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Dr law & partners scheduled report (primarymedicalservices location oct 2014)
Dr Law & Partners Tel: 01283 564848 Date of inspection visit: 1 October 2014 Date of publication: 08/01/2015 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.
Overall rating for this service Are services safe? Are services effective? Are services caring? Are services responsive to people's needs? Are services well-led? 1 Dr Law & Partners Quality Report 08/01/2015
Summary of findings ContentsSummary of this inspection Overall summary 2The five questions we ask and what we found 4The six population groups and what we found 6What people who use the service say 8Areas for improvement 8Outstanding practice 8 Detailed findings from this inspectionOur inspection team 9Background to Dr Law & Partners 9Why we carried out this inspection 9How we carried out this inspection 9Detailed findings 11 Overallsummary
Letter from the Chief Inspector of General
changes to respond to this and on-going monitoring demonstrated that changes still needed to be We inspected this service on 1 October 2014 as part of our considered. The practice had been working with the new comprehensive inspection programme.
Local Area Team, Clinical Commissioning Group andPatient Participation Group (PPG) to address this issue.
The overall rating for this practice is good. We found the PPGs are an effective way for patients and GP practices practice to be good in the safe, caring, responsive and to work together to improve the service and to well-led domains and outstanding in the effective promote and improve the quality of care patients domain. We found the practice provided good care to older people; people with long term conditions; people in • There were systems in place to keep patients safe from vulnerable circumstances; families, children and young the risk and spread of infection. Systems were in place people; working age people and people experiencing to monitor and make required improvements.
poor mental health.
• Evidence we reviewed demonstrated that most Our key findings were as follows: patients were satisfied with how they were treated andthat this was with compassion, dignity and respect. It • Patients were kept safe because there were also demonstrated that the GPs were good at listening arrangements in place for staff to report and learn to patients and gave them enough time.
from key safety risks. The practice had a system inplace for reporting, recording and monitoring We saw several areas of outstanding practice including: significant events over time.
• The practice recognised that patient satisfaction with access to appointments had fallen over the past year.
There was evidence that the practice had made 2 Dr Law & Partners Quality Report 08/01/2015
Summary of findings • The provider had developed a referrals feedback slip However, there were also areas of practice where the to gather information from the hospital physiotherapy provider needs to make improvements.
department to monitor the appropriateness of their The provider should: patient referrals.
• The lead nurse at the practice was supported by the • Ensure that all electrical equipment at the practice is GP partners within and outside of the service to take safety tested.
on a leadership role. An example of this is where thelead practice nurse led and chaired the local practice Professor Steve Field CBE FRCP FFPH FRCGP
nurse forums to promote best practice in the Chief Inspector of General Practice administration of influenza, pneumonia and shinglesvaccinations for older people.
Professor Steve Field (CBE FRCP FFPH FRCGP)
Chief Inspector of General Practice 3 Dr Law & Partners Quality Report 08/01/2015
Summary of findings ThefivequestionsweaskandwhatwefoundWe always ask the following five questions of services.
Are services safe?
The practice is rated as good for safe. Patients were kept safebecause there were arrangements in place for staff to report andlearn from key safety risks to patients. The practice had a system inplace for reporting, recording and monitoring significant events overtime. The GP senior partner and staff we spoke with told us therewas a blame free culture within the practice. They told us thepractice was open and transparent when things went wrong. Therewere robust systems in place to protect children and vulnerableadults from the risk of abuse. The practice worked with otherservices to prevent abuse and to put plans of care in place.
Medicines were stored safely. The system that ensured temperaturesensitive medicines were stored appropriately was effective. Therewere systems in place to keep patients safe from the risk and spreadof infection. Patients were also protected from unsafe or unsuitableclinical equipment however, some non-clinical electrical equipmenthad not been safety tested since 2010. Patients were cared for bysuitably qualified and trained staff and staffing establishments wereregularly reviewed to keep patients safe and meet their needs.
Are services effective?
The practice is rated as outstanding for effective. Our findings atinspection showed systems were in place to ensure that allclinicians were not only up-to-date with both the National Institutefor Health and Care Excellence guidelines and other locally agreedguidelines but we also saw evidence that confirmed that theseguidelines were influencing and improving practice and outcomesfor their patients. We saw data that showed the practice wasperforming highly when compared to neighbouring practices in theClinical Commissioning Group (CCG).
The practice was using innovative and proactive methods toimprove patient outcomes. Examples of this included a referralsfeedback slip to gather information from the hospital physiotherapydepartment to monitor the appropriateness of their patient referrals;easy read care plans for patients with learning disabilities; 100% ofwomen were offered long acting reversible contraception whenprovided with emergency contraception and the lead practice nursewas supported by the practice to take on a leadership role for thedevelopment of other practice nurses in the region.
Are services caring?
The practice is rated as good for providing caring services. Datashowed that patients rated the practice higher than others for 4 Dr Law & Partners Quality Report 08/01/2015
Summary of findings several aspects of care. Patients said they were treated withcompassion, dignity and respect and they were involved in decisionsabout their care and treatment. Information to help patientsunderstand the services available was easy to understand. We alsosaw that staff treated patients with kindness and respect, andmaintained confidentiality Are services responsive to people's needs?
The practice is rated as good for responsive. We found the practicehad initiated many positive service improvements for their patientpopulation that were over and above their contractual obligations.
The practice was supported by a very active Patient ParticipationGroup (PPG) who helped with a number of initiatives to benefitpatients. The practice reviewed the needs of their local populationand engaged with the NHS Local Area Team (LAT) and CCG to secureservice improvements where these were identified. All patients over75 years were provided with a named doctor for continuity of careand urgent appointments were available the same day. The practicehad good facilities and was well equipped to treat patients andmeet their needs. There was an accessible complaints system withevidence demonstrating that the practice responded appropriatelyto issues raised. There was evidence of shared learning fromcomplaints with staff and other stakeholders.
Are services well-led?
The practice is rated as good for being well-led. It had a clear visionand strategy. Staff were clear about the vision and theirresponsibilities in relation to this. There was a clear leadershipstructure and staff felt supported by management. The practice hada number of policies and procedures to govern activity and heldregular governance meetings. There were systems in place tomonitor and improve quality and identify risk. The practiceproactively sought feedback from staff and patients, which it actedon. The patient participation group (PPG) was active. PPGs are aneffective way for patients and GP practices to work together toimprove the service and to promote and improve the quality of carepatients receive. Staff had received inductions, regular performancereviews and attended staff meetings and events.
5 Dr Law & Partners Quality Report 08/01/2015
Summary of findings ThesixpopulationgroupsandwhatwefoundWe always inspect the quality of care for these six population groups.
The practice is rated as good for the care of older people. Nationallyreported data showed that outcomes for patients were good forconditions commonly found in older people. The practice offeredproactive, personalised care to meet the needs of the older peoplein its population and had a range of enhanced services, for example,in dementia and end of life care. It was responsive to the needs ofolder people, and offered home visits and rapid accessappointments for those with enhanced needs.
People with long term conditions
The practice is rated as good for the care of people with long-termconditions. There were emergency processes in place and referralswere made for patients whose health deteriorated suddenly. Longerappointments and home visits were available when needed. Allthese patients had a structured annual review to check that theirhealth and medication needs were being met. For those people withthe most complex needs, GPs worked with relevant health and careprofessionals to deliver a multidisciplinary package of care.
Families, children and young people
This practice is rated as good for families, children and youngpeople. We saw that the practice provided services to meet theneeds of this population group. Staff were knowledgeable abouthow to safeguard children from the risk of abuse. Quarterly face toface meetings between the GPs, health visitors and midwives wereheld at the practice to discuss how to manage and support childrenand families in vulnerable situations. There were effective screeningand vaccination programmes in place to support patients andhealth promotion advice was provided. Information was available toyoung people regarding sexual health and family planning advicewas provided by staff at the practice. The GPs and nurses that wespoke with demonstrated a clear understanding of the importanceof determining if a child was Gillick competent when gainingconsent to care and treatment. A Gillick competent child is a childunder 16 who has the legal capacity to consent to care andtreatment. They are capable of understanding implications of theproposed treatment, including the risks and alternative options.
Working age people (including those recently retired and
This practice is rated as good for working age patients. We saw thatthe practice offered a range of appointments which included 6 Dr Law & Partners Quality Report 08/01/2015
Summary of findings pre-bookable appointments, same day appointments andtelephone consultations. Staff told us that they tried to ensure thatpatients who were working were able to have an early appointmentat 8am whenever possible. The practice offered all patients aged 40to 75 years old a health check with the practice nurse. Well womenand well men checks were available for patients to request. Familyplanning services were provided by the practice for women ofworking age. There was evidence that the practice monitored theeffectiveness of their family planning service through audit.
Following changes in practice identified in these audits, 100% ofwomen were offered long acting reversible contraception whenemergency hormonal contraception had been given. This helped toprevent unwanted pregnancies.
People whose circumstances may make them vulnerable
The practice is rated as good for the care of people whosecircumstances may make them vulnerable. The practice held aregister of patients living in vulnerable circumstances includinghomeless people and those with a learning disability. It had carriedout annual health checks for people with a learning disability.
People experiencing poor mental health (including people
This practice is rated as good for patients experiencing poor mentalhealth. The practice maintained a register of patients whoexperienced mental health problems. We saw that staff had theknowledge, skills and competencies to assess and respond to theirneeds. Patients experiencing poor mental health received an annualhealth review to ensure appropriate treatment and support was inplace. The practice worked with the local primary care mentalhealth team to provide appointments at the practice for patientsexperiencing poor mental health. This enabled patients to receivecounselling and treatment in surroundings that were familiar tothem and maintained their discretion.
7 Dr Law & Partners Quality Report 08/01/2015
Summary of findings WhatpeoplewhousetheservicesaySeventeen of the 18 patients we spoke with on the day of spoke with on the day of our inspection told us they our inspection were complimentary about the care and experienced problems getting through to the practice on treatment they received. We reviewed the four patient the phone to make an appointment. Most patients comments cards from our Care Quality Commission however told us the appointment system was easy to use (CQC) comments box that had been placed in the and met their needs. The results of the GP Patient survey practice prior to our inspection. We saw that comments supported these findings.
were overwhelmingly positive. Patients told us the staff The results from the National Patient Survey showed that were always caring and treated them with dignity and 98% of patients said that their overall experience of the respect. They said the nurses and doctors listened and practice was good and that 90% of patients would responded to their needs and they were involved in recommend the practice to someone new to the decisions about their care. Patients told us that the practice was always clean and tidy. Some patients we Areasforimprovement
Action the service SHOULD take to improve
The provider should ensure that all electrical equipmentat the practice is safety tested.
OutstandingpracticeThere were examples of outstanding practice at Dr Law The lead nurse at the practice was supported by the GP and partners as follows: partners within and outside of the service to take on aleadership role. An example of this is where the lead The practice had developed a referrals feedback slip to practice nurse led and chaired the local practice nurse gather information from the local hospital's forums to promote best practice in the administration of physiotherapy department to monitor the influenza, pneumonia and shingles vaccinations for older appropriateness of their patient referrals.
8 Dr Law & Partners Quality Report 08/01/2015
Dr Law & Partners Our inspection team and family medicine since 1992. They do not provide anout-of-hours service to their own patients but they havealternative arrangements for patients to be seen when the Our inspection team was led by:
practice is closed Our inspection team was led by a CQC lead inspector.
Why we carried out this The lead inspector was accompanied by two GPspecialist advisors and an expert by experience who had personal experience of using primary medical services.
We inspected this service as part of our new Background to Dr Law & comprehensive inspection programme. This provider hadnot been inspected before and that was why we included Dr Law and Partners' practice provides primary medical How we carried out this services to patients living in Burton-on-Trent, Staffordshire.
The practice is a two storey purpose built town surgery.
There are nine consulting rooms and two treatment rooms.
The surgery has its own patient car park with easy access To get to the heart of patients' experiences of care and for patients with disabilities. The surgery building is owned treatment, we always ask the following five questions: jointly by some of the partners. The practice houses attached staff including district nurses, health visitors, • Is it effective? midwife and counsellors all of whom provide clinics within • Is it caring? the surgery.
• Is it responsive to people's needs? A team of six GP partners, one salaried GP, three GP • Is it well-led? Registrars, six nurses including an advanced nurse We also looked at how well services are provided for prescriber, a practice manager, 10 receptionists and seven specific groups of people and what good care looks like for administrative staff provide care and treatment for them. The population groups are: approximately 10,200 patients. There are five female andtwo male doctors at the practice to provide patients with a choice of who to see. The practice provides an • People with long-term conditions anticoagulation clinic for patients who are on warfarin and • Families, children and young people need to have their blood monitored on a regular basis. The • Working age people (including those recently retired practice has been a training practice for doctors to gain experience and higher qualifications in General Practice • People living in vulnerable circumstances• People experiencing poor mental health (including people with dementia) 9 Dr Law & Partners Quality Report 08/01/2015
Detailed findings Before carrying out our inspection, we reviewed a range of 1 October, 2014. During our inspection we spoke with three information we held about the practice and asked other GPs, one GP Registrar, two nurses, three receptionists, the organisations to share what they knew. We spoke with the practice manager, three receptionists, a Health Visitor and chair of the Patient Participation Group and managers of 18 patients. We observed how patients were cared for. We three care homes where Dr Law & Partners provide care reviewed four patient comment cards sharing their views and treatment. We carried out an announced inspection on and experiences of the practice.
Dr Law & Partners Quality Report 08/01/2015 Are services safe? Barring Service (DBS) check had been completed for allclinical and administrative staff. DBS checks help Safe Track Record
employers make safer recruitment decisions and preventunsuitable people from working with vulnerable adults and Patients were kept safe because there were arrangements children. It replaced the Criminal Records Bureau (CRB) in place for staff to report and learn from key safety risks to patients. Staff we spoke with knew it was important toreport incidents and significant events to keep patients The practice worked with other services to prevent abuse safe from harm. They were aware of the most appropriate and to implement plans of care. We spoke with a Health person to report their concerns to. We saw that a log of Visitor on the day of our inspection. They told us that they incidents, complaints and significant events had been kept had quarterly face to face meetings with the GPs to discuss at the practice. We saw they had all been appropriately how to manage and support children and families in investigated. We saw that reviews of incidents and vulnerable situations. They told us the GPs were significant events over time had been completed to identify approachable and were able to contact them to discussif there were any reoccurring concerns across the service.
any concerns they may have.
Learning and improvement from safety incidents
Patients were kept safe from the risk of abuse during an The practice had a system in place for reporting, recording intimate examination. There was an up to date chaperone and monitoring significant events. They kept records of policy in place to ensure patients were protected from significant events that had occurred over the last 12 potential abuse during an intimate examination. Nursing months and these were made available to us. The practice staff were aware of their chaperone responsibilities and was open and transparent when things went wrong. The GP some patients confirmed that a chaperone had beensenior partner and staff we spoke with told us there was a offered during an intimate examination. There was one blame free culture within the practice. Clinical staff poster on display within the reception area informing described to us how learning from significant events was patients of their right to request a chaperone. It was not shared with them at a weekly practice based learning clearly visible and could only be seen when a patient stood session or on an individual basis. We found there was no at the reception desk.
formal system in place that documented when learning had been shared with clinical and non-clinical staff.
Medicines were stored safely. We checked medicines stored Reliable safety systems and processes including
in the locked medicine cupboard, fridges and the GP's emergency blue box. We found that they were stored Children and vulnerable adults were kept safe from the risk appropriately and were in date. There was a policy that of abuse because there were safeguarding systems in clearly outlined how temperature sensitive medicines, such place. Safeguarding policies were in place and staff knew as vaccines, should be stored to ensure they were fit for where to find them. There were two safeguarding leads at purpose. It provided guidance on the action to take in the the practice and staff knew to go to them for advice and event of a problem. We saw that this system was effective support. All staff had received training on safeguarding because it had detected a problem with the temperature of children and vulnerable adults at a level appropriate to one of the medicine fridges and appropriate action had their role. GPs had received the higher level three been taken. Emergency medicines for medical emergencies safeguarding training to support them in their role. A log were available and all staff knew where they were stored.
containing records of this was made available to us. We Controlled drugs were not kept at the practice.
asked medical, nursing and administrative staff about their Medicines were administered safely. We saw there were most recent training. Staff knew their responsibilities signed Patient Group Directions (PGD) in place to support regarding information sharing, documentation of the nursing staff in the administration of vaccines. A PGD is safeguarding concerns and how to contact the relevant a written instruction from a qualified and registered agencies in and out of hours. We saw that safeguarding prescriber, such as a doctor, enabling a nurse to administer contact details were easily accessible for staff and a medicine to groups of patients without individual displayed in most rooms. We saw that a Disclosure and Dr Law & Partners Quality Report 08/01/2015 Are services safe? prescriptions. A member of the nursing staff was qualified the equipment was checked weekly to ensure it was in as an independent prescriber. They had also completed the working order and fit for purpose. We saw there wasClinical Health Assessment module to provide them with equipment at the practice that contained mercury. Mercury the knowledge they required when prescribing.
is a hazardous substance and is subject to the Control of The practice had a protocol for repeat prescribing which Substances Hazardous to Health Regulations 2002. We saw was in line with General Medical Council (GMC) guidance.
a risk assessment had been carried out and two mercury This covered how staff that generated prescriptions were spillage kits were available to keep patients and staff safe in trained, how changes to patients' repeat medicines were the event of a mercury spillage. We saw records that managed and the system for reviewing patients' repeat demonstrated that clinical equipment had been calibrated and safety checked in July 2014. The practice could not Cleanliness & Infection Control
provide evidence that non-clinical electrical equipmenthad recently been safety checked. Some electrical There were systems in place to keep patients safe from the equipment had not been safety tested since 2010.
risk and spread of infection. There was an appropriate
infection control policy available for staff to refer to. We saw Staffing & Recruitment
that the infection control lead had received appropriate Patients were cared for by suitably qualified and trained infection control training. An infection control audit had staff. We saw evidence that health professionals, such as been carried out in May 2014. Several issues had been doctors and nurses, were registered with their appropriate identified and an action plan put in place. We saw that professional body and so considered fit to practice. There action had been taken to address the issues and a date of was a system in place that ensured health professionals' completion recorded. Minor surgery was carried out at the registrations were in date. There was a recruitment policy practice. We saw that single use instruments were used in place and we saw that it met the requirements of our and they were in date. There were arrangements in place regulations. We looked at the records of three members of for the safe disposal of clinical waste and sharps, such as staff and saw that appropriate recruitment processes and needles and blades. We saw evidence that their disposal checks had been carried out before staff started to work at was arranged through a suitable company.
the practice. There were clearly defined staffing rotas andsystems in place to cover annual leave.
On the day of our inspection the practice was clean andtidy. Patients we spoke with told us that the reception area Monitoring Safety & Responding to Risk
and consulting rooms were always clean. They told us that Staffing establishments were reviewed to keep patients when appropriate, staff wore personal protective safe and meet their needs. Where staffing issues had been equipment such as gloves. Staff confirmed personal identified, we saw that action plans were in place outlining protective equipment was readily available and we saw how risks would be managed and work re-allocated. We that it was.
saw that the practice population size of the practice hadbeen continually increasing. An appointments audit had The practice had taken reasonable steps to protect staff been carried out in February, March and May 2014 which and patients from the risks of health care associated highlighted the increased demand for appointments with infections. We saw that staff had received the relevant GPs. To help to meet this demand, a GP had been immunisations and support to manage the risks of health employed to provide an additional five sessions per week.
care associated infections. A legionella risk assessment had There were systems in place to deal with busy periods and been completed in May 2014 and an action plan put in staff shortages. The practice had a business continuity plan place. We saw that work was being carried out to address in place that contained a risk assessment and an action the identified issues.
plan detailing how the practice would respond to busy periods such as the increase demand for appointments in Patients were protected from unsafe or unsuitable equipment. Emergency equipment such as a defibrillator Maintenance of the premises was designed to keep was available for use in a medical emergency. We saw that patients safe. We saw there was subsidence and cracks inthe plaster at the practice. We were shown risk Dr Law & Partners Quality Report 08/01/2015 Are services safe? assessments, action plans, quotes and timeframes for the confirmed they had received CPR training and repair work to be completed. A fire risk assessment and appropriately described the care they would provide to asbestos management plan had been completed which patients in the event of a medical emergency. There were confirmed that the building was safe.
emergency drugs, a defibrillator, oxygen, pulse oximeters Arrangements to deal with emergencies and major and airway maintenance equipment for adults and
children available at the practice. There were systems inplace to ensure that the emergency drugs and oxygen were There were systems in place to deal with medical in date and that the emergency equipment was fit for emergencies. We saw records demonstrating that staff were trained in cardiopulmonary resuscitation (CPR) andwhen they would be due for an update. Staff we spoke with Dr Law & Partners Quality Report 08/01/2015 Are services effective?(for example, treatment is effective) method of communicating with patients with learningdifficulties was effective and met their needs. There were Effective needs assessment
systems in place that ensured babies received a new bornand eight week development assessment. A GP told us that Patients' needs were assessed and care and treatment patients with mental health difficulties received an annual delivered in line with current evidence based guidance. We health review. We saw there was a care plan template to saw electronic records demonstrating that clinical staff had enable GPs to plan the care for patients with mental health access to the National Institute for Health and Care difficulties. GPs we spoke with were able to describe how Excellence (NICE) guidelines. Clinical staff described to us this template was applied during a patient's assessment.
how they used these to assess the needs of their patients.
Every patient over 75 years had a named GP and each of For example, we saw that changes to the guidance for the the 14 care homes had a named GP. We spoke with prescription of statins (medicines that can help to lower representatives from three of the 14 care homes the cholesterol levels in blood) had been followed. We saw practice provided care and support to. They confirmed that minutes of practice meetings where new guidelines were needs assessments were completed when required. The disseminated and the implications for the practice's senior GP partner told us that they were exploring the performance and patients were discussed. All the GPs introduction of weekly ward rounds within the care homes interviewed were aware of their professional to ensure that older patients' needs were assessed and responsibilities to maintain their knowledge.
monitored effectively. The representatives from the homes The practice referred patients appropriately to secondary we spoke with confirmed this had been discussed with and other community care services. National data showed the practice had a high referral rate to ophthalmology, Staff told us there was a high turnover of temporary general surgery and trauma. The practice told us they were residents registered with them at one time. This was due to investigating why this was and what they could do to a nearby housing association that accommodated reduce it. We saw that the practice was proactive and had temporary residents and a nearby residential drug and developed a referrals feedback slip to gather information alcohol addiction centre. The practice informed us that from the physiotherapy department regarding the they had a policy to accept homeless patients and any appropriateness of their referrals. An analysis of the patient who lived within their practice boundary feedback slips was ongoing.
irrespective of race, culture, religion or sexual preference.
Patients with long term conditions received an annual They told us all patients received the same quality of needs assessment. We saw that an audit had been carried service from all staff to ensure their needs were met.
out on blood test requests for routine long term conditions Management, monitoring and improving outcomes
such as high blood pressure or diabetes. The audit for people
identified that the blood tests requested varied amongst The practice participated in the Quality and Outcomes GPs. As a result of the audit a proforma had been Framework (QOF). The QOF rewards practices for providing developed that standardised which blood tests were quality care and helps to fund further improvements. We appropriate and effective for patients with a stable long saw that there was a robust system in place to frequently term condition.
review QOF data and recall patients when needed. The Patients with a learning disability received an annual practice participated in a benchmarking process with other health assessment using the Cardiff Health Check practices within East Staffordshire Commissioning Group template. We saw that the assessment was carried out by a (CCG). This allowed practices to compare their performance practice nurse who had completed a health assessment against other practices in the CCG in areas such as referrals module. A GP buddying system was in place if the nurse to A&E. We saw minutes demonstrating that the GP who required additional support or advice. At the end of the attended these meetings shared the information with the review we saw that the patient was provided with a health other staff at the practice.
action plan which was agreed with them. Information The practice had a system in place for completing clinical inviting them to the assessment and the health action plan audit cycles. The practice showed us 10 clinical audits that were provided in an easy read format ensuring that the Dr Law & Partners Quality Report 08/01/2015 Are services effective?(for example, treatment is effective) had been completed recently. Following each clinical audit, to support new doctors into the practice. A GP registrar wechanges to treatment or care were made where needed spoke with told us they felt very supported at the practice.
and the audit repeated to ensure outcomes for patients They told us they valued the GP buddying system which had improved. For example, following an alert from the provided them with a daily named GP they could go to for Medicines and Healthcare Products Regulatory Agency advice and support. The senior GP partner told us that they (MHRA) regarding the use of simvastatin (a medicine used had been asked by the Deanery of the local university to to reduce blood cholesterol levels) a clinical audit was support two GP registrars who required additional support.
carried out by the practice. The aim of the audit was to The GP registrars went on to successfully complete their ensure that all patients prescribed simvastatin were not training. GPs we spoke with told us they were supported in put at risk of serious drug interactions. The first audit their revalidation through an appraisal system.
demonstrated that 187 patients were not receiving the Revalidation is the process by which licensed doctors are revised dose of simvastatin. The information was shared required to demonstrate that they are up to date with with GPs and patients were called for a medication review.
current best practice and fit to practise.
A second clinical audit was completed one year later which A management task planner was in place for 2014-2015 demonstrated that only one patient was not receiving the which identified when staff appraisals and training were new recommended dose.
due. We looked in the records of three recently recruited The practice had taken on the enhanced service for the members of staff and saw that they had all received an avoidance of unplanned hospital admissions. Enhanced induction to the practice, completed an appraisal within services are additional services provided by GPs to meet the last year and identified their training needs. Staff we the needs of their patients. To meet this objective they have spoke with all confirmed they received an annual appraisal.
recently completed 170 care plans for elderly patients. We Where staff had identified the need for additional training spoke with representatives from three of the 14 care homes specific to their role or for their professional development,the practice provided care and support to. They confirmed staff told us they had been supported to access this. The that care plans had been put in place and the care that the practice manager showed us a training log that identified practice provided was of a high standard. They told us they what training staff had completed, when they had had a good working relationship with the practice and that completed it and when it needed to be repeated. Continual the practice responded quickly to any concerns they had clinical development and supervision was supported about patients. Every patient over 75 years of age had a through a weekly one hour practice based learning session named GP and each of the 14 care homes had a named GP within the practice. We saw evidence that these sessions to ensure continuity of care and to develop relationships included such areas as reviewing significant events and between the GP and care home staff. The practice had 23 audit or guest speakers. All staff were provided with one patients on their end of life register. We saw minutes from hour of protected learning time each week to enable them multi-disciplinary meetings between GPs, palliative care to access online training.
nurses and district nurses that demonstrated care plans for Working with colleagues and other services
patients near the end of their life were reviewed on a The practice worked with other service providers to meet regular basis. The practice used special notes to ensure patients' needs and manage complex cases. We saw, and a that the out of hours service were also aware of the needs Health Visitor confirmed, that quarterly meetings between of these patients when the practice was closed.
GPs, Health Visitors and midwives were held to discuss, assess and plan care around safeguarding concerns. The Staff had the skills, knowledge and experience to deliver practice held multidisciplinary team meetings to discuss effective care and treatment. The practice manager, a lead the needs of patients with end of life care needs. Minutes GP and lead practice nurse were responsible for staff from multi-disciplinary meetings between the practice, training. The practice was a training practice for GP palliative care nurses and district nurses demonstrated that registrars. GP registrars are qualified doctors who patients who were receiving end of life care were provided undertake additional training to gain experience and higher with appropriately co-ordinated care. We saw that thequalifications in general practice and family medicine.
practice used special notes to ensure that the out of hours There was a comprehensive induction programme in place service were also aware of the needs of these patients Dr Law & Partners Quality Report 08/01/2015 Are services effective?(for example, treatment is effective) when the practice was closed. We saw that the practice legal capacity to consent to care and treatment. They are worked with the district nursing teams and community capable of understanding implications of the proposed matrons to assist in the provision of long term condition treatment, including the risks and alternative options. The monitoring and management of care for housebound practice had access to interpreting services to ensure patients. The practice worked with the local primary care patients understood procedures if their first language was mental health team to provide appointments at the not English.
practice for patients experiencing poor mental health.
Some staff we spoke with had not received training in the Mental Capacity Act 2005 but demonstrated knowledge There was a system in place for receiving, managing, regarding best interest decisions for patients who lacked reviewing and following up the results of tests requested capacity. Mental capacity is the ability to make an informed for patients. Reception staff we spoke with clearly decision based on understanding a given situation, the understood their role and responsibilities in handling these options available and the consequences of the decision.
results and who the results were to be shared with. Blood People may lose the capacity to make some decisions and X-ray results were received electronically and reviewed through illness or disability. We saw examples of how by a GP on a daily basis. The GP who reviewed the results young people, patients with a learning disability, mental was responsible for taking the appropriate action. The health difficulty or dementia were supported to make practice used special notes to ensure that the out of hours decisions. For example, there were easy read leaflets and service were also aware of the needs of patients receiving health action plans to enable patients with learning end of life care when the practice was closed. The practice difficulties to understand their planned treatment and care.
was in the process on putting patient care plans on to the When patients did not have capacity the staff we spoke special notes system so that the out of hours service were with gave us examples of how the patient's best interest aware of patients' needs.
was taken into account.
Hospital discharge, A&E, outpatients and discharge letters When a person does not wish to be resuscitated in the were received in paper format. Once the practice received event of severe illness a 'Do not attempt resuscitation' the letters they were allocated to the most appropriate (DNAR) form is completed to record this in their records to doctor and followed up the same day.
protect them from the risk of receiving inappropriate Consent to care and treatment
treatment. We spoke with a representative from three carehomes that the practice provided care and support to. They There were mechanisms to seek, record and review confirmed that DNARs were reviewed by GPs from the consent decisions. We saw there were consent forms for practice and that GPs reviewed new DNARs that had been patients to sign agreeing to minor surgery procedures. We put in place whilst a patient was in hospital.
saw that the need for the surgery and the risks involvedhad been clearly explained to patients. We saw a minor Health Promotion & Prevention
surgery audit for 2013–2014 had been carried out at the The practice offered all new patients registering with the practice which included consent to treatment. The audit practice and patients aged 40 to 75 years old a health demonstrated that 100% of minor surgery procedures check with the practice nurse. Well women and well men carried out on patients had written consent in place.
checks were available for patients on request. The practicenurse carried out weekly vaccination sessions for children We saw signed consent forms for children who had in line with the Healthy Child Programme. We saw that the received immunisations. The practice nurse was aware of percentage of children who had received the appropriate the need for parental consent and what action to follow if a vaccination at the appropriate time ranged from 90 to parent was unavailable. There were leaflets available for 100% which was in line with the Clinical Commissioning parents informing them of potential side effects of the Group (CCG) regional average. A travel vaccination immunisations. The GPs and nurses that we spoke with programme was also carried out at the practice which demonstrated a clear understanding of the importance of included the vaccination for yellow fever.
determining if a child was Gillick competent especiallywhen providing contraceptive advice and treatment. A Family planning services were provided by the practice for Gillick competent child is a child under 16 who has the women of working age. Three clinical audit cycles had Dr Law & Partners Quality Report 08/01/2015 Are services effective?(for example, treatment is effective) been completed exploring the percentage of women who The practice nurses offered healthy living advice and had received long acting reversible contraception (LARC) support to patients. This included referrals to weight when emergency hormonal contraception had been given.
watchers and council physical activity exercise classes for The first audit cycle demonstrated that 83% of women had patients who needed a weight management programme.
been provided with LARC. Following a raise in awareness We saw that one of the council exercise classes was amongst clinical staff and the introduction of information specifically for women from the black minority ethnic packs in consulting rooms, the third clinical audit cycle population group. All patients with a learning disability demonstrated that 100% of women were offered LARC to were offered an annual physical health check and provided prevent unwanted pregnancies. All six of the practice with healthy living advice leaflets in an easy read format.
nurses were trained in performing cervical smears and Flu vaccination was offered to all patients over the age of Chlamydia screening kits were available in the toilets for 65, those in at risk groups and pregnant women. The young patients to access discreetly. Condoms were also shingles vaccination was offered according to national available free on request.
guidance for older people.
Dr Law & Partners Quality Report 08/01/2015 Are services caring? Patients we spoke with on the day of our inspectionconfirmed that they had never overheard anything Respect, Dignity, Compassion & Empathy
confidential at the reception desk. The practiceswitchboard was located upstairs away from the reception We reviewed the most recent data available for the practice desk so telephone conversations could not be overheard.
on patient satisfaction. This included information from 126patients who took part in the GP patient survey. The GP The practice told us that they had a high turnover of patient survey is an independent survey run by Ipsos MORI temporary patients registered with them at one time. This on behalf of NHS England. We also reviewed data from a was due to a nearby housing association that survey of 526 patients undertaken by the practice's Patient accommodated temporary residents and a nearby Participation Group (PPG). PPGs are an effective way for residential drug and alcohol addiction centre. The practice patients and GP practices to work together to improve the informed us that they had a policy to accept homeless service and to promote and improve the quality of the care. patients and any patient who lived within their practiceThe evidence from these sources demonstrated that boundary irrespective of race, culture, religion or sexual patients were satisfied with how they were treated and that preference. They told us all patients received the samethis was with compassion, dignity and respect. For quality of service from all staff to ensure their needs were example, data from the national GP patient survey showed that 98% of patients described their overall experience of There was a clearly visible notice in the patient reception this practice as good or very good. This was 10% above the area stating the practice's zero tolerance for abusive Clinical Commissioning Group (CCG) regional average.
behaviour. We saw an example where the practice had Ninety-four per cent of practice respondents said the GP actioned this policy following an incident.
was good at listening to them and 96% said the GP gavethem enough time. All these scores were above the CCG Care planning and involvement in decisions about
care and treatment
The GP patient survey information we reviewed showed Patients completed CQC comment cards to provide us with patients responded positively to questions about their feedback on the practice. We received four completed involvement in planning and making decisions about their cards and all were positive about the service they care and treatment and generally rated the practice well in experienced. Patients said they felt the practice offered an these areas. For example, data from the national patient excellent service and staff were friendly, helpful and survey showed 81% of practice respondents said the GP respectful. They said staff treated them with dignity and involved them in care decisions and 89% felt the GP was respect and never patronised them. We also spoke with 18 good at explaining treatment and results. Both these patients on the day of our inspection. Seventeen out of the results were above average compared to the CCG regional 18 patients we spoke with told us they were satisfied with the care provided by the practice and said their dignity andprivacy was respected.
Patients we spoke to on the day of our inspection told usthat health issues were discussed with them and they felt Staff and patients told us that all consultations and involved in decision making about the care and treatment treatments were carried out in the privacy of a consulting they received. They also told us they felt listened to and room. Disposable curtains were provided in consulting supported by staff and had sufficient time during rooms and treatment rooms so that patients' privacy and consultations to make an informed decision about the dignity was maintained during examinations, investigations choice of treatment they wished to receive. Patient and treatments. We saw that consultation treatment room feedback on the comment cards we received was also doors were closed during consultations and that positive and aligned with these views. One of the GP conversations taking place in these rooms could not be partners offered alternative therapies for patients who preferred non-invasive, drug free pain relief treatment. Staff We observed staff were careful to follow the practice's told us that translation services were available for patients confidentiality policy when discussing patients' treatments who did not have English as a first language.
in order that confidential information was kept private.
Dr Law & Partners Quality Report 08/01/2015 Are services caring? There were 80 patients on the practice's learning difficulties with care and concern with a score of 82% for nurses. Theseregister. We saw that annual health reviews were carried results were above the CCG regional average. The patients out for patients with learning difficulties using the Cardiff we spoke with on the day of our inspection and the Health Check template. At the end of the review the patient comment cards we received were also consistent with this was provided with a health action plan which was agreed survey information. For example, patients described the with them. We saw two examples where the health action care they received as excellent and of a higher standard plan was provided in an easy read format so that patients than other practices they had previously been registered understood it. There were 68 patients on the practices' register for patients with mental health difficulties. There Notices in the patient's waiting room and on the practice was a system in place to ensure that patients with mental website sign posted patients to a number of support health difficulties received an annual health review. We saw groups and organisations. The practice provided support there was a care plan template to enable GPs to plan the for carers and had developed a carer's register working with care for patients with mental health difficulties. The staff the Carers Association for South Staffordshire (CASS). We told us that the recall system for patients with long term saw that GPs had access to electronic leaflets that they conditions, such as diabetes or high blood pressure, had printed off to provide advice and support to carers recently been updated. Patients were called for a review of regarding certain conditions. The practice website provided their care and treatment on their birthday and were a direct link to the carer's association which provided provided with an extended appointment at a time financial and practical advice and applications to the convenient for them. Changes to the recall system for carer's health respite break fund.
annual reviews were clearly communicated to patientsthrough the patient newsletter.
Staff told us families who had suffered bereavement were Patient/carer support to cope emotionally with
called by their usual GP and offered a GP consultation if care and treatment
required. However, patients we spoke with on the day ofinspection who had suffered bereavement told us they had The GP patient survey information we reviewed showed not received this support. Some staff were also unclear of patients were positive about the emotional support where to direct patients to for bereavement support and provided by the practice and rated it good or very good in there were no information leaflets on display in the this area. For example, 92% of patients surveyed said the last GP they saw or spoke to was good at treating them Dr Law & Partners Quality Report 08/01/2015 Are services responsive to people's needs?(for example, to feedback?) regular membership of 14 patients with an age range of 30to 60 years. PPG meetings were held on a monthly basis Responding to and meeting people's needs
and the minutes were available on the practice's website.
The practice had implemented many suggestions for We found the service was responsive to patients' needs and improvements and made changes to the way it delivered had sustainable systems in place to maintain the level of services as a consequence of the PPG feedback. These service provided. The practice was innovative and willing included the introduction of text messaging to remind to take on new approaches to meet the needs of their patients when their appointment was and the patients. We saw that the practice offered an management of patients who regularly failed to attend for anti-coagulation monitoring and dosing clinic for patients their appointment.
on warfarin (a medicine that is given to stop clots formingin the blood). A practice nurse led the clinic and was The practice had achieved and implemented the gold supported by a GP through the practice's buddying system.
standard framework for end of life care. They had a The clinic supported up to 75 patients removing the need palliative care register and had regular internal as well as for them to travel to the hospital and provided patients multidisciplinary meetings to discuss patients and their with their test results immediately. The practice had also families' care and support needs. As a consequence of staff opted into the Flo hypertension monitoring system which training and better understanding of the needs of patients, enabled patients to monitor their own blood pressure the practice had 23 patients on their end of life register. The using a text messaging service. This included a 20 minute practice had developed a personalised care pathway for patient education session and the loan of a blood pressure the care of the dying patient which involved advanced monitoring devise. The patient texted their results to Flo.
planning and symptomatic support. It was supported by an The GP analysed the results weekly and responded with end of life policy and a palliative care policy and protocol.
the appropriate advice. This system ran alongside the Tackle inequity and promote equality
practice's own system for monitoring high blood pressure The practice had recognised the needs of different groups and offered choice to patients who preferred to use text in the planning of its services. The practice staff told us messaging as part of their management.
there was a nearby housing association that The needs of the practice population were understood and accommodated temporary residents. They told us there systems were in place to address identified needs. The NHS was also a nearby residential drug and alcohol addictionLocal Area Team (LAT) and Clinical Commissioning group centre. The practice had a policy to accept patients living in (CCG) told us that the practice engaged regularly with them these areas as a temporary resident to ensure they had and other practices to discuss local needs and service access to primary medical services during their time there.
improvements that needed to be prioritised. We saw The practice informed us they had a policy to accept minutes of meetings where this had been discussed and homeless patients and any patient who lived within their actions agreed to implement service improvements and practice boundary irrespective of race, culture, religion or manage delivery challenges to its population. This sexual preference. They told us all patients received the included A&E referrals and the introduction of an urgent same quality of service from all staff to ensure their needs care dashboard. The dashboard provided practices with the facility to identify frequent attenders to A&E. The use of Patients with learning difficulties were provided with an special notes when sharing information between the annual health review and health advice leaflets in an easy practice and the out of hours service was also discussed read format. The primary care mental health team offered and plans put in place to support practices in the use of appointments at the practice. This enabled patients with this service.
mental health difficulties to receive counselling and The practice had an active Patient Participation Group treatment in surroundings that were familiar to them and (PPG) to help it to engage with a cross-section of the maintained their discretion. The practice had completed practice population and obtain patient views. We spoke 170 care plans for some of their most vulnerable patients.
with the chair of the PPG who explained their role and how The majority of these patients were elderly and included all they worked with the practice. They told us there was a Dr Law & Partners Quality Report 08/01/2015 Are services responsive to people's needs?(for example, to feedback?) their patients in care homes as well as housebound and There were arrangements in place to ensure patients mobile elderly patients. Representatives from three of the received urgent medical assistance when the practice was care homes confirmed care plans had been put in place closed. This was provided by an out-of hours service. If with the agreement of the patient.
patients called the practice when it was closed, there wasan answerphone message giving the telephone number We saw that the premises and services met the needs of they should ring depending on the circumstances.
patients with disabilities such as hearing and mobility Information on the out-of-hours service was provided to difficulties. We saw there were baby changing facilities and patients on the practice's website, in the patient's practice that breast feeding mothers were offered a private room in guide and displayed in the reception area.
which to feed their babies.
There were arrangements to ensure that care and The practice population was 91.5% British or mixed British.
treatment was provided to patients with regard to their Whilst the majority of the practice population were English disability. There was a hearing loop system available for speaking there was a four per cent eastern European patients with a hearing impairment and clear signage population which was increasing. Staff told us they had informing patients where to go. There was a wheelchair access to a telephone translation service if a patient did not available for patients with mobility problems, a disabled speak English.
toilet and disabled parking spaces. Consulting rooms were Access to the service
situated on the ground floor of the practice making rooms The practice opened 8am until 6pm Monday to Friday. The easily accessible for patients. The waiting area was large practice opened from 8am to accommodate working age enough to accommodate patients with wheelchairs and patients. It was closed from 12.30pm until 1.30pm on prams and allowed for easy access to the treatment and Thursdays for staff training. Appointments could be booked consultation rooms.
up to four weeks in advance, by telephone or face to face.
Listening and learning from concerns and
There were also a limited number of online appointments available. Emergency appointments were provided on the The practice had a system in place for handling complaints day or the GP rang the patient back. Six of the 18 patients and concerns. We saw their complaints policy was in line we spoke with told us that getting through on the with recognised guidance and contractual obligations for telephone to book an appointment could be difficult GPs in England. There was a designated responsible person however, 15 of the 18 patients we spoke with told us they who handled all complaints in the practice. Patients were were satisfied with the timing of the appointments they made aware of how to complain by a poster in the reception area, through the practice's website and The practice told us the demand for appointments was information in the practice leaflet. Reception staff informed continually increasing with patients transferring from other us they tried to deal with complaints at source and practices. They recognised that patient satisfaction with informed the practice manager immediately. We looked at access to appointments had fallen from excellent to the practice's complaints register for 2013-2014 and saw difficult in the latest GP patient survey. They showed us a they had received 19 complaints. We saw that all summary of four appointment audits that had been carried complaints had been investigated, analysed andout throughout 2014. We saw changes to the ratio of on the responded to in a timely manner. Where learning had taken day and pre-bookable appointments had been made to try place there was a system in place to share learning with to meet patients' requirements. Changes to the practice staff members.
boundary had also been trialled and text messaging Staff told us that there was an open and transparent reminders introduced. A robust system had been put in culture in place and their concerns were listened to. We place to address patients who constantly failed to attend saw there was a whistleblowing policy in place. Staff we for their appointments. The practice informed us there spoke with were aware of why whistleblowing was would be on-going monitoring and that they had been important and who to go to if they had any concerns. They working with the PPG, LAT and CCG to address this issue.
were also aware of where to locate the policy if they Spokespersons for these groups confirmed they had.
needed to refer to it for support Dr Law & Partners Quality Report 08/01/2015 Are services well-led? (for example, are they well-managed and do senior leaders listen, learn and take appropriate action) The practice held weekly business meetings and six weeklypartners' meetings. The practice manager held regular Vision and Strategy
meetings with the administrative staff and the lead nurseheld regular team meetings with clinical staff. We looked at The practice had a clear vision to deliver high quality care minutes from the last partner's meeting which contained and promote good outcomes for patients. There had been updates from the nursing and administrative meetings. We several staff changes at the practice over the previous year saw that performance, quality and risks had been but the management team were in the process of considering their three to five year business plan. Thepractice values were clearly displayed in the waiting areas, The practice held a General Medical Services (GMS) in the staff room, on their website, in their patient charter contract with NHS England for delivering primary care and patient practice guide. It stated, ‘Our aim is to offer the services to their local community. As part of this contract, best personal care to you and your family'.
quality and performance was monitored using the Qualityand Outcomes Framework (QOF). The QOF rewards We spoke with 13 members of staff and they all understood practices for the provision of 'quality care' and helps to and demonstrated the vision and values and knew what fund further improvements in the delivery of clinical care.
their responsibilities were in relation to these. The We looked at the QOF data for this practice which showed it practice's strategy to achieve their vision placed a high was performing in line with national standards scoring 99.4 emphasis on supporting staff through education, training out of a possible 100 points.
and embracing new and innovative ideas. We saw thatprogress against delivering this was monitored and The practice used clinical audit to monitor quality and reviewed at the GP partner's business meeting. We looked systems to identify where action needed to be taken. The at the minutes from this meeting which included practice had completed a number of clinical audits, for monitoring of education and training; finance; example the prescribing of Strontium Ralenate, a medicine commissioning and federation; staffing and personal; used in the treatment of osteoporosis. Following an alert information technology and communication; contract from the Medicines and Healthcare Products Regulatory arrangements and clinical governance. We saw there was Agency (MHRA) relating to Strontium Ralenate and system in place whereby the lead practice nurse and the cardiovascular safety the practice reviewed all patients practice manager shared updates from the nursing and prescribed this medicine to consider whether or not to continue treatment. The first audit cycle identified that eight patients were receiving this medication. All patientswere called in for a review of their medication. A second There was an effective governance framework in place to audit cycle identified that all the patients had received a support the delivery of good quality care. The practice had medication review and their prescription stopped where invested in a governance system. The system contained clinically indicated and replaced by an alternative.
around 170 policies which could be download and adaptedto meet the practices' needs. We saw that the practice had The practice had robust arrangements for identifying, downloaded the appropriate policies for its service and recording and managing risks. The practice manager adapted them to reflect the needs of their patients. The showed us their risk log which addressed a wide range of practice manager and senior GP partner told us this potential issues, such as Control of Substances Hazardous ensured that all areas of service delivery followed best to Health (COSHH), asbestos, fire safety, buildings practice and were up to date. The practice manager had a maintenance, access to appointments and prevention of management task planner in place for 2014-2015 which the legionella virus. We saw that the risks were regularly identified when each policy was due to be reviewed. We discussed at team meetings and updated in a timely way.
saw that policies had been reviewed in line with the task Risk assessments had been carried out where risks were planner. Staff we spoke with were aware of where to locate identified and action plans had been produced and the policies if they needed to refer to them for support or implemented. For example, we saw there was subsidence and cracks in the plaster at the practice. We were shown Dr Law & Partners Quality Report 08/01/2015 Are services well-led? (for example, are they well-managed and do senior leaders listen, learn and take appropriate action) risk assessments, action plans, quotes and timeframes for and why it was important. Whistleblowing occurs when an the repair work to be completed. A fire risk assessment and internal member of staff reveals concerns to the asbestos management plan had been completed which organisation or the public, and their employment rights are confirmed that the building was safe.
Leadership, openness and transparency
The practice recognised the importance of the views of There was a clear leadership structure with named patients and had systems in place to do this. This included members of staff in lead roles. For example there was a the use of patients' comments, analysis of complaints, lead nurse for infection control, a GP lead for training and patient surveys and working in partnership with the Patient development and a GP lead for safeguarding. We spoke Participation Group (PPG). Results of patients' surveys and with 13 members of staff and they were all clear about their PPG comments were shared with patients through theown roles and responsibilities. They told us they felt valued, practice website. We saw that the PPG had developed anwell supported and knew who to go to in the practice with action plan and the practice had worked with the PPG to any concerns.
carry out the issues within the action plan. The chairperson for the PPG confirmed that they had a very good The lead nurse at the practice was also the chair of the working relationship with the practice and that the partners local practice nurses' forum. The lead practice nurse was were open and honest and listened to what they said.
not available to speak with on the day of our inspection.
Another nurse at the practice told us that they and practice Management lead through learning &
nurses from other practices found this forum informative, supportive and provided peer review. We looked at the The practice had been a GP training practice for qualified minutes from the last forum which showed that current doctors to become general practitioners since 1992. The issues were discussed and the opportunity to compare best ethos of learning and improvement in terms of knowledgepractice between services was provided. For example, with and skills was evident throughout the inspection. There the approach of winter, updates and discussion had taken was a lead GP responsible for the induction and overseeing place regarding vaccinations for influenza, pneumonia and of the GP registrar's training. We spoke with a GP registrar shingles. The GP partners told us they recognised the who told us there was strong leadership within the practice.
leadership role their lead practice nurse held within and There was a buddying system in place to support GP outside of the practice and were committed to supporting registrars that provided them with a named GP who they her. The lead nurse at the practice also sat on the regional had direct access to for advice and support. The senior GP practice nurse panel and had promoted student nurse partner told us that they had been asked by the deanery of placements in general practice.
the local university to support two GP registrars whoneeded additional support to complete their GP training.
We saw minutes that demonstrated that meetings such as The GP registrars went on to successfully complete their team, business and partners' meetings were held on a regular basis. Staff told us that there was an open culturewithin the practice and they had the opportunity and were We were shown evidence that staff in all roles were happy to raise issues at team meetings.
provided with a thorough induction process. We saw that Practice seeks and acts on feedback from users,
staff had access to a range of training opportunities. We public and staff
looked at records which showed that all staff training wasup to date. The lead practice nurse had completed an Feedback and comments by staff were encouraged, extended nurse prescriber's course alongside a health listened to and acted upon. The practice actively assessment module. This had enabled them to lead in encouraged the participation and involvement of staff areas such as health reviews for patients with learning through annual appraisals. Team meetings were held for difficulties. The practice had reviewed the effectiveness of staff and they were encouraged to add items to the agenda these additional skills and had committed to supporting that they wished to discuss. Staff told us they felt involved another practice nurse through the extended nurse and listened to within the practice. There was a whistleblowing policy available for staff at the practice andstaff we spoke with understood what whistleblowing was Dr Law & Partners Quality Report 08/01/2015 Are services well-led? (for example, are they well-managed and do senior leaders listen, learn and take appropriate action) Staff told us that the practice supported them to maintain The practice had completed reviews of significant events their clinical professional development through training and other incidents. There was no system in place for and mentoring. We looked at three staff files and saw that recording when learning had been shared with staff but the regular appraisals took place. Staff told us that the practice senior GP partner told us staff were informed via meetings was very supportive of training and that they had weekly and on a one to one basis. For example, we saw a patient practice based learning sessions which included such had become very aggressive towards a member of staff. We issues as learning from audits and complaints and guest saw that appropriate action was taken by the practice to speakers from outside of the practice. We saw there was a protect other staff. The practice informed us that staff had meeting schedule for the whole of the year which was been reminded of procedures to follow in the event of this clearly displayed in the staffroom. Staff were also provided with protected learning time each week to ensure that theirmandatory training was up to date. The partners from thepractice valued learning and improvement and we saw thatthis had a regular agenda item in the partner's businessmeetings.
Dr Law & Partners Quality Report 08/01/2015
The relationship between riverine lithium isotope composition and silicate weathering rates in iceland
Earth and Planetary Science Letters 287 (2009) 434–441 Contents lists available at Earth and Planetary Science Letters The relationship between riverine lithium isotope composition and silicateweathering rates in Iceland N. Vigier , S.R. Gislason K.W. Burton , R. Millot , F. Mokadem a CRPG-CNRS, Nancy-Université, 15 rue ND des Pauvres, 54501 Vandoeuvre les Nancy Cedex, Franceb Univ. of Iceland, Icelandc The Open University, Milton Keynes, UKd BRGM, Metrology, Monitoring, Analysis Division, 3 Av. Claude Guillemin, BP 6009, 45060 Orleans Cedex 2, France