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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 –––

CastlecrCastlecroftoft MedicMedicalal PrPracticacticeeQuality Report

Castlecroft AvenueCastlecroftWolverhamptonWest MidlandsWV3 8JNTel: 01902 761629Website: Castlecroftmedicalpractice.co.uk

Date of inspection visit: 12 December 2014Date of publication: 11/06/2015

1 Castlecroft Medical Practice Quality Report 11/06/2015

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 9

Areas for improvement 9

Outstanding practice 9

Detailed findings from this inspectionOur inspection team 10

Background to Castlecroft Medical Practice 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 a comprehensive inspection at CastlecroftMedical Practice on 12 December 2014. The practice isregistered with the Care Quality Commission to provideprimary care services to its local population. This is thereport of the findings from our inspection.

We have rated each section of our findings for each keyarea. The practice provided an effective, caring,responsive and well led service for the six populationgroups it served but required improvement to provide asafe service. The overall rating was good and this wasbecause the practice staff consistently strived to providea good standard of care for patients.

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.

• Infection prevention and control systems were wellmanaged and staff had received appropriate training.Lead roles had been assigned to manage infectioncontrol and staff were aware of who held the lead role.

• The practice was proactive in measuring andmonitoring risks to patients and services provided.Risks identified were discussed at practice meetingsand evidence was available to demonstrate thatnecessary action had been taken where risks wereidentified.

• Systems were in place to review the care needs ofthose patients with complex health needs or those invulnerable circumstances. Patient care co-ordinatorsat the practice made regular contact with thesepatients to help ensure that they attended routinehealth checks and immunisations.

• Patients said that the GPs listened to what they had tosay and treated them with compassion, dignity andrespect. Patients told us that they were involved intheir care and decisions about their treatment.

• Patients reported good access to the service; thosepatients who required an urgent appointment were

Summary of findings


given an appointment on the same day that theytelephoned. Those patients who were hard of hearingwere able to email requests for urgent appointments.Patients were able to book and cancel appointmentson-line, by telephone or by visiting the practice.

• The practice had good facilities and was well equippedto treat patients and meet their needs.

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

• The practice manager, business manager and GPpartners were responsible for monitoring and review ofsystems and practices with the aim of continuousimprovement. These management staff were aware ofareas that required improvement and had identifiedaction to be taken to address these issues.

• There was an open culture within the practice and staffwere actively encouraged to raise concerns andsuggestions for improvement. The practice philosophyand practice charter were available for patients. Thisdocument included information regarding access tothe service, waiting times and complaints. The practicehad a clear vision to deliver high quality care and goodoutcomes for patients. Staff demonstrated aperson-centred approach and through discussions itwas obvious that delivering high quality care to meetpatient’s needs was of paramount importance.

• There was an active Patient Participation Group (PPG)who met on a regular basis. The PPG reported anexcellent relationship with the practice and confirmedthat the practice listened and acted upon suggestionsmade by them. Learning events requested by the PPG,which related to the needs of the practice populationhad been organised. One PPG member had beeninvolved in the recent employment of the Businessmanager.

We saw the following areas of outstanding practice:

The practice provided a good range of nurse led clinicswhich supported the role of the GP. Patients with longterm conditions were allocated to patient care advisors.Patient care advisors were responsible for ensuring that arobust system of patient calling for long term conditionswas in place. Each member of the team had their own listof patients. Patients would be contacted by telephoneand then letter. A system of recording contacts andattempted contacts with patients had beenimplemented.

The practice encouraged membership of their PatientParticipation Group (PPG) through posters displayed inthe waiting room and information on their website. ThePPG met on a regular basis and received support withmeetings from practice staff who also attended thesemeetings. Educational events were organised by practicestaff for the PPG and recent events had included painmanagement, stroke and resuscitation training. Guestspeakers had been invited to talk about the local alcoholservices, a urology talk, eating disorders and dementia.Some of the guest speakers had been suggested by thePPG and some by the GP according to the needs of thepractice population. The PPG confirmed that they wereinformed and involved in any changes at the practice.One of the PPG members had been involved in the recentemployment of the Business Manager. PPG members hadbeen invited to meet candidates prior to their interviewand to give feedback to the practice manager and leadGP.

However, there were also areas where the practice shouldmake improvements.

• Ensure that recruitment processes are followed so thatinformation required under current legislation isobtained prior to employment.

• Ensure the appraisal system for nursing staff includespersonal development plans.

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 a safe service. Staffunderstand and fulfil their responsibilities to raise concerns, andreport incidents and near misses. Lessons are learned andcommunicated widely to support improvement. Information aboutsafety is recorded, monitored, appropriately reviewed andaddressed. Risks to patients are assessed and well managed. Thereare enough staff to keep people safe. However, at the time of ourinspection the practice had not followed their recruitment policy forone member of staff and had not undertaken criminal recordsbureau checks on all relevant staff.

Good –––

Are services effective?The practice is rated as good for providing an effective service. Datashows that patient outcomes are at or above average for the locality.National Institute for Health and Care Excellence (NICE guidance isreferenced and used routinely. Patient’s needs are assessed andcare is planned and delivered in line with current legislation. Thisincludes assessment of capacity and the promotion of good health.Staff have received training appropriate to their roles and furthertraining needs have been identified and planned. The practice canidentify all appraisals and the personal development plans for themajority of staff. Multidisciplinary working was evidenced.

Good –––

Are services caring?The practice is rated as good for providing a caring service. Datashows that patients rate the practice higher than others for severalaspects of care. Patients said they are treated with compassion,dignity and respect and they are involved in care and treatmentdecisions. Accessible information is provided to help patientsunderstand the care available to them. We also saw that stafftreated patients with kindness and respect ensuring confidentialitywas maintained.

Good –––

Are services responsive to people’s needs?The practice is rated as good for providing a responsive service. Thepractice reviews the needs of their local population and engageswith their Clinical Commissioning Group (CCG) to secure serviceimprovements where these are identified. Patients report goodaccess to the practice, a named GP and continuity of care, withurgent appointments available the same day. The practice has goodfacilities and is well equipped to treat patients and meet their needs.

Good –––

Summary of findings


There is an accessible complaints system with evidencedemonstrating that the practice responds quickly to issues raised.There is evidence of shared learning from complaints with staff andother stakeholders.

Are services well-led?The practice is rated as good for being well-led. The practice has aclear vision which has quality and safety as its top priority. Thestrategy to deliver this vision has been produced with stakeholdersand is regularly reviewed and discussed with staff. High standardsare promoted and owned by all practice staff with evidence of teamworking across all roles. Governance and performance managementarrangements are proactively reviewed and take account of currentmodels of best practice. The practice carried out proactivesuccession planning. We found there was a high level of constructivestaff engagement and a high level of staff satisfaction. The practicesought feedback from patients, which included using newtechnology, and they have a very active patient participation group(PPG).

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 the practice had good outcomes forconditions commonly found amongst older people The practiceoffered proactive, personalised care to meet the needs of the olderpeople in its population and had a range of enhanced services, forexample in dementia and end of life care. Care plans had beendeveloped for the patients at the practice with more complex needswith the aim of avoiding unplanned hospital admissions. All patientshad access to a named GP with those over the age of 75 beingspecifically informed of who this is. Extended opening hours wereprovided two nights per week to allow carers and relatives of olderpatients to gain access to the service. The practice was responsive tothe needs of older people, including offering home visits and rapidaccess appointments for those with enhanced needs. Home visitswere undertaken every day by all GPs on duty and the nursing teamprovided a home visit service on most days to support the serviceprovided by the local district nursing service and to provide longterm condition management and reviews.

Good –––

People with long term conditionsThe practice is rated as good for the population group of peoplewith long term conditions. All patients with long term conditionswere offered reviews appropriate to their condition and personalneeds. The reviews were undertaken by both GPs and nurses withthe recall system managed by the patient care advisor team toensure a patient centred robust approach to calling patients forfollow ups and reviews. Emergency processes were in place andreferrals made for patients in this group that had a suddendeterioration in health. When needed, longer appointments andhome visits were available. Patients who were housebound or livingin residential homes were visited by either a nurse or GP dependentupon their needs. All these patients had a named GP and structuredannual reviews to check their health and medication needs werebeing met. For those people with the most complex needs thenamed GP worked with relevant health and care professionals todeliver a multidisciplinary package of care. The practice wasworking closely with a diabetes consultant to improve overalloutcomes for diabetes patients whilst focussing on those withcomplex or uncontrolled symptoms.

Good –––

Summary of findings


Families, children and young peopleThe practice is rated as good for the population group of families,children and young people. The practice provided clinics for allchildhood immunisations and post natal mother and baby checks.There was an additional GP led child health clinic every Tuesdayafternoon and the local health visiting team visited the practice formother and child drop in once a week. Community midwives heldantenatal sessions twice a week. Systems were in place foridentifying and following-up children living in disadvantagedcircumstances and who were at risk. For example, children andyoung people who had a high number of A&E attendances.Immunisation rates were high for all standard childhoodimmunisations. For example, MMR vaccination rates for five year oldchildren were 92.5% compared to an average of 84.7% in the localCCG area and PCV Booster rates for the same age group were 96.3%compared to an average locally of 92.4%. Patients told us and wesaw evidence that children and young people were treated in an ageappropriate way and recognised as individuals. Appointments wereavailable outside of school hours and the premises were suitable forchildren and babies. We were provided with good examples of jointworking with midwives and health visitors. Emergency processeswere in place and referrals made for children and pregnant womenwho had a sudden deterioration in health. All practice staff receiveregular safeguarding training appropriate to their role.

Good –––

Working age people (including those recently retired andstudents)The practice is rated as good for the population group of theworking-age people (including those recently retired and students).The needs of the working age population, those recently retired andstudents had been identified and the practice had adjusted theservices it offered to ensure these were accessible, flexible andoffered continuity of care. Patients could book appointments andorder repeat medication on-line as well as being able to submitcomments and change personal details via the practice website. Thepractice was proactive in offering a full range of health promotionand screening which reflected the needs for this age group. Thepractice offered appointments until 8.00pm twice a week for bothGP and nurse. A number of patient group meetings were alsoscheduled in the evening to allow this population group to attend.

Good –––

People whose circumstances may make them vulnerableThe practice is rated as good for the population group of peoplewhose circumstances may make them vulnerable. The practice helda register of patients living in vulnerable circumstances includingthose with learning disabilities. The practice had carried out acomprehensive annual health check; part GP, part nurse for people

Good –––

Summary of findings


with learning disabilities, to ensure their health needs were met andall of these patients had received a follow-up. Appointments wereavailable for a variety of times to accommodate the booking needsof patients who may need help from relatives or carers. The practiceoffered longer appointments for people with learning disabilities.

The practice sign-posted vulnerable patients to various supportgroups and voluntary or community sector organisations. Staff knewhow to recognise signs of abuse in vulnerable adults and children.Staff were aware of their responsibilities regarding informationsharing, documentation of safeguarding concerns and how tocontact relevant agencies in and out of hours.

There were no barriers to access for any patients and a fullinterpreting service was available including British Sign Language(BSL).

People experiencing poor mental health (including peoplewith dementia)The practice is rated as good for the population group of peopleexperiencing poor mental health (including people with dementia).All patients with mental health problems were offered an annualreview including general healthy lifestyle advice from the nurses.Most of this patient group had a personalised care plan according totheir needs. The practice regularly worked with multi-disciplinaryteams in the case management of people experiencing poor mentalhealth including those with dementia.

The practice had sign-posted patients experiencing poor mentalhealth to various support groups and community and voluntarysector organisations including the local Healthy Minds Service.Patients were also signposted to a counsellor who was based at thepractice for one day every two weeks and the practice had goodlinks to the wider mental health service network provided by theBlack Country Partnership.

Good –––

Summary of findings


What people who use the service sayAs part of the inspection we sent the practice a box withcomment cards so that patients had the opportunity togive us feedback. We received eight completed commentcards and on the day of our inspection we spoke with fivepatients. All of the comments received were positive.Patients commented that staff were caring, the GP washelpful and the service was efficient. Patients spoken withon the day of inspection said that they received a goodquality of service provided by helpful, efficient and caringstaff.

The latest National GP Patient Survey completed in 2013showed patients were satisfied with the services thepractice offered. The results were mainly in line with

other GP practices nationally, and in some areas better.The practice were rated as among the best regarding theproportion of patients who would recommend their GPsurgery (88%) and the proportion of respondents whodescribed the overall experience of their GP surgery asgood or very good (92.8%). Patients also were satisfiedwith the opening hours (78%) and 86.2% of patients saidthat the last time they wanted to see or speak to a GP ornurse from their GP surgery they were able to get anappointment.

These results were based on 103 surveys that werereturned from a total of 253 sent out; a response rate of41%.

Areas for improvementAction the service SHOULD take to improve

• Ensure that recruitment processes are followed so thatinformation required under current legislation isobtained prior to employment.

• Ensure the appraisal system for nursing staff includespersonal development plans.

Outstanding practiceThe practice provided a good range of nurse led clinicswhich supported the role of the GP. Patients with longterm conditions were allocated to patient care advisors.Patient care advisors were responsible for ensuring that arobust system of patient calling for long term conditionswas in place. Each member of the team had their own listof patients. Patients would be contacted by telephoneand then letter. A system of recording contacts andattempted contacts with patients had beenimplemented.

The practice encouraged membership of their PatientParticipation Group (PPG) through posters displayed inthe waiting room and information on their website. ThePPG met on a regular basis and received support withmeetings from practice staff who also attended these

meetings. Educational events were organised by practicestaff for the PPG and recent events had included painmanagement, stroke and resuscitation training. Guestspeakers had been invited to talk about the local alcoholservices, a urology talk, eating disorders and dementia.Some of the guest speakers had been suggested by thePPG and some by the GP according to the needs of thepractice population. The PPG confirmed that they wereinformed and involved in any changes at the practice.One of the PPG members had been involved in the recentemployment of the Business Manager. PPG members hadbeen invited to meet candidates prior to their interviewand to give feedback to the practice manager and leadGP.

Summary of findings


Our inspection teamOur inspection team was led by:

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

Background to CastlecroftMedical PracticeCastlecroft Medical Practice was based in theWolverhampton Clinical Commissioning Group (CCG) Thepractice provided primary medical services toapproximately 12,100 patients in the local community. Thepopulation covered was predominantly white British.

The lead GP at the Castlecroft Medical Practice was presentduring our inspection. There were four male and threefemale GP partners in this medical practice. CastlecroftMedical Practice is a teaching practice and medicalstudents from Imperial College London spent part of theirtraining at the practice. We were told that during 2015 thepractice would also be training doctors to become GPs.Additional staff included a business manager, practicemanager, five female practice nurses and a female healthcare assistant. There were fourteen administrative staff thatsupported the practice.

The practice offered a range of clinics and servicesincluding, asthma, child health and development, diabetic,contraception and minor surgery.

The practice opening times were from 8:00am until 6.30pmMonday, Wednesday and Friday and extended openinghours were provided on a Tuesday and Thursday from

8:00am until 8:00pm. The practice had opted out ofproviding out-of-hours services to their own patients. Thisservice was provided by Primecare, an external out of hoursservice contracted by the CCG

Why we carried out thisinspectionWe inspected this service as part of our newcomprehensive inspection programme.

We 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 wasplanned 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.

This provider had not been inspected before and that waswhy we included them.

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?

CastlecrCastlecroftoft MedicMedicalal PrPracticacticeeDetailed findings


• 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• The working-age population and those recently retired

(including students)• People in vulnerable circumstances who may have poor

access to primary care• People experiencing poor mental health

Before visiting, we reviewed a range of information we holdabout the practice and asked other organisations to share

what they knew. We reviewed comment cards wherepatients and members of the public shared their views andexperiences of the service. We carried out an announcedvisit on 12 December 2014. During our visit we spoke with arange of staff including GPs, nurses, business manager,practice manager and administration staff and we spokewith patients who used the service. We also spent sometime observing how staff interacted with patients. Wespoke with a member of the Patient Participation Group(PPG) who told us their experience not only as a member ofthe PPG but also as a patient of the service. The PPG is away in which patients and the practice can work togetherto improve the service.

Detailed findings


Our findingsSafe Track Record

The practice used a range of information to identify risksand improve quality in relation to patient safety. Formsused to record significant events were detailed andrecorded any follow up action taken. We reviewed two ofthe significant events received within the last 12 months.We saw that these had been discussed at the weeklymeeting held by GPs at the practice and also at themonthly clinical staff meeting. We saw evidence todemonstrate that action had been taken as necessary, suchas staff training. Information seen demonstrated that thepractice had managed incidents, complaints andsignificant events consistently over time and so couldevidence a safe track record over the long term.

Staff we spoke to were aware of their responsibilities toraise concerns, and how to report incidents and nearmisses.

Learning and improvement from safety incidents

We spoke with the lead person responsible for recordingand reviewing significant events. We identified that thepractice had a system in place for reporting, recording andmonitoring significant events, incidents and accidents. Welooked at records of the significant events that hadoccurred during the last 12 months. A slot for significantevents was on the practice meeting agenda, informationdiscussed included a review of actions from past significantevents and complaints. There was evidence thatappropriate learning had taken place and that the findingswere disseminated to relevant staff. All staff spoken withincluding, administration and nursing staff, were aware ofthe system for raising issues and felt that they wereencouraged to do so. Staff confirmed that incidents,significant events and complaints were discussed atpractice meetings.

National patient safety alerts were received at the practicevia email. The practice manager confirmed that theyreviewed the information and cascaded the relevant safetyalerts to all staff, we saw that these were available on thepractice intranet. Safety alerts were also discussed at thepractice staff meetings to ensure all were aware of anyrelevant to the practice and where action needed to betaken.

Reliable safety systems and processes includingsafeguarding

The practice had systems to manage and review risks tochildren, young people and vulnerable adults. Practicetraining records made available to us showed that all staffhad received relevant role specific training on safeguarding.Staff were aware of their responsibilities regardinginformation sharing, documentation of safeguardingconcerns and how to contact the relevant agencies in andout of hours. Contact details for the relevant agencies wereeasily accessible on staff noticeboards around the practice.

The practice had a dedicated GP appointed as the lead insafeguarding vulnerable adults and children. All clinicalstaff had been trained to level 3 in safeguarding vulnerableadults and children and all administration staff had beentrained to basic level 1. All staff we spoke to were awarewho the safeguarding lead was and who to speak to in thepractice if they had a safeguarding concern.

We were told that there were no children registered at thepractice on the child protection register and no vulnerableadults subject to safeguarding referrals. However, staffconfirmed that there was a system to highlight vulnerablepatients on the practice’s electronic records which wouldbe used if required. The practice had a system foridentification and follow up for children and young peoplewith a high number of attendances at the Accident andEmergency department and for those families, children andyoung people who regularly did not attend appointments.Health visitors were available at the practice on a weeklybasis and we were told that GPs would share informationwith them as appropriate to assist in the protection ofvulnerable adults and children.

A GP at the practice undertook a weekly review of patientsbeing treated for drug and alcohol addiction. This helpedto monitor their recovery and keep these patients safe.

A chaperone could be present during intimateexaminations. This is a person who acts as a safeguard andwitness for a patient and health care professional during amedical examination or procedure. A chaperone policy wasin place and available to all staff via each computerdesktop. This recorded the duties and responsibilities of achaperone. Information about the availability ofchaperones was visible in consulting rooms and wasrecorded in the practice leaflet which was available to allpatients. Patients we spoke with confirmed that they had

Are services safe?

Good –––


been offered a chaperone. We saw training documentationto demonstrate that internal chaperone training had beenundertaken by all staff. We were told that clinical staff suchas nurses and the health care assistant would be calledupon initially to act as a chaperone; if these staff were notavailable a member of reception staff would be required toact as a chaperone. Staff spoken with understood theirresponsibilities when acting as chaperones includingwhere to stand to be able to observe the examination.There were no checks of criminal records with thedisclosure and barring service (DBS) for thoseadministration staff who also acted as a chaperone.Following our inspection we were told that DBSchecks would be undertaken on all staff and that thisprocess had already commenced.

Patient’s individual records were written and managed in away to help ensure safety. Records were kept on anelectronic system which collated all communicationsabout the patient including scanned copies ofcommunications from hospitals. We saw that hard copiesof letters and other information were scanned onto thesystem on the day it was received and forwarded to the GPfor action. We saw that there was no backlog of scanning,coding or follow up of electronic patient information.

Medicines Management

We checked medicines stored in the treatment rooms andmedicine refrigerators. There was a clear policy for ensuringmedicines were kept at the required temperatures whichincluded the action to take in the event of a possible ‘coldchain failure’. Staff spoken with were aware of and followedthis policy. Records were available to demonstrate thatvaccination fridge temperatures were monitored on a dailybasis; we saw that records were available from 2008.

Processes were in place to check medicines were withintheir expiry date and suitable for use. We saw that nursingstaff kept records to demonstrate this. Medicines checkedon the day were all within their expiry dates. We discussedthe storage of medication to be taken out by GPs on homevisits. We were told about the arrangements in place toensure secure storage and for ensuring that medicationwas within its use by date.

A stock rotation and control system was in place and wewere told that vaccines were ordered on an as neededbasis which helped to reduce the risk of overstocking.Expired and unwanted medicines were disposed of in linewith waste regulations.

All prescriptions were reviewed and signed by a GP beforethey were given to the patient. Blank prescription formswere handled in accordance with national guidance andthese were kept securely and a logging system had beenimplemented which kept a track of prescriptions used.

Electronic ordering of repeat prescriptions was introducedat the practice approximately six months ago. All staffconfirmed that they had undertaken training regarding this.We saw that there was a protocol for repeat prescribingwhich was in line with national guidance and was followedin practice. This helped to ensure that patient’s repeatprescriptions were still appropriate and necessary.

Medication policies were available to all staff as requiredon the practice’s intranet. We saw that the medicationpolicy had been reviewed during 2014.

We were told about the shared care arrangements in placewith the hospital for patients taking high risk medicines.Medicines initiated in hospital and prescribed forpotentially serious conditions often require specificmonitoring. At the time of discharge, and to enable thepatient to return home, the medicines may be the subjectof shared care guidelines requesting the transfer ofprescribing to a GP while the hospital consultant retainsoverall clinical care of the patient. We were told about thesystems in place to ensure that all necessary checks wereundertaken and for the repeat prescribing of medicationunder shared care arrangements.

Cleanliness & Infection Control

Patients we spoke with told us they always found thepractice clean and had no concerns about cleanliness orinfection control. We observed the premises to be visiblyclean and tidy. An external cleaning company wereresponsible for cleaning the premises. We saw that therewere cleaning schedules in place and cleaning recordswere kept. We also saw that cleaning audits had beencompleted. The practice manager was able to raise anyissues regarding the cleanliness of the practice with thecleaning supervisor.

Are services safe?

Good –––


The practice manager and head nurse were the leads forinfection control. Records seen confirmed that they hadundertaken further training to enable them to provideadvice on the practice infection control policy and carry outstaff training. We saw evidence that the infectionprevention and control lead had carried out an audit inFebruary 2014 with a separate audit being undertaken forthe room used to undertake minor surgery. Recordsshowed that any improvements identified were completed,for example the replacement of chairs which had clothcovered seats in treatment rooms.

An infection control policy and supporting procedures wereavailable for staff to refer to. Infection control measures inplace included use of personal protective equipment (PPE)such as disposable gloves, aprons and coverings, use ofspill kits and clearly labelled sharps bins.

Blood or bodily fluids such as vomit or urine could generatespills and as such need to be treated to reduce thepotential for spread of infection with patients, staff or othervisitors. We saw that spill kits were available in clinicalareas and in the reception. Staff were aware where spill kitswere stored and when they should be used. This wouldhelp to ensure that any potentially infectious substanceswere attended to by staff in a timely and effective manner.

All staff had received infection control training specific totheir role including hand hygiene training.

A hand hygiene audit and guidance was available whichenabled staff to self-assess their hand hygiene practices.Hand hygiene techniques signage was displayed in staffand patient toilets. Hand washing sinks with hand soap,hand gel and hand towel dispensers were available intreatment rooms.

We were told that all clinical staff were up to date withrelevant immunisations and we saw records to confirm this.

We saw that clinical waste was stored appropriately in alocked room with no public access.

Systems were in place regarding the management, testingand investigation of legionella (a germ found in theenvironment which can contaminate water systems inbuildings). We saw records that confirmed the practice wascarrying out regular checks such as testing of water andflushing taps that were not used on a daily basis in order to

reduce the risk of infection to staff and patients. We did notsee a copy of the original risk assessment undertaken as wewere told that the landlord of the building held thisinformation.

Equipment

We saw records to confirm that all portable electricalequipment and fire fighting equipment was routinelytested. Fire fighting equipment checks were next due in2015. Portable electrical appliances and equipmentdisplayed stickers indicating the last testing date. Aschedule of testing was in place. We saw evidence ofcalibration of relevant equipment; for example weighingscales and the fridge thermometer.

We were told about recent problems with anElectrocardiogram machine (ECG) which was caused by achange to the provider’s computer package. An ECGrecords the electrical activity of the heart and can be usedto help find the cause of symptoms such as palpitations orchest pain. A representative from the patient participationgroup confirmed that they were fund raising to try andpurchase an additional ECG machine.

Staff we spoke with told us that the equipment they usedwas well maintained and they felt that they had sufficientequipment to enable them to carry out diagnosticexaminations, assessments and treatments.

Staffing & Recruitment

There were no staff vacancies at the practice although wewere told about two future vacancies due to staffretirement. We were told about the succession plans inplace regarding these staff and the forward thinking thathad taken place in order to provide additional support tothe GPs. We saw that there was a low staff turnover with themajority of staff having worked at the practice for manyyears.

We looked at the recruitment information for the two mostrecently employed staff. Records we looked at containedevidence that some recruitment checks had beenundertaken prior to employment. For example, proof ofidentification, qualifications, registration with theappropriate professional body and criminal records checksvia the Disclosure and Barring Service (DBS). The practicehad a recruitment policy which had recently beenimplemented and which set out the standards it shouldfollow when recruiting clinical and non-clinical staff. We

Are services safe?

Good –––


discussed DBS checks with the business manager and weretold that those clinical staff who had been employed at thepractice for many years had not had a DBS checkundertaken. We were told that two nursing and one healthcare assistant did not have any form of criminal recordscheck undertaken. We were also informed that thoseadministration staff who undertook chaperone duties didnot all have a DBS check. Following our inspection wereceived confirmation that the process of checking criminalrecords (DBS checks) had been completed for the clinicalstaff and DBS checks had been requested for threeadministrative staff. We were told that the practice werebeginning a programme of undertaking DBS checks for allexisting employees including administration staff whoacted as a chaperone. The practice had completed a riskassessment for those administrative staff that had not asyet undertaken a DBS check.

We saw that there was no written references for onemember of administration staff recently employed. Wewere told that this member of staff was known to other staffemployed at the practice and had not previously been infull time employment; having recently left education. Thebusiness manager confirmed that character referenceswould be sought in the future if potential staff had notbeen in employment.

We were told about the systems in place to ensure that thepractice was sufficiently staffed at all times includingduring annual leave, sick leave or staff training.Administration staff spoken with said that the majority ofstaff were trained to undertake each other’s job roles whichwas beneficial when a member of staff was on leave. Allstaff would be expected to cover each other’s annual leave.We were told that there were usually enough staff tomaintain the smooth running of the practice and to ensurepatients were kept safe. We were shown a copy of theadministration staff duty rota which recorded the names ofstaff on duty and their responsibilities for the day. Thishelped to ensure that all duties were covered on a day today basis.

We saw that relevant checks were completed to ensureclinical staff were up to date with their professionalregistration, for example nurses were registered with theNursing and Midwifery Council (NMC). The NMC was set upto protect the public by ensuring that nurses and midwivesprovide high standards of care to their patients and clients.The practice also kept a record to demonstrate that GPs

were registered on the performers list which demonstratesthat GPs were up to date with their appraisal andrevalidation. Every GP is appraised annually and every fiveyears undertakes a fuller assessment called revalidation.Only when revalidation has been confirmed by the GeneralMedical Council can the GP continue to practice andremain on the performers list with NHS England.

The practice used a locum GP on a regular basis. Recordsdemonstrated that sufficient checks had been undertakento demonstrate that the locum was suitable to work at thepractice. This included written references, DBS checks,training information and evidence that the locum was onthe performers list. We were told that other locums wereoccasionally used. We saw records to demonstrate thatsufficient checks had been undertaken.

Monitoring Safety & Responding to Risk

The practice had systems, processes and policies in placeto manage and monitor risks to patients, staff and visitorsto the practice. These included annual and monthly checksof the building, the environment, medicines management,staffing, dealing with emergencies and equipment. Thepractice also had a health and safety policy. Health andsafety information was displayed for staff to see and therewas an identified health and safety representative. We sawthat risk assessments had been undertaken following anaccident at the practice, this resulted in the provision of allnew seating in waiting areas.

An environmental risk had been undertaken. Each risk wasassessed, rated and mitigating actions recorded to reduceand manage the risk, for example the replacement ofcarpet to stairs. We saw that any risks were discussed atGP’s weekly meetings and other staff meetings.

A disability discrimination act risk assessment had beenundertaken which included assessing wheelchair access,sound and visual systems for hearing and visually impairedpatients at the practice. We saw that actions required wererecorded. Other risk assessments completed included alegionella risk assessment and control of substanceshazardous to health (COSHH) which had been completedby the company who undertook cleaning of the practice.

Arrangements to deal with emergencies and majorincidents

The practice had arrangements in place to manageemergencies. We saw records showing all staff had received

Are services safe?

Good –––


training in basic life support. Emergency equipment wasavailable including access to oxygen and an automatedexternal defibrillator (AED) which is used to attempt torestart a person’s heart in an emergency. All staff askedknew the location of this equipment and records we sawconfirmed these were checked regularly.

Emergency medicines were available in a secure area of thepractice and all staff knew of their location. These includedthose for the treatment of cardiac arrest, anaphylaxis andhypoglycaemia. Processes were also in place to checkemergency medicines were within their expiry date andsuitable for use. All the medicines we checked were in dateand fit for use.

A business continuity plan was in place to deal with a rangeof emergencies that may impact on the daily operation of

the practice. The plan covered both short and long termloss of premises, facilities, systems or staffing. Each risk wasrecorded and mitigating actions detailed to reduce andmanage the risk. Risks identified included power failure,unplanned absence of staff and computer system failure.The document also contained relevant contact details forstaff to refer to. We were told about an informalarrangement with a nearby practice for short term use oftheir facilities or if these premises were not availablealternative arrangements were in place.

A fire risk assessment had been undertaken that includedactions required to maintain fire safety. We saw recordsthat showed staff had completed fire training and that a firedrill had taken place recently.

Are services safe?

Good –––


Our findingsEffective needs assessment

The GPs and nursing staff we spoke with were familiar withcurrent best practice guidance; accessing guidelines fromthe National Institute for Health and Care Excellence (NICE).We were given examples of instances where NICEguidelines had been referred to and acted upon, forexample blood pressure monitoring of those patients withhypertension. We were told that regular monitoring tookplace until it was agreed that the patient was able to attendnurse led clinics. We saw that clinical audits had beencompleted using NICE guidelines and criteria.

Vulnerable patients, those with long term conditions andpatients over 75 years old were assessed and care plansgenerated to enable increased monitoring and follow up ofpatients.

The practice held a register of patients with learningdisabilities and care plans were in place. Care plans inplace for patients with complex mental health need werereviewed at least quarterly, if the patient was taking arepeat medication for mental health needs the care planwould be reviewed as required, this may include a weeklyreview.

The practice followed the Royal College of General Practiceguidance and completed annual health checks for patientswith learning disabilities, including an annual thyroid testfor patients with Down’s syndrome.

Systems were in place to ensure that patients sufferingfrom long term conditions had their care needs reviewed asrequired. Patient care advisors were employed at thepractice with the responsibility for ensuring that thesepatients attended relevant health checks andimmunisations. The practice’s prescribing policy ensuredthat those patients who were taking regular medicationhad this reviewed regularly and therefore saw a GP.

Two practice nurses had undertaken a university courseregarding diabetes to further enhance the service providedto patients with this condition at the practice.

Systems were in place to ensure that the initialappointment of a pregnant patient would be with the GP.This helped to ensure that all pre-existing health conditions

and prescriptions were reviewed; the GP confirmed thatthey would liaise with other services such as the midwife asappropriate to ensure that all care needs were consideredand acted upon.

The practice was undertaking an enhanced service toreduce unnecessary emergency admissions to secondarycare. GP practices can opt to provide additional servicesknown as enhanced services that are not part of the normalGP contract. By providing these services, GPs can help toreduce the impact on secondary care and expand therange of services to meet local need and improveconvenience and choice for patients. The focus of thisenhanced service was to optimise coordinated care for themost vulnerable patients to best manage them at home.These patient groups included vulnerable, older patients,patients needing end of life care and patients who were atrisk of unplanned admission to hospital. A minimum of 2%of the practice's adult population (aged 18 and older),should be identified and case managed proactively.

We saw that discussions were held regarding patients whoattended the accident and emergency department andpatients discharged from hospital at the monthly clinicalmeetings. This helped to ensure that unplannedadmissions and re-admissions to hospital were regularlyreviewed enabling improvements to services to beidentified and discussed.

We saw no evidence of discrimination when making careand treatment decisions. Interviews with GPs showed thatthe culture in the practice was that patients were referredon need and that age, sex and race was not taken intoaccount in this decision-making.

Management, monitoring and improving outcomes forpeople

The practice had completed a number of clinical audits, forexample Chronic Obstructive Pulmonary Disease (COPD)management, an audit of thiamine prescribing in patientswith excess alcohol intake and an audit of type twodiabetes mellitus screening in polycystic ovary syndromepatients with additional risk factors. We saw that the COPDaudit had initially been completed in 2012 and a re-auditconducted in 2014. The practice was able to demonstratechanges resulting since the initial audit which had resultedin them fully meeting NICE guidance criteria for theoptimum management of COPD. Conclusions were

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

Good –––


recorded for other audits and lessons learnt disseminatedamongst all GPs with details of action to be taken. Auditswere also undertaken by the CCG prescribing advisor andchanges made to practice as required.

The practice also used the information they collected forthe Quality and Outcomes Framework QOF and theirperformance against national screening programmes tomonitor outcomes for patients. To date the practice hadreached a 91.7% achievement against QOF targets QOFachievement targets run from April until March each year.(QOF is a voluntary incentive scheme for GP practices in theUK. The scheme financially rewards practices for managingsome of the most common long-term conditions and forthe implementation of preventative measures).

Staff regularly checked that all routine health checks werecompleted for long-term conditions such as diabetes andthe latest prescribing guidance was being used. Patientcare advisors were responsible for making contact withpatients with long term conditions and arranging relevantappointments for immunisations and health checks.

Minor surgery was completed at this practice. We were toldthat three of the GPs at the practice undertook this and hadundertaken appropriate training. Records were available todemonstrate that additional infection control audits wereundertaken in the minor surgery room to ensure infectioncontrol standards were met.

Effective staffing

Practice staffing included medical, nursing, managerial andadministrative staff. A good skill mix was noted amongstthe doctors with GPs having additional diplomas orspecialist interests in diabetes, dermatology, sexual andreproductive medicine and minor surgery.

We were told by the business manager that annualappraisals were completed for all staff and we saw recordsto confirm this. Appraisal of nursing staff had beenidentified by the practice as an area for improvement. Thenursing staff appraisal records that we saw did not recordidentified learning needs and there were no personaldevelopment plans in place. We were told that a newappraisal system had been introduced for administrationstaff and this was to be rolled out for clinical staff within thenear future. We will review this at our next inspection of the

practice. Staff that we spoke with confirmed that they werewell supported, could speak to management at any timeand were offered or could suggest training courses thatthey wished to attend.

Staff interviews confirmed that the practice was proactivein providing training and funding for relevant courses. Wesaw training certificates to demonstrate that staff hadundertaken recent mandatory training such as manualhandling, fire safety, infection control and basic lifesupport. A training matrix had been developed whichrecorded all staff training completed. We saw that themajority of staff had completed safeguarding vulnerableadults and children training and times were beingallocated for the remaining staff to complete e learning.Additional training had been undertaken by staff that hadlead roles, for example the practice manager and practicenurse had undertaken additional training to be thenominated infection control leads.

We were told about the systems in place to review theperformance of locums who had worked at the practicewhich also helped to ensure that patients were kept safe.

Practice nurses had defined duties they were expected toperform and were able to demonstrate they were trained tofulfil these duties. Those with extended roles, for exampleseeing patients with long-term conditions such as asthma,COPD, and diabetes were also able to demonstrate theyhad appropriate training to fulfil these roles.

Working with colleagues and other services

The practice worked with other service providers to meetpeople’s needs and manage complex cases. Blood results,X ray results, letters from the local hospital includingdischarge summaries, out of hours providers and the 111service were received both electronically and by post. Thepractice had a policy outlining the responsibilities ofrelevant staff in passing on, reading and taking action onany issues arising from communications with other careproviders on the day they were received. All staff we spokewith understood their roles and felt the system in placeworked well. We saw that there was no backlog ofinformation to be scanned on to the computer or to beactioned.

As well as the GP and nursing services provided at thepractice, other services were available which wereintroduced in response to population needs. Health visitorsheld regular clinics at the practice and were also involved,


Good –––


along with practice staff in assessing, planning anddelivering patients care and treatment. Phlebotomyservices were available as well as a counselling service,Healthy Minds and midwifery services. Healthy Minds is apsychological therapy service for people who areexperiencing common mental health problems such asdepression, anxiety and stress.

The practice held monthly multidisciplinary team meetingsto discuss patients with complex care needs, for examplethose patients with end of life care needs. These meetingswere attended by district nurses and community matrons.The practice’s Gold Standards Framework (GSF) registerwas updated following these meetings. Staff felt thissystem worked well and remarked on the usefulness of theforum as a means of sharing important information. Wesaw the minutes of the monthly clinical staff meetings.Both health visitors and midwives were invited to attendthese meetings to share information as required.

We were told about the systems in place to refer patientsfor community services. Staff told us about theWolverhampton urgent care triage and access service(WUCTAS) which gave access to community services suchas the falls prevention team, district nurses and hospital athome. This helped to ensure that patients had easy accessto the care that they required.

The GP told us that they referred children and youngpeople to local services such as the child and adolescentmental health service (CAMHS) and Base 25 who providesupport for people in Wolverhampton aged 11 – 25. Base 25is a young person information and advice centre offering adaily drop in service and provides, for example counsellingand Improving Access to Psychological Therapies (IAPT).IAPT is a national NHS programme increasing theavailability of services across England offering treatmentsfor people with depression and anxiety disorders.

With effect from 1 December a new community outpatientservice for dermatology was being hosted at the practicewho provided rooms and a reception service.

Information Sharing

The practice used several electronic systems tocommunicate with other providers. For example, there wasa shared system with the local out of hours provider toenable patient data to be shared in a secure and timelymanner. Electronic systems were also in place for makingreferrals, and the practice used the Choose and Book

system. (The Choose and Book system enabled patients tochoose which hospital they would be seen in and to booktheir own outpatient appointments in discussion with theirchosen hospital). Staff reported that this system was easyto use.

For emergency patients, there was a practice policy ofproviding a printed copy of a summary record for thepatient to take with them to A&E. The practice also hassigned up to the electronic Summary Care Record and hadplans to have this fully operational by 2015. Summary CareRecords provide healthcare staff treating patients in anemergency or out-of-hours with faster access to key clinicalinformation.

The practice had systems in place to provide staff with theinformation they needed. An electronic patient recordsystem was used by all staff to coordinate, document andmanage patients’ care. All staff were fully trained on thesystem, and commented positively about the system’ssafety and ease of use. This software enabled scannedpaper communications, such as those from hospital, to besaved in the system for future reference.

Consent to care and treatment

We found that staff were aware of the Mental Capacity Act2005 and their duties in fulfilling it. The GP we spoke withstated that clinical staff had received training regarding theMental Capacity Act and a practice nurse spoken withconfirmed this.

Clinical staff that we spoke with demonstrated a clearunderstanding of Gillick competencies. These helpclinicians to identify children aged under 16 who have thelegal capacity to consent to medical examination andtreatment.

The practice had enrolled for a dementia enhanced service.This helped to ensure the timely assessment of patientswho may be at risk of dementia. We were told that patientswith learning disabilities and those with dementia weresupported to make decisions through the use of care planswhich they were involved in agreeing. These care planswere reviewed annually or more frequently if changes inclinical circumstances dictated it. Advance care planningdecisions for patients with dementia would be recorded intheir care plans in line with the their wishes. We saw that allcare plans for patients with learning disabilities had beenreviewed within the last year.


Good –––


There was a practice policy for documenting consent forspecific interventions. For example, written consent for allminor surgical procedures. Details of all consent, including,a patient’s verbal consent was documented in theelectronic patient notes with a record of the relevant risks,benefits and complications of the procedure. We were toldabout an audit which was undertaken in 2011 regardinghow satisfied patients were with consent processes andexplanations given regarding treatment. The GP told usthat they were going to repeat this audit in the near futureto identify any improvements.

The majority of patients registered at the practice wereable to communicate in English; however translationservices were available if required. The British signlanguage service was used for those patients who werehard of hearing if applicable. This helped to ensure that allpatients were aware of their treatment options and gaveconsent upon full receipt and understanding ofinformation.

Health Promotion & Prevention

The practice offered various health promotion andprevention services and was able to signpost patients toother available services. An in-house weight managementservice was provided and patients could also be referred toweight watchers. The practice had also identified thesmoking status of 78% of patients over the age of 16 andactively offered nurse led smoking cessation clinics tothese patients.

All new patients registering with the practice were offered ahealth check with the health care assistant. The GP wasinformed of all health concerns detected and these werefollowed-up in a timely manner. NHS Health Checks wereoffered to all patients aged 40-75. Practice data showedthat a third of patients registered at the practice in this agegroup took up the offer of the health check during the lastquarter. There was a policy to offer telephone reminders forpatients who did not attend for NHS Health Checks andpractice nurses were responsible for following-up patientswho did not attend screening

The practice had numerous ways of identifying patientswho needed additional support, and were pro-active inoffering additional help. For example, the practice kept a

register of all patients with learning disabilities and practicerecords showed that all of these patients had been offeredand received an annual physical health check within thelast 12 months.

The practice offered a full range of immunisations forchildren, travel vaccines including yellow fever, shinglesand flu vaccinations in line with current national guidance.Systems were in place to follow up patients who do notattend appointments and to remind at risk patients of theavailability of vaccination programmes. These systems hadresulted in a high achievement against targets.

A GP at the practice had a particular interest in sexualhealth and completed sexual health assessments duringnormal clinic time. Patients would be signposted torelevant services as needed including genitourinarymedicine.

We saw that waiting areas contained well-keptnoticeboards with relevant up to date information, forexample regarding bereavement support, healthpromotion flu and carers services. Leaflets were availablefor teenagers to promote youth friendly services. We weretold that a carer’s support representative regularlyattended the surgery and talked to patients and to the PPG.We saw that the practice held a carers register. Staff spokenwith told us how this information was used to offer carersextra support, flexibility with appointments or to ensurevaccinations were offered to try to keep them healthy.

The practice’s performance for cervical smear uptake was82% which was in line with the national average. There wasa policy to offer telephone reminders for patients who didnot attend for cervical smears and practice nurses wereresponsible for following-up patients who did not attendscreening.

The practice’s website provided health promotion andself-help information. A link to the NHS Choices website forspecific conditions was available or an information leafletcould be downloaded. Information was available regardinga range of topics such as head lice, coughs, hay fever andheadache. The website also signposted patients to variousmental health and carers support services such as YoungMinds, Mind, Carers Direct and Wolverhampton Carers. Thishelped patients access relevant support groups and


Good –––


services. There was a short video on the practice websiteabout caring and the website signposted people to Carerssupport groups and requested patients who are carers toinform the doctor at their appointment.


Good –––


Our findingsRespect, Dignity, Compassion & Empathy

We reviewed the most recent data available for the practiceon patient satisfaction. This included information from thenational patient survey and a survey of 183 patientsundertaken by the practice’s Patient Participation Group(PPG). The evidence from both of these sources showedpatients were satisfied with the service provided, 96% ofrespondents to the PPG survey rated the practice asexcellent or good regarding the “overall experience” and96% would recommend the practice to someone movinginto the area. Data from the national patient survey showedthe practice was rated ‘among the best’ for patients ratingthe practice as good or very good. Patients spoken with onthe day stated that all of the staff at the practice treatedthem with respect.

Both male and female GPs were available at this practiceand we were told that patients were offered anappointment with a clinician of the same sex asthemselves. Where patients did not express a preference, achaperone was offered if an intimate examination wasrequired. Patients we spoke with on the day confirmed thatthey had been offered a chaperone as required. We sawrecords and staff spoken with confirmed that they hadundertaken equality and diversity training and this was alsodiscussed regularly during practice meetings. In-housetraining was provided to staff on how to dealsympathetically with all people who use services. Staff toldus that dealing with patients in a caring and sympatheticmanner is embedded in the culture of the practice and staffwould be reminded of this if found to be actinginappropriately.

Patients completed CQC comment cards to provide us withfeedback on the practice. We received eight completedcards and all were extremely positive about the serviceexperienced. Patients said they felt the practice offered anoutstanding service, GPs were responsive and clear in theiradvice and all staff were friendly, efficient and caring. Theysaid staff treated them with dignity and respect. We alsospoke with five patients on the day of our inspection. Alltold us that the practice provided good care and said theirdignity and privacy was respected.

Staff and patients told us that all consultations andtreatments were carried out in the privacy of a consulting

room. Disposable curtains were provided in consultingrooms and treatment rooms so that patients’ privacy anddignity was maintained during examinations, investigationsand treatments. We noted that consultation / treatmentroom doors were closed during consultations and thatconversations taking place in these rooms could not beoverheard.

We observed staff were careful to follow the practice’sconfidentiality policy in order that confidential informationwas kept private. Patients that we spoke with were awarethat they should stand behind the barrier and only onepatient at a time was allowed to approach the receptiondesk. The waiting area was located away from thereception area and further shielded from the conversationstaking place at the reception by a glass partition’. Thetelevision was playing which also prevented patientsoverhearing potentially private conversations betweenpatients and reception staff. We saw this system inoperation during our inspection and noted that it enabledconfidentiality to be maintained. On the day of inspectionwe spoke with patients in a private room at the back of thereception. Administration staff confirmed that they alsoused this room to speak with patients in private if requiredor requested.

Care planning and involvement in decisions aboutcare and treatment

Patients we spoke to on the day of our inspection told usthat health issues were discussed with them and they feltinvolved in decision making about the care and treatmentthey received. They also told us they felt listened to andsupported by staff and had sufficient time duringconsultations to make an informed decision about thechoice of treatment they wished to receive. Patientfeedback on the comment cards we received was alsopositive and aligned with these views. Patients recordedthat GPs were understanding, listened and gave clearadvice. The practice was rated highly for the GPs, nursesand reception staff as being polite, courteous and listeningto patients.

Staff told us that translation and sign language serviceswere available for patients who did not have English as afirst language or for those patients who were hard ofhearing. The practice website could be translated into 80

Are services caring?

Good –––


different languages. British Sign Language interpreterswere made available for those who were hard of hearing.This helped to ensure that people were aware of andinvolved in decisions about their care.

We saw that personalised care plans were in place forpatients with a view to avoiding unnecessary hospitaladmissions. In addition care plans for those patients withlearning disability or those with complex mental healthneeds were available. These were reviewed on at least aquarterly basis. All patients with long term conditions suchas chronic obstructive pulmonary disease (COPD), diabetesor asthma were invited to attend an annual review of theircondition. Any medication these patients were taking wasreviewed so that patients were on the most appropriatemedication for their condition.

There was a palliative care register to help optimise qualityof life for patients and their families via the use of symptomcontrol and good supportive care.

We saw information leaflets in the waiting area. Theinformation included details of advocates, groups andagencies to contact should patients require advice andsupport. Further information about support agencies wasavailable on the practice website.

Patient/carer support to cope emotionally with careand treatment

The patients we spoke to on the day of our inspection andthe comment cards we received showed that patients werepositive about the emotional support provided by thepractice. During our inspection we observed staff to becaring and compassionate.

We were told that GPs assess those with long termconditions and multi-morbidities for anxiety anddepression as part of routine reviews. This helped to ensurethat patient’s emotional and physical health was keptunder review.

Notices in the patient waiting room, on the TV screen andpatient website also signposted people to a number ofsupport groups and organisations. The practice’s computersystem alerted GPs if a patient was also a carer. We wereshown the written information available for carers toensure they understood the various avenues of supportavailable to them. Good support was available to carers.

Nursing staff had received additional training regarding endof life care and bereavement support. The practice websiteguided patients what to do “in times of bereavement”, forexample registering the death and contacting a funeraldirector. We were told that GPs would make a telephonecall or a visit to a patient who had recently been bereaved.Patients would also be signposted to other supportagencies as appropriate. We saw that informationregarding bereavement services was detailed on the carer’snoticeboard in the practice.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needs

We found the practice was responsive to people’s needsand had systems in place to maintain the level of serviceprovided. The needs of the practice population wereunderstood and systems were in place to addressidentified needs. Flexibility in appointment booking, textreminders, availability of a named GP and on sitephlebotomy services all helped to ensure that the needs ofthose patients with enduring mental illness wereaccommodated at the practice. Systems were in place forpicking up alerts received from the clinical commissioninggroup (CCG) for example regarding drug users and missingpersons. Alerts were placed on the practice’s computersystem to flag patients who may display challengingbehaviours to make staff aware of possible conflictsituations.

The practice provided a good range of nurse led clinicswhich supported the role of the GP. We saw from theminutes of practice meetings that patients with long termconditions were allocated to patient care advisors. We weretold that the role of the patient care advisor was anenhancement of the traditional medical receptionist roleand had the additional responsibility of ensuring a robustsystem of patient calling for long term conditions. Eachmember of the team had their own list of patients. Patientswould be contacted by telephone and then letter. A systemof recording contacts and attempted contacts with patientshad been implemented. Patient care advisors that wespoke with told us that they had built up a goodrelationship with those patients on ‘their list’ and thesepatients were aware who they should contact if they hadany queries.

There had been very little turnover of staff during the lastthree years which enabled good continuity of care andaccessibility to appointments with a GP of choice. Longerappointments were available for people who needed themand those with long term conditions. This also includedappointments with a named GP or nurse. Home visits werecompleted by GPs and practice nurses. Practice nurses wespoke with told us that they completed diabetic checks,spirometry, dressings and staple removal post surgery attheir home visits.

The practice had implemented suggestions forimprovements and made changes to the way it deliveredservices as a consequence of feedback from patients andthe Patient Participation Group (PPG). We were told thatstaff rotas and duties had been changed to ensure thatmore staff were available to answer the telephones at peaktimes and a new telephone system had been put in placeto allow efficient call queuing and distribution of callsbetween staff.

The practice had a palliative care register and had regularinternal as well as multidisciplinary meetings to discusspatient and their families care and support needs.

Tackle inequity and promote equality

The practice had recognised the needs of different groupsin the planning of its services. The premises and serviceshad been adapted to meet the needs of people withdisabilities. The building and treatment rooms could beaccessed by patients using wheelchairs or mobilityscooters. This building had been assessed as beingdisability discrimination act compliant . A lift providedaccess to all areas of the service and disabled toilets wereavailable.

Patients are able to book appointments on line, bytelephone or in person at the surgery. Those people whoare hard of hearing are able to book urgent appointmentsby email. Extended opening hours were provided on aTuesday and Thursday evening until 8pm. This helpedthose patients with work commitments access the service.Longer appointment times were given to those patientswho requested this or for those who the reception staff feltwould require a longer appointment time.

The practice had access to online and telephonetranslation services. In addition to this the practice websitegave a link to the Department of Health website fact sheetswhich had been written to explain the role of the UK healthservices, the NHS, to newly-arrived individuals seekingasylum. They covered a variety of issues such as how toregister with a GP and how to access emergency services.

The practice also offered online services for appointmentsand repeat prescription. Patients could speak with the GPover the telephone if they were unable to attend thepractice, for example due to work commitments. Changeshad recently been made to the appointment systems toenable easier access to appointments for patients.

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

Good –––


Access to the service

Appointments were available from 8:30 am to 6:30 pm onMonday, Wednesday and Friday. Extended opening hourswere available on a Tuesday and Thursday until 8pm whichwere particularly useful to patients with workcommitments. The practice used a scheme calledAdvanced Access and were able to offer same day and nextday appointments as well as advance booking up to sixweeks in advance. Patients were advised of this in thepractice leaflet and on the practice website.

Comprehensive information was available to patientsabout appointments on the practice website. Patients wereable to book and cancel appointments through the websiteand order repeat prescriptions. Patients could have textreminders of their appointment and the websiteencouraged patients to inform staff if they wished toreceive this service and to ensure that their contact detailswere up to date. Patients were advised that there was a freeapp to download to allow easy access to online bookingand repeat prescription services. Information was availableregarding arranging urgent appointments, home visits ordiscussing queries with the patient’s usual doctor over thetelephone. When the practice was closed there was ananswerphone message giving the telephone number thatthey should ring depending on the circumstances. Thewebsite and practice leaflet also gave information whichguided patients to use the NHS 111 service or to dial 999 inan emergency. Details of the nearest NHS Walk In Centreswere also recorded on the practice leaflet.

Patients were satisfied with the appointments system. Theyconfirmed that they could see a doctor on the same day ifthey needed to and they could see another doctor if therewas a wait to see the doctor of their choice. One patient wespoke with told us that they had telephoned in the morningfor an urgent appointment and had been offered a morningor afternoon appointment.

Castlecroft Medical Practice is located in a purpose builtmedical centre. An automatic front entrance door isprovided which is suitable for wheelchair users. Twowaiting areas were available; one on the ground and oneon the first floor of the building. Lift access enabledpatients to access all areas. Disabled toilets were providedon both floors. The practice had wide corridors and we

were told that all areas were accessible for the use ofpatients with wheelchairs or mobility scooters. This mademovement around the practice easier and helped tomaintain patients’ independence.

Following monitoring of the availability of appointments,changes were made to the booking system we were toldthat further monitoring would be undertaken to review thechanges made.

We were told that students were able to register at thepractice as a temporary patient outside of term time.

Listening and learning from concerns and complaints

The practice had a system in place for handling complaintsand concerns. Their complaints policy and procedureswere in line with recognised guidance and contractualobligations for GPs in England. The practice manager wasthe designated lead and handled all complaints in thepractice. Administration staff spoken with were aware oftheir role in handling complaints and confirmed thatcomplaints leaflets were available. We were told that theyhad been trained to deal with difficult situations. Staff saidthat meetings could be arranged with the complainant andthe practice manager or a GP.

We saw that information was available to help patientsunderstand the complaints system this includedinformation on the practice website which guided patientsto speak with the practice manager if they had anyconcerns. Patient Advice and Liaison Services (PALS)contact details were provided in the practice leaflet. PALSprovide information, advice and support to patients, theirfamilies and carers. Information regarding who the patientcan go to if they were unhappy with the outcome of theircomplaint investigation was included in letters sent tocomplainants.

We looked at a sample of complaints. Complaintsinvestigation records demonstrated that relevant staff andpeople who used the services were involved in anyinvestigation as relevant. The complaints registercontained detailed outcomes and action points. We foundthat the outcome of any complaint was explainedappropriately to the complainant.

Patients we spoke with were aware of the process to followshould they wish to make a complaint. None of the patientsspoken with had needed to make a complaint about thepractice.


Good –––


We looked at the summary of six complaints received in thelast twelve months. The summary information recordedthe outcome, learning points and whether or not a meetinghad been held with the complainant. We found thatcomplaints were investigated and written and/or verbalapologies were given to complainants if issues wereidentified.

Details of complaints and their outcome were recorded ona template. The minutes of practice meetingsdemonstrated that complaints were discussed at thesemeetings, with learning identified and acted upon asnecessary.


Good –––


Our findingsVision and Strategy

The practice had a clear vision to deliver high quality careand promote good outcomes for patients. All staff wespoke with demonstrated a patient centred approach toproviding the service. We found details of the practicephilosophy recorded in a practice charter leaflet which wasavailable to patients on the reception desk. The practiceaims were to “offer the highest standards of health care andadvice to patients with the resources available”.

The practice charter included information for patientsregarding access to the services, complaints, commentsand waiting times, for example the practice had a standardof seeing 80% of patients within 30 minutes of theirappointment time, urgent appointments with a doctorwould usually be offered on the same day. The leaflet alsorecorded patient’s rights to general medical services andtheir responsibilities as well as some other generalinformation about staffing and opening times.

The practice charter stated that patients would be treatedwith courtesy and respect by all practice personnel. Thepractice charter leaflet demonstrated that the serviceaimed to provide a caring good quality service that wasaccessible to all patients. Staff spoken with demonstrated apatient centred approach, were caring and showedempathy for those patients who were suffering ill health.

The practice had a vision for the future which includedsuccession planning for staff who were due to retire.

Governance Arrangements

The practice had a number of policies and procedures inplace to govern activity and these were available to staff onthe desktop on any computer within the practice. Welooked at a sample of these policies and procedures andsaw that they had been reviewed annually and were up todate. The Business Manager told us that standardisedpolicies had been purchased and they had amended themajority to meet the needs of Castlecroft Medical Practice.We were told that this was an ongoing process. We saw thatthese were available to staff via the desktop of anycomputer within the practice.

We were told about the nominated Caldicott Guardian. ACaldicott Guardian is a senior person responsible for

protecting the confidentiality of a patient and service-userinformation and enabling appropriate information-sharing.Organisations that access patient records are required tohave a Caldicott Guardian

We were told that the information governance (IG) toolkittraining had recently been set up and staff would becompleting this training shortly.

The practice used the Quality and Outcomes Framework(QOF) to measure their performance. The QOF data for thispractice showed it was performing in line with nationalstandards.

The practice had completed a number of clinical audits, forexample COPD management, an audit of thiamineprescribing in patients with excess alcohol intake and anaudit of type two diabetes mellitus screening in polycysticovary syndrome patients with additional risk factors. Wesaw one completed clinical audit. The practice were able todemonstrate changes made which improved patient carefollowing the initial audit. We also saw other auditsundertaken such as infection control, hand hygiene and anaudit regarding consent processes. These audits helped toensure that the practice continually monitored anddeveloped systems and practices in place.

Leadership, openness and transparency

We were shown a clear leadership structure which hadnamed members of staff in lead roles. For example therewas a lead nurse for infection control; the businessmanager was the lead for health and safety, businessplanning and the building and facilities and the practicemanager was the lead for complaints and the PPG. Staff wespoke with were all clear about their own roles andresponsibilities. They all told us that felt valued, wellsupported and knew who to go to in the practice with anyconcerns.

We saw from minutes that GP meetings were held weekly,clinical team meetings were held monthly and separateadministration staff meetings were held. Staff told us thatthere was an open culture within the practice and they hadthe opportunity and were happy to raise issues at teammeetings. Administration staff spoken with felt that theymay benefit from more regular meetings with a full team ofstaff, which they understood was difficult to arrange due tothe surgery opening hours. We saw that reviews of systemsand practices had been undertaken and had resulted in thepractice identifying areas for improvement which were

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

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shared with us during our inspection. One area forimprovement identified was the need for more regular fullteam meetings. We were told that these meetings would beintroduced in the near future.

There was an active PPG which met on a regular basis. Wesaw that the PPG was advertised in the practice. Membersof the PPG that we spoke with told us that they receivedsupport from the practice during meetings and were keptup to date with any potential changes at the practice. Wewere told that the Practice staff, organised educationalevents for the PPG and recent events had included painmanagement, stroke and resuscitation training. Guestspeakers had been invited to talk about the local alcoholservices, a urology talk, eating disorders and dementia.Some of the guest speaks had been suggested by the PPGand some by the GP according to the needs of the practicepopulation. We met with three members of the PPG. Wewere told that the practice was supportive of the PPG andthat they were informed and involved in any changes at thepractice. One of the PPG members told us that they hadbeen involved in the recent employment of the BusinessManager. PPG members had been invited to meetcandidates prior to their interview and to give feedback tothe practice manager and lead GP.

The practice had developed a newsletter and we saw acopy of the Summer 2014 information provided to patients.This newsletter updated patients regarding on-lineappointments, repeat prescribing, practice survey resultsand other information of interest.

Practice seeks and acts on feedback from users, publicand staff

The practice used various methods to gather feedbackfrom patients including patient satisfaction surveys,complaints and the recently introduced friends and familytest (FFT). The FFT commenced on the 1 December 2014.We saw questionnaires and a collection box in thereception, along with notices asking patients to completethe questions. We saw that the practice website also had aFFT section to allow patients to submit their responseselectronically if they preferred.

The practice had an active patient participation group(PPG) which had steadily increased in size and now had 20members. The PPG contained representatives from variouspopulation groups. We were told that the age of the groupranged from 50’s upwards and the representation reflected

that of the wider practice demographic. One PPG memberspoken with confirmed that they found it difficult tomaintain group members who were from a younger agegroup and we were told that discussions had been held totry and encourage younger people to be involved in thePPG.

The PPG members that we spoke with told us that they hadmade changes to meeting times to try and accommodateall members. The PPG had carried out annual surveys andmet approximately every six weeks. The results, analysis ofthe results and action plan were available on the practicewebsite.

We saw minutes of meetings which confirmed that clinicalstaff meetings took place on a regular basis. GPs at thepractice met on a weekly basis and a full clinical staffmeeting was held monthly. Administration staff that wespoke with told us that they were kept informed about anychanges at the practice but felt that they would benefitfrom a full team practice meeting as they generally metwith the same few administration staff on each occasion.We saw that administration staff meetings were not held asregularly as clinical and GP meetings. This had beenhighlighted by the practice as an issue for action and wewere told that more regular meetings would be held in thefuture.

The practice had a whistle blowing policy which wasavailable to all staff in the staff handbook and electronicallyon any computer within the practice.

Management lead through learning & improvement

Staff said that they received training relevant to their role.We were told that the practice was very supportive oftraining and staff said that they were encouraged toundertake training to further their professionaldevelopment and skills.

Minutes of practice meetings demonstrated thatdiscussions were held regarding any complaints received,significant events or incidents. This helped to ensure thatthe practice improved outcomes for patients. Recordsdemonstrated that reviews of significant events and otherincidents had been completed. We saw that action hadbeen taken following risk assessments, for example allseating had been replaced in waiting areas and carpets


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replaced to stairways. From discussions with staff andreview of records it was evident that the practice was openand transparent and encouraged staff to learn fromincidents, complaints and audits undertaken.


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