improvements.

The provider should :

• Review the health and safety risk assessmentcompleted in May 2014 so that potential risks areassessed and managed.

Professor Steve Field (CBE FRCP FFPH FRCGP)Chief Inspector of General Practice

Summary of findings


The five questions we ask and what we foundWe always ask the following five questions of services.

Are services safe?The practice is rated as good for providing safe services. Staffunderstood and fulfilled their responsibilities to raise concerns, andto report incidents and near misses. Lessons were learned andcommunicated widely to support improvement. Information aboutsafety was recorded, monitored, appropriately reviewed andaddressed. Risks to patients were assessed and well managedhowever, the health and safety risk assessment required updating.

Good –––

Are services effective?The practice is rated as good for providing effective services. Datashowed patient outcomes were comparable to other practicesnationally. Staff referred to guidance from the National Institute forHealth and Care Excellence (NICE) and used it routinely. Patients’needs were assessed and care was planned and delivered in linewith current legislation. This included assessing capacity andpromoting good health. Staff had received training appropriate totheir roles and any further training needs had been identified andappropriate training planned to meet these needs. There wasevidence of appraisals and personal development plans for all staff.Staff worked with multidisciplinary teams in managing the needs ofpatients with long term conditions and complex needs.

The practice was proactive in completing clinical audits thatdemonstrated quality improvement. There was evidence thatclinical audits were effective in improving outcomes for patients.

Good –––

Are services caring?The practice is rated as good for providing caring services. Datashowed that patients rated the practice comparable to otherpractices locally and nationally for several aspects of care. Patientssaid they were treated with compassion, dignity and respect andthey were involved in decisions about their care and treatment.There were examples of how the practice had responded to theneeds of vulnerable patients with compassion and empathy.Information for patients about the services available was easy tounderstand and accessible. We also saw that staff treated patientswith kindness and respect, and maintained confidentiality.

Good –––

Are services responsive to people’s needs?The practice is rated as good for providing responsive services. Itreviewed the needs of its local population and engaged with the

Good –––

Summary of findings


Clinical Commissioning Group (CCG) to secure improvements toservices where these were identified. A CCG is an NHS organisationthat brings together local GPs and experienced health professionalsto take on commissioning responsibilities for local health services.

Patients said they found it easy to make an appointment with anamed GP and that there was continuity of care, with urgentappointments available the same day. The practice websiteprovided patients with the option of sending medical queries via thewebsite which would be beneficial for patients unable to visit thepractice during the main part of the day. For example, patients whoworked during these hours.

The practice had good facilities and was well equipped to treatpatients and meet their needs. Information about how to complainwas available and easy to understand and evidence showed that thepractice responded quickly to issues raised. Learning fromcomplaints was shared with staff.

Are services well-led?The practice is rated as good for being well-led. It had a clear visionand strategy. Staff were clear about the vision and theirresponsibilities in relation to this. There was a strong and visibleleadership structure and staff felt supported by management. Thepractice had a number of policies and procedures to govern activityand held regular meetings. There were systems in place to monitorand improve quality and identify risk. The practice proactivelysought feedback from staff and patients, which it acted on. Thepatient participation group (PPG) was active. PPGs are a way inwhich patients and GP surgeries can work together to improve thequality of the service. Staff had received inductions, regularperformance reviews and attended staff meetings and events.

The practice team was forward thinking and innovative andparticipated in local schemes to improve outcomes for patients. Forexample, making available specialist minor surgical procedures topatients in the local community such as vasectomy (malesterilisation) and carpal tunnel syndrome (a condition that causes atingling sensation, numbness and sometimes pain in the hand andfingers).

Good –––

Summary of findings


The six population groups and what we foundWe always inspect the quality of care for these six population groups.

Older peopleThe practice is rated as good for the care of older people. Nationallyreported data showed that outcomes for patients were good forconditions commonly found in older people. The practice offeredproactive, personalised care to meet the needs of the older patientsin its population and had a range of enhanced services, for example,in dementia and end of life care. It was responsive to the needs ofolder patients, and offered home visits and rapid accessappointments for those with enhanced needs.

People with long term conditionsThe practice is rated as good for the care of people with long-termconditions. Nursing staff had lead roles in chronic diseasemanagement and patients at risk of hospital admission wereidentified as a priority. Longer appointments and home visits wereavailable when needed. All these patients had a named GP and astructured annual review to check that their health and medicationneeds were being met. For those patients with the most complexneeds, the named GP worked with relevant health and careprofessionals to deliver a multidisciplinary package of care.

Families, children and young peopleThe practice is rated as good for the care of families, children andyoung people. There were systems in place to identify and follow upchildren living in disadvantaged circumstances and who were at risk,for example, children and young people who had a high number ofA&E attendances. Immunisation rates were relatively high for allstandard childhood immunisations. Appointments were availableoutside of school hours and children were given appointments as apriority. An audit had been completed on children’s asthma whichhad resulted in positive outcomes for patients. The premises wassuitable for children and babies.

Working age people (including those recently retired andstudents)The practice is rated as good for the care of working-age people(including those recently retired and students). The needs of theworking age population, those recently retired and students hadbeen identified and the practice had adjusted the services it offeredto ensure these were accessible, flexible and offered continuity ofcare. The practice offered online services and telephoneconsultations as well as a full range of health promotion andscreening that reflected the needs of this age group.

Summary of findings


The practice website provided patients with the option of sendingmedical queries via the website which was beneficial for patientsunable to visit the practice during the main part of the day. Forexample, patients who worked during these hours.

People whose circumstances may make them vulnerableThe practice is rated as good for the care of people whosecircumstances may make them vulnerable. The practice held aregister of patients living in vulnerable circumstances includinghomeless people, travellers and those with a learning disability. Wesaw that there were 11 patients on the learning disability registerand the practice had carried out annual health checks for all ofthose on the register. It offered longer appointments for patientswith a learning disability.

The practice regularly worked with multidisciplinary teams in thecase management of vulnerable patients. It had told vulnerablepatients about how to access various support groups and voluntaryorganisations. Staff knew how to recognise signs of abuse invulnerable adults and children. Staff were aware of theirresponsibilities regarding information sharing, documentation ofsafeguarding concerns and how to contact relevant agencies innormal working hours and out of hours. There were examples ofhow the practice had responded to the needs of vulnerable patientswith compassion and empathy.

People experiencing poor mental health (including peoplewith dementia)The practice is rated as good for the care of people experiencingpoor mental health (including people with dementia). We saw thatthere were 48 patients on the mental health register and the practicehad carried out annual physical health checks for all of those on theregister.

The practice regularly worked with multidisciplinary teams in thecase management of patients experiencing poor mental health,including those with dementia.

The practice had told patients experiencing poor mental healthabout how to access various support groups and voluntaryorganisations. Information was made available at the practice tosign post patients to various support groups and services. It had asystem in place to follow up patients who had attended accidentand emergency (A&E) where they may have been experiencing poormental health.

Good –––

Summary of findings


What people who use the service sayThe national GP patient survey results published on 2July 2015 for the practice had a 110 responses and aresponse rate of 31.9%. The survey showed the practicewas performing in line or above local and nationalaverages in a number of areas. For example:

• 89% found it easy to get through to this surgery byphone compared with a CCG average of 75.5% and anational average of 73%.

• 86% found the receptionists at this surgery helpfulwhich was similar to the CCG and national average of86%.

• 64% with a preferred GP usually got to see or speakto that GP compared with a CCG average of 60% anda national average of 60%.

• 87.9% were able to get an appointment to see orspeak to someone the last time they tried comparedwith a CCG average of 82.8% and a national averageof 85%.

• 96.5% said the last appointment they got wasconvenient compared with a CCG average of 92%and a national average of 91.8%.

• 83.6% described their experience of making anappointment as good compared with a CCG averageof 73% and a national average of 73%.

• 68% usually waited 15 minutes or less after theirappointment time to be seen compared with a CCGaverage of 69.7% and a national average of 64.8%.

• 65% feel they don't normally have to wait too long tobe seen compared with a CCG average of 59% and anational average of 57.7%.

As part of our inspection we also asked for CQC commentcards to be completed by patients prior to our inspection.We received 17 comment cards all were positive aboutthe standard of care received. Patients described a goodservice and staff who were caring, helpful and took timeto listen and explain their health needs. However, twocards also included comments about difficulty accessingroutine appointments.

On the day of the inspection we spoke with sevenpatients including two members of the patientparticipation group (PPG). PPGs are a way in whichpatients and GP surgeries can work together to improvethe quality of the service. All of the patients told us thatthey were involved in their care and staff took time toexplain their treatment in a way that they understood.However, we received mixed views about access toappointments, with three patients commenting thataccess to routine appointments could at times bedifficult.

Areas for improvementAction the service SHOULD take to improve

• Review the health and safety risk assessmentcompleted in May 2014 so that potential risks areassessed and managed.

Outstanding practice• There were examples of how the practice had

responded to the needs of vulnerable patients withcompassion and empathy. The practice told us thatthey had supplied a stair lift for a patient from their

donation funds when other services were unable to.We saw a letter from the patients carer thanking thepractice for their support and that it had made apositive impact on their life.

Summary of findings


• The practice was proactive in completing clinicalaudits that demonstrated quality improvement.There was evidence that clinical audits were effectivein improving outcomes for patients. For example, an

audit identifying patients who were at risk of highcholesterol due to family history, asthma diagnosisin children, minor surgery audits and an audit onspirometry rates.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC inspector. Theteam included a GP specialist advisor and a practicemanager specialist advisor.

Background to Dr N Pillai andDr L NairDr N Pillai and Dr L Nair also known as St Luke's Surgeryprovides primary medical services to approximately 5000patients in the local community. There are two GP partners(one male, one female) and three long term locum GPs (allmale). The practice is a training practice for GP trainees(fully qualified doctors who wish to become generalpractitioners) and a teaching practice for medical students.At the time of the inspection there were two trainee GPs(both male) and one medical student. The GPs aresupported by an advanced nurse practitioner (ANP), apractice nurse and one health care assistant. Thenon-clinical team consists of administrative and receptionstaff and a practice manager.

The practice has a General Medical Services contract (GMS)with NHS England. A GMS contract ensures practicesprovide essential services for people who are sick as wellas, for example, chronic disease management and end oflife care. The practice also provides some directedenhanced services such as minor surgery, childhoodvaccination and immunisation schemes. Enhancedservices require an enhanced level of service provisionabove what is normally required under the core GPcontract.

The practice opening times are 8am to 6.30pm Mondays,Wednesday and Thursdays with the exception of Fridayswhen the practice closes at 1pm and does not re-openduring the afternoon. The practice provides an extendedhours service on Tuesdays when it is open from 7.30am to7.30pm.

The practice has opted out of providing out-of-hoursservices to their own patients. This service is provided by‘Primecare’ the external out of hours service provider.When the practice is closed during core hours on a Fridayafternoon patients can access general medical services bycontacting ‘WALDOC’ which is an out-of-hours serviceprovider.

We reviewed the most recent data available to us fromPublic Health England which showed that the practice islocated in an area with a low deprivation score comparedto other practices nationally. Data showed that the practicehas a higher than average practice population aged 65years and over in comparison to other practices nationally.The practice also has a higher than the national averagenumber of patients with a long-standing health condition

The practice achieved 100% points for the Quality andOutcomes Framework (QOF) for the financial year2013-2014. This was above the national average of 94.2%.The QOF is a voluntary annual reward and incentiveprogramme which awards practices achievement points formanaging some of the most common chronic diseases, forexample asthma and diabetes

Why we carried out thisinspectionWe carried out a comprehensive inspection of this serviceunder Section 60 of the Health and Social Care Act 2008 aspart of our regulatory functions. This inspection was

DrDr NN PillaiPillai andand DrDr LL NairNairDetailed findings


planned to check whether the provider is meeting the legalrequirements and regulations associated with the Healthand Social Care Act 2008, to look at the overall quality ofthe service, and to provide a rating for the service under theCare Act 2014.

Please note that when referring to information throughoutthis report, for example any reference to the Quality andOutcomes Framework data, this relates to the most recentinformation available to the CQC at that time.

How we carried out thisinspectionTo get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?• Is it effective?• Is it caring?• Is it responsive to people’s needs?• Is it well-led?

We also looked at how well services are provided forspecific groups of people and what good care looks like forthem. The population groups are:

• Older people• People with long-term conditions• Families, children and young people• Working age people (including those recently retired

and students)• People whose circumstances may make them

vulnerable• People experiencing poor mental health (including

people with dementia)

Before visiting, we reviewed a range of information that wehold about the practice and asked other organisations toshare what they knew. We carried out an announced visiton 15 October 2015. During our visit we spoke with a rangeof staff (GPs, advanced nurse practitioner, a health careassistant, reception and administrative staff).

We talked with carers and/or family members and reviewedthe personal care or treatment records of patients. Wereviewed comment cards where patients and members ofthe public shared their views and experiences of theservice. We also spoke with the palliative care nursing teamand practice pharmacist. We received written feedbackfrom the community mental health team.

Detailed findings


Our findingsSafe track record and learningThe practice had systems in place to monitor safety andused a range of information to identify risks and improvepatient safety. This included reporting incidents, reviewingnational patient safety alerts and acting on comments andcomplaints received from patients. The staff we spoke withwere aware of their responsibilities to raise concerns, andknew how to report incidents and near misses. Staff told usthey would inform the practice manager or a GP partner ofany incidents and there was a recording form available onthe practice’s computer system.

There was an open and transparent approach for reportingsignificant events and systems in place to record andanalyse them. There were 10 significant events that hadoccurred during the last 12 months. We reviewed records ofthese and saw this system was followed appropriately. Wesaw that significant events were discussed at monthlypractice meetings as well as by email to staff, structureddiscussions and reviews took place and lessons wereshared to ensure action was taken to improve safety in thepractice. For example, following an incident where aprescription had been sent in an incorrect collection bag areview of the storage of prescriptions and other items forcollection was undertaken and systems put in place toprevent reoccurrence.

Overview of safety systems and processesThe practice had clearly defined and embedded systems,processes and practices in place to keep people safe, whichincluded:

• Arrangements were in place to safeguard vulnerableadults and children from abuse. There was a leadmember of staff for safeguarding and staff knew whothis was if they needed advice or support. Staffdemonstrated they understood their responsibilitiesand all had received training relevant to their role. TheGPs had received level three childrens safeguardingtraining. There were polices in place and contact detailswere accessible to staff for reporting safeguardingconcerns to the relevant agencies responsible forinvestigating. We saw an example of a referral made bythe practice in response to a child safeguarding concern.There was a system to highlight vulnerable patients on

the practice’s electronic records. This includedinformation to make staff aware of any relevant issueswhen patients attended appointments; for examplechildren subject to child protection plans.

• Notices were displayed on consulting room doorsadvising patients that a chaperone was available ifrequired. Only clinical staff acted as chaperones andthey were trained for the role and had received adisclosure and barring check (DBS). (DBS checks identifywhether a person has a criminal record or is on anofficial list of people barred from working in roles wherethey may have contact with children or adults who maybe vulnerable).

• There were procedures in place for monitoring andmanaging risks to patients and staff . The practice hadan up to date fire risk assessments and fire drills werecarried out. All electrical equipment was checked toensure the equipment was safe to use and clinicalequipment was checked to ensure it was workingproperly. The practice also had a variety of other riskassessments in place to monitor safety of the premisessuch as control of substances hazardous to health andlegionella. The practice had a health and safety policy inplace but the health and safety risk assessment was lastcompleted in May 2014 and required review.

• Appropriate standards of cleanliness and hygiene werefollowed. We observed the premises to be clean andtidy. There were schedules in place for the cleaning ofequipment used in consulting rooms. The cleaning ofthe general environment was undertaken by an externalcleaning company and we saw that cleaningspecifications were in place and these had beencompleted appropriately to demonstrate the cleaningundertaken. There were also spot checks undertaken toensure standards of cleaning were maintained. Therewas a procedure in place for the deep cleaning ofcurtains and blinds. The practice nurse was the infectioncontrol clinical lead who liaised with the local infectionprevention teams to keep up to date with best practice.There was an infection control policy in place and staffhad received up to date training. The last infectioncontrol audit which included an assessment of theminor surgery room had been undertaken in April 2015by a NHS Trust commissioned by the ClinicalCommissioning Group (CCG). A CCG is an NHSorganisation that brings together local GPs and

Are services safe?

Good –––


experienced health professionals to take oncommissioning responsibilities for local health services.The practice had received an overall score of 97%. Wesaw that there was only one action outstanding whichwas in progress, this was repairing the flooring andskirting board seal in one of the rooms.

• There were arrangements in place for managingmedicines, including emergency medicines andvaccinations. We checked medicines for use in amedical emergency and medicines in refrigerators andfound they were stored securely, in date and were onlyaccessible to authorised staff. Records showed thatfridge temperature checks were carried out whichensured medication was stored at the appropriatetemperature.

• A system was in place for repeat prescribing so thatpatients were reviewed appropriately to ensure theirmedications remained relevant to their health needs.There was an alert system on the practice’s electronicrecords to highlight when a patient was due theirmedication review. All prescriptions were reviewed byeither a GP or the practice pharmacist and then signedby a GP before they were given to the patient.Prescription pads were securely stored and there weresystems in place to monitor their use. Both blankprescription forms for use in printers and those for handwritten prescriptions were held securely. The serialnumbers for paper prescription pads taken on homevisits were recorded to ensure a clear audit trail.However, the practice had not implemented theelectronic prescription service with local communitypharmacists which could benefit some patients. We sawthat a number of complaints included complaints aboutrepeat prescriptions systems. However, we spoke withthe practice pharmacist who told us that since theinspection the practice had requested training on theelectronic prescription service. As a result of the trainingthey had now implemented the system and their usagewas 70%.

• National prescribing data showed that the practice wassimilar to the national average for medicines such as

hypnotics and lower that the national average forprescribing certain antibiotic medicines, the practicerate was 1.82% compared to the national average of5.3%.

• The nurses used Patient Group Directions (PGDs) toadminister flu vaccines and other medicines that hadbeen produced in line with legal requirements andnational guidance. The health care assistants usedPatient Specific Directives (PSD) for flu vaccinationswhich were undertaken for a group of named patientswho had been individually assessed and reviewed bythe GP.

• Recruitment checks were carried out and the files wereviewed showed that appropriate recruitment checkshad been undertaken prior to employment. Forexample, proof of identification, references,qualifications, registration with the appropriateprofessional body and the appropriate checks throughthe DBS.

• Arrangements were in place for planning andmonitoring the number of staff and mix of staff neededto meet patients’ needs. There was a rota system inplace for all the different staffing groups to ensure thatenough staff were on duty. Regular locum GPs wereemployed when necessary to ensure continuity inpatients care and treatment.

Arrangements to deal with emergencies and majorincidentsThere was an instant messaging system on the computersin all the consultation and treatment rooms which alertedstaff to any emergency. All staff had received annual basiclife support training. The practice had a defibrillator (usedin cardiac emergencies) available on the premises andoxygen with adult and children’s masks. Emergencymedicines were easily accessible to staff in a secure area ofthe practice and all staff knew of their location. All of themedicines we checked were in date and fit for use.

The practice had a comprehensive business continuity planin place for major incidents such as power failure orbuilding damage and the plan was also available remotelyin the event this was required.

Are services safe?

Good –––


Our findingsEffective needs assessmentThe practice carried out assessments and treatment in linerelevant and current evidence based guidance andstandards, including National Institute for Health and CareExcellence (NICE) best practice guidelines. The practicestaff had access to guidelines from NICE which wasavailable on the practice computer and used thisinformation to develop how care and treatment wasdelivered to meet needs. The practice had systems in placeto ensure all clinical staff were kept up to date whichincluded discussions in weekly clinical meetings whereclinical staff presented new NICE guidance which were thenimplemented in practice. The practice monitored thatthese guidelines were followed through audits for example,an audit to ensure NICE guidance was followed for newlydiagnosed patients with hypertension (high bloodpressure). As a result of the audit the practice developed apractice protocol for the management of hypertensionwhich was displayed in all clinical consulting room.

The practice had systems in place to identify and assesspatients who were at high risk of admission to hospital.This included reviewing discharge summaries followinghospital admission to establish the reason for admissionand included members of the relevant multidisciplinaryteam such as the practice pharmacist. These patients werereviewed to ensure care plans were documented in theirrecords and their needs were being met which assisted inreducing the need for them to go into hospital.

Management, monitoring and improving outcomesfor peopleThe practice participated in the Quality and OutcomesFramework (QOF). (This is a system intended to improvethe quality of general practice and reward good practice).The practice used the information collected for the QOFand performance against national screening programmesto monitor outcomes for patients. The practice proactivelyreviewed its QOF figures and recalled patients whennecessary for reviews. A staff member was the QOF leadresponsible for overseeing QOF and there was a teamapproach to the management of patients with long termconditions. This included running regular searches toidentify progress and discussions at weekly clinicalmeetings which ensured a high score.

The published data from 2013/14 showed that the practicewas a high achieving practice and had achieved 100% ofthe total number of QOF points available with an overallexception reporting rate of 3.3% (Exception reporting is theexclusion of patients from a QOF target who meets specificcriteria. For example, patients who choose not to engage inthe review process or where a medication cannot beprescribed due to a contraindication or side-effect).

This practice was not an outlier for any QOF (or othernational) clinical targets. Data from 2013/14 showed thatthe practice was in line or above the national average for anumber of QOF indicators, for example:

• Performance for diabetes related indicator for footexaminations was 93.5% which was higher than thenational average of 88%.

• The percentage of patients with a mental health needwho had a comprehensive agreed care plan was 93%which was higher than the national average of 86%.

• The percentage of patients with hypertension havingregular blood pressure tests was 85% which was similarto the national average of 83%.

• The dementia diagnosis rate was 83% which was similarto the national average of 83%.

The practice was proactive in completing clinical auditsthat demonstrated quality improvement. There wasevidence that clinical audits were effective in improvingoutcomes for patients. The GPs had a genuine interestand a positive attitude towards completing clinicalaudits and there had been ten clinical audits completedin the last 12 months.

• We saw evidence of completed audits whereimprovements were implemented and monitored. Forexample, following an audit on spirometry rates thepractice had trained the health care assistant toundertake spirometry testing to increase their uptake.An audit had been completed on children’s asthma in2013 which involved reviewing diagnosis rates, lookingat follow up of these patients and their uptake of the fluvaccination. The initial audit had shown the diagnosishad been mistaken in 30 out of 94 patients; follow up inchildren was 25% and no flu vaccinations had beengiven. When re audited in November 2014 this hadimproved with a diagnosis correct in 100% of patients,follow up had increased to 50% and flu vaccination

Are services effective?(for example, treatment is effective)

Good –––


uptake was 48%. An audit was also completed toidentify patients who were at risk of high cholesterol. Asa result of the audit 62 patients were identified, of these11 patients were referred to a specialist clinic, 11patients were identified as having a risk of heart diseaseand were started on medication and given lifestyleadvice, seven patients did not attend their appointmentand were sent information by post. The remaining 33patients had no current risks and were given lifestyleadvice and told to attend for cholesterol testing in sixmonths’ time.

• The practice participated in applicable local audits,pilots, peer review and research. For example, one of theGPs was the Clinical Commissioning Group (CCG) leadfor minor surgery and undertook a high number ofminor surgical procedures at the practice. This includedspecialist surgery such as vasectomy (male sterilisation)and carpal tunnel syndrome surgery (a condition thatcauses a tingling sensation, numbness and sometimespain in the hand and fingers). A CCG is an NHSorganisation that brings together local GPs andexperienced health professionals to take oncommissioning responsibilities for local health services.The practice audited the vasectomy provision at thesurgery as part of a peer review based on nationalstandards. The results showed no failures in theprocedure and the practice compared favourably tonational standards on failure rates and complications.

Effective staffingStaff had the skills, knowledge and experience to delivereffective care and treatment.

• There was an established team which included two GPpartners. The team also included an advanced nursepractitioner (ANP), a practice nurse and one health careassistant. The non-clinical team consisted ofadministrative/ reception staff and a practice manager.

• The practice had an induction programme for newlyappointed members of staff which included inductionpacks for GP trainees and locums.

• The practice was proactive in providing training to staff.Staff had access to appropriate training to meet theirlearning needs and to cover the scope of their work. Thisincluded core training in areas such as safeguardingchildren and vulnerable adults, basic life support andinfection prevention and control. Staff had received

training and updates relevant to their role, for examplethe GPs had received level three safeguarding children’straining, the GP undertaking minor surgery had receivedan update. The ANP had received updates on childhoodimmunisations and cervical screening. Staff discussedwith us training opportunities they had been given todevelop skills in line with their roles and responsibilities.For example, the ANP had completed a diploma inasthma which was funded by the practice. There wastraining provided to the GP trainees to support theirprofessional development and monthly protectedlearning time for all staff.

• The GP partners in the practice had specialist interestsand utilised their knowledge and skills in practice toimprove outcomes for patients. For example, one of theGPs was a former surgeon as a result they had a leadrole for minor surgery in the CCG and provided a highnumber of specialist minor surgery to patients in thelocal community. Another GP was a former paediatricianand had completed a diploma in dermatology as aresult they had lead roles in these areas within thepractice.

• The learning needs of staff were identified through asystem of appraisals and meetings. We saw that anumber of staff had received an appraisal within the last12 months although some staff had not yet had theirappraisal due to a change in management however,these were scheduled.

• The GPs we spoke with confirmed they were up to datewith their yearly continuing professional developmentrequirements and had recently been revalidated. EveryGP is appraised annually, and undertakes a fullerassessment called revalidation every five years. Onlywhen revalidation has been confirmed by the GeneralMedical Council can the GP continue to practise andremain on the performers list with NHS England.

• Staff had various lead roles within the practice tosupport the management of patients’ care andtreatment. These included QOF, safeguarding, womenand children health and diabetes.

• Regular staff meetings provided the opportunity toshare important information with staff. The minutesshowed that these meetings were detailed and covereda number of areas including significant events andcomplaints.


Good –––


Coordinating patient care and information sharingThe information needed to plan and deliver care andtreatment was available to relevant staff in a timely andaccessible way through the practice’s patient recordsystem, their intranet and an integrated pathology anddischarge summaries system linked to the local acutehospital. This included care plans, risk assessments,medical records and results of tests and investigations. Allrelevant information was shared with other services in atimely way, for example when people were referred to otherservices.

The practice referred patients appropriately to secondaryand other community care services such as the districtnurses. The practice used the Choose and Book system formaking the majority of patient referrals. The Choose andBook system enables patients to choose at which hospitalthey would prefer to be seen.

Staff worked together and with other health and social careservices to understand and meet the range and complexityof patients’ needs and to assess and plan ongoing care andtreatment. This included when patients moved betweenservices, including when they were referred to other healthprofessionals, or after they were discharged from hospital.

The practice implemented the gold standards frameworkfor end of life care (GSF). This framework helps doctors,nurses and care assistants provide a good standard of carefor patients who may be in the last years of life. Thisincluded a palliative care register and regularmultidisciplinary meetings to discuss the care and supportneeds of patients and their families. Our discussions withthe palliative care nursing team suggested that there waseffective communication with the practice to shareinformation in a timely manner. Regular GSF meetings tookplace and the GPs were approachable and responsive tofeedback. We also received feedback from the communitymental health team who provided brief interventions forpatients with mental health needs. The service could beaccessed by patients self-referring or by a GP referral. Theytold us that the GPs at the practice always madeappropriate referrals and they were very approachable,accessible and information was shared in a timely manner.

Consent to care and treatmentPatients’ consent to care and treatment was sought in linewith legislation and guidance. Booklets were madeavailable to all staff on the principles of the Mental CapacityAct 2005. Our discussion with staff demonstrated that they

understood the relevant consent and decision-makingrequirements of legislation when providing care andtreatment and would act on any concerns about a personlacking capacity to consent. This included Gillickcompetence (the Gillick test is used to help assess whethera child has the maturity to make their own decisions and tounderstand the implications of those decisions). Staffconfirmed that assessments of capacity to consent wouldbe carried out in line with relevant guidance.

There were 11 patients on the learning disability registerand 48 patients on the mental health register all of whomhad received a health review. We reviewed a sample of careplans for patients with a learning disability and those withmental health needs and saw that they were supported tomake decisions through the use of care plans, which theywere involved in agreeing.

Health promotion and preventionPatients who may be in need of extra support wereidentified by the practice. These included patients in thelast 12 months of their lives, carers, those at risk ofdeveloping a long-term condition, those requiring adviceon their diet, smoking cessation and sexual health advice.

The practice had an electronic screen with healthpromotion information. There was also posters andpractice leaflets with details of services for patients toaccess including a range of self-referral service such assexual health, physiotherapy, smoking cessation andmental health services.

The practice had a comprehensive screening programme.Data showed that the practice’s uptake for the cervicalscreening test was 83% which was similar to the CCGaverage of 81.8%. There was a system in place to recall andfollow up patients who did not attend for their cervicalscreening test. Findings were audited to ensure goodpractice was being followed.

Childhood immunisation rates were mostly above the CCGaverages. For example, childhood immunisation rates forthe vaccinations given to under one year olds was 100%,two year olds ranged from 97% to 98% with the exceptionof the Infant Men C which was 67% however, the practiceprovided us more recent data which showed the uptakewas 90%. Vaccinations for five year olds ranged from 95%


Good –––


to 100%. Flu vaccination rates for patients over 65 yearswas 73.9% this was similar to the CCG average of 73%. Fluvaccination for at risk groups was 50%, this was similar tothe national average of 52%.

Patients had access to appropriate health assessments andchecks. These included health checks for new patients and

NHS health checks for people aged 40–74. Appropriatefollow-ups on the outcomes of health assessments andchecks were made where abnormalities or risk factors wereidentified.


Good –––


Our findingsRespect, dignity, compassion and empathyWe observed throughout the inspection that members ofstaff were courteous and very helpful to patients bothattending at the reception desk and on the telephone andthat people were treated with dignity and respect. Curtainswere provided in consulting rooms so that patients’ privacyand dignity was maintained during examinations,investigations and treatments. We noted that consultationand treatment room doors were closed duringconsultations and that conversations taking place in theserooms could not be overheard. We saw that there was aqueuing system in place in the reception area and a posterrequesting patients not to approach the desk if someoneelse was there. There were also posters informing patientsthat they could discuss any issues in private away from themain reception desk.

All of the 17 CQC comment cards we received were positiveabout the service experienced. Patients said staff werehelpful, caring and treated them with dignity and respect.Comment cards highlighted that staff respondedcompassionately when they needed help and providedsupport when required. We also spoke with seven patientsincluding two members of the patient participation group(PPG) on the day of our inspection. They also told us theywere satisfied with the care provided by the practice andsaid their dignity and privacy was respected.

There were examples of how the practice had responded tothe needs of vulnerable patients with compassion andempathy. The practice told us that they had supplied a stairlift for a patient from their donation funds when otherservices were unable to. We saw a letter from the patientscarer thanking the practice for their support and that it hada made positive impact on their life.

Results from the national GP patient survey published inJuly 2015 showed patients were happy with how they weretreated and that this was with compassion, dignity andrespect. The practice was in line or above local andnational average for its satisfaction scores on consultationswith doctors and nurses. For example:

• 86.6% said the GP was good at listening to themcompared to the CCG average of 85.9% and nationalaverage of 88.6%.

• 81.7% said the GP gave them enough time compared tothe CCG average of 84.7% and national average of86.6%.

• 94.7% said they had confidence and trust in the last GPthey saw compared to the CCG average of 94% andnational average of 95%.

• 89% said the last GP they spoke to was good at treatingthem with care and concern compared to the CCGaverage of 83% and national average of 85%.

• 94% said the last nurse they spoke to was good attreating them with care and concern compared to theCCG average of 90.6% and national average of 90%.

• 86.6% patients said they found the receptionists at thepractice helpful compared to the CCG average of 86.6%and national average of 86.8%.

Care planning and involvement in decisions aboutcare and treatmentPatients we spoke with told us that health issues werediscussed with them and they felt involved in decisionmaking about the care and treatment they received. Theyalso told us they felt listened to and supported by staff andhad sufficient time during consultations to make aninformed decision about the choice of treatment availableto them. Patient feedback on the comment cards wereceived was also positive and aligned with these views.

Results from the national GP patient survey we reviewedshowed patients responded positively to questions abouttheir involvement in planning and making decisions abouttheir care and treatment and results were in line with localand national averages. For example:

• 84% said the last GP they saw was good at explainingtests and treatments compared to the CCG average of84% and national average of 86%.

• 82% said the last GP they saw was good at involvingthem in decisions about their care compared to the CCGaverage of 78% and national average of 81%.

Staff told us that translation services were available forpatients who did not have English as a first language.However, we did not see any posters in the reception areasinforming patients that this service was available.

Are services caring?

Good –––


Patient and carer support to cope emotionallywith care and treatmentNotices in the patient waiting area and information on anelectronic screen told patients how to access a number ofsupport groups and organisations.

The practice’s computer system alerted GPs if a patient wasalso a carer. There was a practice register of all people whowere carers and 77 patients on the practice list had beenidentified as carers and were being supported, for example,by offering health checks and referral for social services

support. Written information was available for carers toensure they understood the various avenues of supportavailable to them, this included a ‘Carers corner’ in thepractice and a carers support service information leaflet.

Staff told us that if families had suffered bereavement, theirusual GP contacted them and a bereavement pack wassent with information on support services available. Thiscall was either followed by a patient consultation at aflexible time and location to meet the family’s needs and/orby giving them advice on how to find a support service.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needsThe practice worked with the local Clinical CommissioningGroup (CCG) to plan services and to improve outcomes forpatients in the area. A CCG is an NHS organisation thatbrings together local GPs and experienced healthprofessionals to take on commissioning responsibilities forlocal health services. For example, the practice providedminor surgical procedures to patients in the practice andlocal community that included more specialist surgerysuch as vasectomy (male sterilisation) and carpal tunnelsyndrome surgery (a condition that causes a tinglingsensation, numbness and sometimes pain in the hand andfingers).

Services were planned and delivered to take into accountthe needs of different patient groups and provide flexibility,choice and continuity of care. For example;

• The practice had three practice pharmacists whoprovided a total of 16 hours pharmacy support to thepractice as part of a CCG scheme. The aim of thescheme was to enable all practices in Walsall to havepharmacy support to ensure safe and appropriateprescribing of medications and increase efficiency inrepeat prescribing. The role of the pharmacists includedundertaking medication reviews of patients specificallythose with complex needs and patients discharged fromhospital. The pharmacists also undertook audits withthe practice to ensure prescribing was in line with bestpractice guidelines and to improve safety andeffectiveness. For example, an audit to review patientsprescribed medications for specific health conditionssuch as diabetes and high cholesterol. The role of thepharmacists also included undertaking a hypertension(high blood pressure) clinic to review patients withuncontrolled hypertension. We spoke with one of thepractice pharmacists who told us there were effectivecommunication systems in place to share informationand manage the needs of patients with complex needsand long term conditions.

• Systems to review and recall patients with long termconditions such as asthma, diabetes and chronicobstructive pulmonary disease (COPD) which is the

name for a collection of lung diseases, including chronicbronchitis and emphysema. Typical symptoms areincreasing shortness of breath, persistent cough andfrequent chest infections.

• Longer appointments were available for patients with alearning disability and long term conditions. There wereannual health checks for patients with a learningdisability and those with mental health needs.

• Home visits were available for older patients / patientswho would benefit from these.

• Urgent access appointments were available on thesame day for children, the elderly and patients whowere vulnerable.

• Systems were in place to follow up urgent requests forappointments which meant that patients would receivea telephone call if a same day appointment was notavailable.

• The facilities were accessible for patients who haddifficulty with their mobility. There was a hearing loopsystem to assist patients who used hearing aids, andtranslation services available.

• There were extended opening hours on Tuesdays whenit was open from 7.30am to 7.30pm and patients couldbook appointments and order repeat prescriptions online which would benefit patients unable to visit thepractice during the main part of the day. For example,patients who worked during these hours.

• The practice had a patient participation group (PPG)and there were 13 members, we spoke with twomembers during the inspection. PPGs are a way inwhich patients and GP surgeries can work together toimprove the quality of the service. There was evidencefrom minutes of meetings and discussion with themembers that the PPG was trying to generate interest,engage with patients and act on feedback. For example,the PPG had developed its own patient survey whichwas distributed to patients to obtain feedback. Actionstaken as a result of patient feedback included ensuringconfidentiality in the patient waiting area.

Access to the serviceThe practice opening times were 8am to 6.30pm Mondays,Wednesday and Thursdays with the exception of Fridays

Are services responsive to people’s needs?(for example, to feedback?)

Good –––


when the practice closed at 1pm and did not re-openduring the afternoon. The practice provided an extendedhours service on Tuesdays when it was open from 7.30amto 7.30pm.

In addition to pre-bookable appointments that could bebooked up to two weeks in advance, urgent same dayappointments were available for patients that neededthem. Patients could book appointments and order repeatprescriptions online. There were telephone consultationsavailable with the GPs. The practice website also providedpatients with the option of sending medical queries via thewebsite which would be beneficial for patients unable tovisit the practice during the main part of the day. Forexample, patients who worked during these hours.

Results from the national GP patient survey showed thatpatient’s satisfaction with how they could access care andtreatment was in line or above local and national averagesfor example:

• 74 % of patients were satisfied with the practice’sopening hours this was similar to the CCG and nationalaverage of 74.9%.

• 89% of patients said they could get through easily to thesurgery by phone compared to the CCG average of75.5% and national average of 73%.

• 83.6% patients described their experience of making anappointment as good compared to the CCG average of73% and national average of 73%.

• 68% patients said they usually waited 15 minutes or lessafter their appointment time compared to the CCGaverage of 69% and national average of 64%.

Listening and learning from concerns andcomplaintsThe practice had a system in place for handling complaintsand concerns. Its complaints policy and procedures were inline with recognised guidance and contractual obligationsfor GPs in England. There was a designated responsibleperson who handled all complaints in the practice.

We saw that information was available to help patientsunderstand the complaints system which included a postera complaints policy and practice leaflet. Patients we spokewith said that they had not needed to make a complaintbut were aware of the process to follow if they wished to.

The practice had received ten complaints in the last 12months. We reviewed these complaints and found they hadbeen handled satisfactorily. There was evidence thatcomplaints were discussed with staff during staff meetingsto ensure learning and reflection.

Are services responsive to people’s needs?(for example, to feedback?)

Good –––


Our findingsVision and strategyThe practice had a clear vision to deliver high quality careand promote good outcomes for patients. The practice hada practice charter which was displayed in the patientwaiting area. Staff spoken with demonstrated acommitment to providing a high quality service thatreflected the vision.

We saw areas of outstanding practice that supported thepractices vision and aspirations.

Governance arrangementsThe practice had an overarching governance frameworkwhich supported the delivery of the strategy and goodquality care. This outlined the structures and procedures inplace and ensured that:

• There was a clear staffing structure and that staff wereaware of their own roles and responsibilities.

• Practice specific policies were implemented and wereavailable to all staff.

• A comprehensive understanding of the performance ofthe practice.

• A programme of continuous clinical and internal auditwhich was used to monitor quality and to makeimprovements.

• There were robust arrangements for identifying,recording and managing risks, issues and implementingmitigating actions.

Leadership, openness and transparencyThe partners in the practice had the experience, capacityand capability to run the practice and ensure high qualitycare. They prioritised safe, high quality and compassionatecare. The partners were visible in the practice and staff toldus that they were approachable and always took the timeto listen to all members of staff. The partners encouraged aculture of openness and honesty. There was a sincererelationship between the staff and partners which nurturedan environment of trust and staff engagement.

Staff told us that regular team meetings were held and theculture in the practice promoted openness andtransparency. Staff told us that they had the opportunity toraise any issues at team meetings. Staff said they wereconfident in raising any issues and felt supported if theydid. There were protected learning events held once amonth to support staff learning and development. Staffsaid they felt respected, valued and supported. All staffwere involved in discussions about how to run and developthe practice, and the partners encouraged all members ofstaff to identify opportunities to improve the servicedelivered by the practice.

Seeking and acting on feedback from patients, thepublic and staffThe practice encouraged and valued feedback frompatients. It had gathered feedback from patients throughthe patient participation group (PPG) and through surveysand complaints received. There was an active PPG whichmet on a regular basis, carried out patient surveys andsubmitted proposals for improvements to the practicemanagement team. For example, improving confidentialityin the patient waiting area.

The practice had also gathered feedback from staff throughstaff meetings, appraisals and discussion. Staff told us theywould not hesitate to give feedback and discuss anyconcerns or issues with colleagues and management.

InnovationThere was a strong focus on continuous learning andimprovement at all levels within the practice. The practiceteam was forward thinking and part of local schemes toimprove outcomes for patients in the area such asproviding specialist minor surgery.

The practice had completed a high number of clinicalaudits with evidence to confirm that these were positivelyinfluencing and improving practice and outcomes forpatients.

Are services well-led?(for example, are they well-managed and do senior leaders listen, learnand take appropriate action)

Good –––


Dr N Pillai and Dr L NairRatingsOverall rating for this serviceAre services safe?Are services effective?Are services caring?Are services responsive to people’s needs?Are services well-led?

ContentsSummary of this inspectionDetailed findings from this inspection

Overall summaryLetter from the Chief Inspector of General PracticeProfessor Steve Field (CBE FRCP FFPH FRCGP)

The five questions we ask and what we foundAre services safe?Are services effective?Are services caring?Are services responsive to people’s needs?

Summary of findingsAre services well-led?The six population groups and what we foundOlder peoplePeople with long term conditionsFamilies, children and young peopleWorking age people (including those recently retired and students)

Summary of findingsPeople whose circumstances may make them vulnerablePeople experiencing poor mental health (including people with dementia)What people who use the service sayAreas for improvementAction the service SHOULD take to improve

Outstanding practice

Summary of findingsDr N Pillai and Dr L NairOur inspection teamBackground to Dr N Pillai and Dr L NairWhy we carried out this inspectionHow we carried out this inspectionOur findingsSafe track record and learningOverview of safety systems and processes

Are services safe?Arrangements to deal with emergencies and major incidentsOur findingsEffective needs assessmentManagement, monitoring and improving outcomes for people

Are services effective?Effective staffingCoordinating patient care and information sharingConsent to care and treatmentHealth promotion and preventionOur findingsRespect, dignity, compassion and empathyCare planning and involvement in decisions about care and treatment

Are services caring?Patient and carer support to cope emotionally with care and treatmentOur findingsResponding to and meeting people’s needsAccess to the service

Are services responsive to people’s needs?Listening and learning from concerns and complaintsOur findingsVision and strategyGovernance arrangementsLeadership, openness and transparencySeeking and acting on feedback from patients, the public and staffInnovation

Are services well-led?

Dr N Pillai and Dr L Nair NewApproachComprehensive Report...

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Transcript of Dr N Pillai and Dr L Nair NewApproachComprehensive Report...