Brundall Medical Partnership

Updated 29 July 2016

Letter from the Chief Inspector of General Practice

We carried out an announced follow up inspection at Brundall Medical Partnership on 21 June 2016. Overall the practice is rated as good. This was to follow up on actions we asked the provider to take after our announced comprehensive inspection on 16 November 2015. During the inspection in November 2015, we identified:

• There was scope to improve the monitoring and auditing of fridge temperatures.
• There was scope to improve the arrangements for the security of medicines stored in the dispensary to ensure they are only accessible to authorised staff.
• Staff who undertake the checking of medicines in the dispensary were not appropriately trained, qualified and competent to undertake this role.
• There was scope to improve the protocols in place for the handling, analysis, audit and review of dispensing errors including discussion at dispensing team meetings. In addition there was scope to improve the systems in place to record near-miss dispensing errors to identify trends and ensure these are monitored and actions taken where necessary.
• There was scope to improve the protocols in place for the monitoring and auditing of the risks involved in receiving telephone repeat prescription requests, ensuring processes for producing repeat prescriptions are undertaken away from avoidable distractions to prevent errors.
• Cascading, sharing and learning from concerns and complaints to all staff required further improvement.
• Patients waiting for their appointments in some areas of the practice could not be clearly seen by reception staff to ensure patients whose health might deteriorate are overlooked by staff.
• There was scope to improve clinical audits undertaken in the practice, including completed clinical audit or quality improvement cycles.
• Audit trails to demonstrate which MHRA (Medicines & Healthcare products Regulatory Agency) alerts and safety updates needed to be improved.

The practice manager provided us with evidence which showed the practice had put systems in place to improve these systems.

However there were areas of practice where the provider needs to make further improvements: Continue to risk assess and monitor patients waiting for their appointments in all areas of the practice to ensure patients whose health might deteriorate are not overlooked by staff

Professor Steve Field (CBE FRCP FFPH FRCGP) 

Chief Inspector of General Practice

Updated 28 January 2016

The practice is rated as good for the care of people with long-term conditions. Nursing staff had lead roles in chronic disease management and patients at risk of hospital admission were identified as a priority. Longer appointments and home visits were available when needed. All these patients had a named GP and a structured annual review to check that their health and medication needs were being met. For those patients with the most complex needs, the named GP worked with relevant health and care professionals to deliver a multidisciplinary package of care. The practice provided space for the diabetic eye screening team three weeks per year. In addition a room was provided once a month for the diabetic nurse to see patients with more complex diabetic needs and the smoking cessation advisor provided a service once a week from the practice. The practice held Gold Standard Framework meetings to discuss those patients with a terminal prognosis and to ensure a multidisciplinary management review of their condition. Meetings involved a range of services including Social Services, palliative care nurses, community matron, physiotherapist and occupational therapists. GPs provided telephone numbers and weekend visits for those patients nearing the end of life.

Updated 28 January 2016

The practice is rated as good for the population group of families, children and young people. Systems were in place for identifying and following-up children living in disadvantaged circumstances and who were at risk. Immunisation rates were in line for all standard childhood immunisations. Patients told us and we saw evidence that children and young people were treated in an age appropriate way and recognised as individuals. Appointments with GPs and nurses were available outside of school hours and the premises were suitable for children and babies. Midwives and health visitors  provided weekly clinics from the practice. We were provided with good examples of joint working with midwives and community services. Antenatal care was referred in a timely way to external healthcare professionals. Patients we spoke with were positive about the services available to them and their families at the practice. Contraceptive services including contraceptive implant and coil fitting services were available weekly for patients; these were also available for patients from a neighbouring practice. One GP with a special interest provided monthly gynaecological clinics from the practice. Emergency processes were in place and referrals made for children and pregnant women who had a sudden deterioration in health.

Updated 28 January 2016

The practice is rated as good for the care of older people. Nationally reported data showed that outcomes for patients were good for conditions commonly found in older people. The practice provided medical support to a high number of patients in care and nursing homes compared to other local practices. The practice undertook weekly scheduled visits and was part of a clinical commissioning group (CCG) pilot to work with the local community matron to jointly work to reduce the number of unplanned hospital admissions while improving patient care. Practice nurses visited patients including housebound patients to provide flu vaccinations. The practice offered proactive, personalised care to meet the needs of the older people in its population and had a range of enhanced services, for example, in dementia and end of life care. It was responsive to the needs of older people, and offered home visits and rapid access appointments for those with enhanced needs.

Updated 28 January 2016

The practice is rated as good for the population group of the working-age people (including those recently retired and students). The needs of this group (including students) had been identified and the practice had adjusted the services it offered to ensure these were accessible, flexible and offered continuity of care. For example following a patient complaint, asthma and smear appointments with the nurses were adjusted to ensure later appointments were available. Patients who requested a telephone call were contacted at the end of surgery by their GP; we were told this was popular with patients who needed to communicate with clinical staff but where an appointment was not required. The practice was proactive in offering online services as well as a full range of health promotion and screening at the practice which reflects the needs for this age group.

Updated 28 January 2016

The practice proactively identified patients who may be at risk of developing dementia. The practice were aware of the number of patients they had registered with dementia and additional support was offered. This included those with caring responsibilities. Practice nurses undertook dementia screening where appropriate at chronic disease reviews. The nurse practitioner undertook dementia reviews for patients who were unable to attend the practice. A register of dementia patients was being maintained and their condition regularly reviewed through the use of care plans. We saw that 76% of patients with a diagnosis of dementia had received a health check and review of their care plan in the previous 12 months (ending March 2015); this was an increase on the previous year’s reviews of 64%.

The practice had told patients experiencing poor mental health about how to access various types of support and we saw information about this available in the reception area. Triage directed these patients for support quickly during periods of significant personal stress. The Norfolk Recovery Partnership (supporting patient with drug and alcohol issues), the Wellbeing Service Mental Health worker and the metal health counsellor visited the practice on a weekly basis to provide a service to patients. There was a system in place to follow up patients who had attended accident and emergency (A&E) where they may have been experiencing poor mental health.

A register of patients experiencing poor mental health was being maintained and their condition regularly reviewed through the use of care plans. We saw that 93% of patients experiencing poor mental health had received a health check and review of their care plan in the previous 12 months (to the end of March 2015). Patients were referred to specialists and then on-going monitoring of their condition took place when they were discharged back to their GP. Annual health checks took place with extended appointment times if required. Patients were signposted to support organisations for provision of counselling and support.

Updated 28 January 2016

The practice is rated as good for the population group of people whose circumstances might make them vulnerable. Double appointment times were offered to patients who were vulnerable or with learning disabilities. Carers of those living in vulnerable circumstances were identified and offered support which included signposting them to external agencies. Staff knew how to recognise signs of abuse in vulnerable adults and children. All staff had been trained in safeguarding and were very aware of the different types of abuse that could occur and their responsibilities in reporting it. Staff were aware of their responsibilities regarding information sharing, documentation of safeguarding concerns and how to contact relevant agencies in normal working hours and out of hours. One nurse practitioner was responsible for learning disability reviews; we saw that 64% of patients with a learning disability had received a health check in the previous year. The practice held monthly multi-disciplinary team (MDT) meetings attended by GPs, district nurses, practice nurses and when possible community psychiatric nurses to discuss vulnerable patients.