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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 –––

DrDr AA RR VVernonernon andand PPartnerartnerssQuality Report

Wallingford Medical PracticeReading RoadWallingfordOxfordshireOX10 9DUTel: 01491 835577Website: wallingfordmedicalpractice.co.uk

Date of inspection visit: 28/01/2015Date of publication: 16/04/2015

1 Dr A R Vernon and Partners Quality Report 16/04/2015

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 Dr A R Vernon and Partners 10

Why we carried out this inspection 10

How we carried out this inspection 10

Detailed findings 12

Overall summaryLetter from the Chief Inspector of GeneralPracticeWe carried out an announced comprehensive inspectionat Dr AR Vernon and Partners at Wallingford MedicalPractice, Reading Road, Wallingford, Oxfordshire OX109DU on 28 January 2015.

Overall the practice is rated as good.

Specifically, we found the practice to be good for all areasincluding all the population groups.

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

• Staff understood and fulfilled their responsibilities toraise concerns and report incidents and near misses.All opportunities for learning from internal andexternal incidents were maximised.

• Patients said they were treated with compassion,dignity and respect and they were involved in theircare and decisions about their treatment. Informationwas provided to help patients understand the careavailable to them.

• The practice implemented suggestions forimprovements and made changes to the way itdelivered services as a consequence of feedback frompatients and from the Patient Participation Group(PPG).

• The practice had good facilities and was well equippedto treat patients and meet their needs. Informationabout how to complain was available and easy tounderstand

• The practice had a clear vision which had quality andsafety as its top priority. High standards werepromoted and owned by all practice staff withevidence of team working across all roles.

We saw several areas of outstanding practice including:

• The practice had an effective and efficient leadershipstructure which included future practice planning. Allstaff shared the practice objectives to deliver highquality person centred care. There was a very strongquality and educational ethos in the practice throughreporting and analysis of significant events and itsaudit programme.

Summary of findings


• The patient participation group, known as theWallingford patients in partnership (PIP) workedclosely with the practice through monthly meetings.The PIP had organised a well-advertised and attendedpractice open day in 2014. This was now scheduled asan annual event. A representative of the PIP wasrecently involved in the interviews for a new GPpartner.

• The practice had installed floor level wash basins tofacilitate dressings changes for patients with leg andfoot ulcers.

However there were areas of practice where the providerneeds to make improvements.

The provider should

• Ensure all medicines management procedures arefollowed consistently and the controlled drugsprocedures include the disposal process.

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

Summary of findings


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

Are services safe?The practice is rated as good for providing safe services. Staffunderstood and fulfilled their responsibilities to raise concerns andreport incidents and near misses. The practice used everyopportunity to learn from internal and external incidents, to supportimprovement. Information about safety was highly valued and wasused to promote learning and improvement. Risk management wascomprehensive, well embedded and recognised as theresponsibility of all staff. There were enough staff to keep patientssafe.

Good –––

Are services effective?The practice is rated as good for providing effective services. Ourfindings at inspection showed that systems were in place to ensurethat all clinicians were up to date with both National Institute forHealth and Care Excellence guidelines and other locally agreedguidelines. We also saw evidence to confirm that these guidelineswere positively influencing and improving practice and outcomesfor patients. Data showed that the practice was performing highlywhen compared to neighbouring practices in the CCG. The practiceidentified 269 patients with complex needs who all had a care planin place and priority access to a GP via a dedicated phone line. Thepractice had consistently achieved 100% in the clinical domain ofthe Quality and Outcomes Framework (QOF) since 2006 and 100%overall for the last two years. The practice was on track to achievethe same this year (2014/15). The practice had identified 531diabetic patients and provided six monthly reviews for all its diabeticpatients as they considered annual reviews to be insufficient toadequately monitor their condition. The majority of patients withlong term conditions had received annual reviews of their condition:93% of patients with chronic obstructive pulmonary disease (lungdisease), 72% of patients with asthma and 100% patients with heartfailure. Eighty per cent of patients with dementia had an annualreview in the previous year. The practice kept a register of allpatients with a learning disability and 51 out of 84 patients had anannual review of their condition so far this year and 100% last year.

Good –––

Are services caring?The practice is rated as good for providing caring services. Datashowed that patients rated the practice higher than others for mostaspects of care. Feedback from patients about their care andtreatment was consistently and strongly positive. We observed apatient-centred culture. Staff were motivated and inspired to offer

Good –––

Summary of findings


kind and compassionate care and worked to overcome obstacles toachieving this. We found many positive examples to demonstratehow patient’s choices and preferences were valued and acted on.Views of external stakeholders were very positive and aligned withour findings.

Are services responsive to people’s needs?The practice is rated as good for providing responsive services. Thepractice had initiated positive service improvements for its patientsthat were over and above its contractual obligations. It acted onsuggestions for improvements and changed the way it deliveredservices in response to feedback from the patient participationgroup (PPG). The practice reviewed the needs of its local populationand engaged with the NHS England Area Team and ClinicalCommissioning Group (CCG) to secure service improvements wherethese had been identified.

Patients told us it was easy to get an appointment and a named GPor a GP of choice, with continuity of care and urgent appointmentsavailable the same day. The practice had good facilities and waswell equipped to treat patients and meet their needs. Informationabout how to complain was available and easy to understand, andthe practice responded quickly when issues were raised. Learningfrom complaints was shared with staff and other stakeholders.

Good –––

Are services well-led?The practice is rated as good for being well-led. The practice had aclear vision with quality and safety as its top priority. High standardswere promoted and owned by all practice staff and teams workedtogether to achieve these. Governance and performancemanagement arrangements had been proactively reviewed andtook account of current models of best practice. The practice carriedout proactive succession planning. There was a high level ofconstructive engagement with staff and a high level of staffsatisfaction. The practice gathered feedback from patients usingnew technology, and it had a very active patient participation group(PPG) also known as the Wallingford patients in partnership (PIP).The PIP worked closely with the practice through monthly meetings.The PIP had organised a well-advertised and attended practiceopen day in 2014. This was now scheduled as an annual event. Arepresentative of the PIP was recently involved in the interviews of anew GP partner.

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 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.

Older people were a large part of the registered practice population.The practice considered the needs of older people in the provisionof the service. For example, they had developed care plans for 269patients with complex needs. The practice worked closely with fivelocal nursing homes to ensure patients received consistent carefrom a named GP. A dispensing service for patients who lived morethan one mile from a pharmacy was provided and a prescriptioncollection and delivery service. The practice had installed floor levelwash basins to facilitate dressing changings for patients with leg andfoot ulcers.

Good –––

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

For those patients with the most complex needs, the named GPworked with relevant health and care professionals to deliver amultidisciplinary package of care. The practice had identified 531diabetic patients and provided six monthly reviews for all its diabeticpatients as they considered annual reviews to be insufficient toadequately monitor their condition. This practice was not an outlierfor any QOF (or other national) clinical targets. The majority ofpatients with long term conditions had received annual reviews oftheir condition: 93% of patients with chronic obstructive pulmonarydisease (lung disease), 72% of patients with asthma and 100%patients with heart failure. Longer appointments and home visits

Good –––

Summary of findings


were available when needed. The practice achieved 100% in theclinical domain of the quality and outcomes framework (QOF)consistently over five years and 100% across all domains for theprevious two years.

Families, children and young peopleThe practice is rated as good for the care of families, children andyoung people. For example, children and young people who had ahigh number of A&E attendances. Last year’s performance for childimmunisations was in line with the CCG average for all age groups.Patients told us that children and young people were treated in anage-appropriate way and we saw evidence to confirm this. Allchildren under the age of one were given an appointment the sameday. Appointments were available outside of school hours.

Good –––

Working age people (including those recently retired andstudents)The practice is rated as good for the care of working-age people(including those recently retired and students). The needs of theworking age population, those recently retired and students hadbeen identified and the practice had adjusted the services it offeredto ensure these were accessible, flexible and offered continuity ofcare, for example early morning and late evening appointmentswere offered. The practice was proactive in providing online servicesas well as a full range of health promotion and screening thatreflects the needs for this age group.

The practice had weekly Saturday morning surgeries toaccommodate the needs of working age people. The practice alsooffered the convenience of a daily phlebotomy service, well womanclinic, minor conditions managements and travel immunisations.

Good –––

People whose circumstances may make them vulnerableThe practice is rated as good for the care of people whosecircumstances may make them vulnerable. The practice held aregister of patients living in vulnerable circumstances includingthose with a learning disability. It had carried out annual healthchecks for people with a learning disability and all of these patientshad received a follow-up. It offered longer appointments for peoplewith a learning disability.

The practice regularly worked with multi-disciplinary teams in thecase management of vulnerable people. It had told vulnerablepatients about how to access various support groups and voluntaryorganisations. Staff knew how to recognise signs of abuse invulnerable adults and children. Staff were aware of theirresponsibilities regarding information sharing, documentation of

Good –––

Summary of findings


safeguarding concerns and how to contact relevant agencies innormal working hours and out-of-hours. A dispensing service forpatients who lived more than one mile from a pharmacy wasprovided and a prescription collection and delivery service.

A small number of patients with a learning disability and diabeteshad been supported to manage their conditions. The practicenurses taught the patients’ carers to administer insulin to thepatients. This contributed to maintaining the patients’independence and impacted on their quality of life.

People experiencing poor mental health (including peoplewith dementia)The practice is rated as good for the care of people experiencingpoor mental health (including people with dementia). Ninety oneper cent of people experiencing poor mental health had received anannual physical health check. The practice regularly worked withmulti-disciplinary teams in the case management of peopleexperiencing poor mental health, including those with dementia.The practice was working towards the joint Oxfordshire dementiaplan to increase awareness and improve identification of patients atrisk of dementia. Eighty per cent of patients with dementia had anannual review in the previous year. GPs worked with the communitymental health team to develop care plans for patients with severemental health conditions.

The practice provided information about how to access appropriategroups and voluntary organisations.

It also provided an in-house counselling service and also referredpatients to ‘Talking Therapies’.

Good –––

Summary of findings


What people who use the service sayThe most recent national GP survey data (January 2015)for Dr AR Vernon and Partners based on 123 completedsurveys (47% response), showed very good satisfaction.For example, 91% of respondents rated their overallexperience of the surgery as good and 86% wouldrecommend the surgery. The areas for improvement fromthe national survey were in relation to access toappointments: 50% of respondents said they found iteasy to get through to this surgery by phone compared tothe local average of 85% and 76% of respondents foundthe receptionists at this surgery helpful compared to 87%.

We spoke with 12 patients during the inspection. All thepatients we spoke with were extremely positive about thecare and treatment they received. They told us staffprovided compassionate care. Three patientscommented they had noticed an improvement inobtaining appointments in the previous few months.

We received 28 comments cards from patients. All thecomments were positive and referred to the kindness andconsideration of GPs, nurses and reception staff. Nonegative comments were recorded.

Areas for improvementAction the service SHOULD take to improve

• Ensure all medicines management procedures arefollowed consistently and the controlled drugsprocedures include the disposal process.

Outstanding practice• The practice had an effective and efficient leadership

structure which included future practice planning. Allstaff shared the practice objectives to deliver highquality person centred care. There was a very strongquality and educational ethos in the practice throughreporting and analysis of significant events and itsaudit programme.

• The patient participation group, known as theWallingford patients in partnership (PIP) worked

closely with the practice through monthly meetings.The PIP had organised a well-advertised and attendedpractice open day in 2014. This was now scheduled asan annual event. A representative of the PIP wasrecently involved in the interviews for a new GPpartner.

• The practice had installed floor level wash basins tofacilitate dressings changes for patients with leg andfoot ulcers.

Summary of findings


Our inspection teamOur inspection team was led by:

Our inspection team was led by a CQC Lead Inspectorand a GP. The team included a CQC pharmacyinspector, a specialist in practice management and aspecialist in practice nursing.

Background to Dr A R Vernonand PartnersDr AR Vernon and Partners, also known as WallingfordMedical Centre, Medical Practice is located in purpose builtpremises in a semi-rural area in the grounds of WallingfordCommunity Hospital. It holds personal medical services(PMS) contract to provide primary medical services toapproximately 16,300 registered patients. The practicedispenses prescriptions to approximately 3300 patients.

Care and treatment is led by six GP partners and fourassociate GPs. There are equal numbers of male andfemale GPs. The practice has three GP trainees, six practicenurses, administration, reception staff, dispensary staffand one practice manager; a total of 50 staff. The practicehas been accredited to provide training to GP trainees.

The practice has a higher proportion of patients over theage of 40 years compared to the local Oxfordshire ClinicalCommissioning Group (CCG) and national average and alower proportion in the 15-34 year age group. The practiceserves a population which is significantly more affluentthan the national average.

The practice takes an active role within the OxfordshireClinical Commissioning Group (CCG) to develop services inthe area.

The practice has opted out of providing out-of-hoursservices to its own patients. There are arrangements inplace for patients to access care from an out-of-hoursprovider, NHS 111.

We visited the practice location at Wallingford MedicalPractice, Reading Road, Wallingford, Oxfordshire, OX109DU.

Why we carried out thisinspectionWe carried out a comprehensive inspection of this serviceunder Section 60 of the Health and Social Care Act 2008 aspart of our regulatory functions. This inspection wasplanned to check whether the provider was meeting thelegal requirements and regulations associated with theHealth and Social Care Act 2008, to look at the overallquality of the service, and to provide a rating for the serviceunder the Care Act 2014.

This provider was inspected in July 2014 and we identifiedimprovements were needed in relation to recruitment. Weinspected the practice on 28 January 2015 to checkwhether improvements had been made.

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 thisinspectionPrior to the inspection we contacted the OxfordshireClinical Commissioning Group (CCG), NHS England areateam and local Healthwatch to seek their feedback about

DrDr AA RR VVernonernon andand PPartnerartnerssDetailed findings


the service provided by Dr AR Vernon and Partners. We alsospent time reviewing information that we hold about thispractice including the action plan they provided followingtheir previous inspection.

The inspection team carried out an announced visit on 28January 2015. We spoke with 12 patients and 13 staff. Wealso reviewed 28 comment cards from patients who hadshared their views and experiences.

As part of the inspection we looked at the managementrecords, policies and procedures, and we observed howstaff interacted with patients and talked with them. Weinterviewed a range of practice staff including GPs, nursingstaff, managers and administration and reception staff.

To get to the heart of patients’ experiences of care andtreatment, we always ask the following five questions:

• Is it safe?

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

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

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

and students)• People whose circumstances may make them

vulnerable• People experiencing poor mental health (including

people with dementia)

Detailed findings


Our findingsSafe track recordThe practice used a range of information to identify risksand improve patient safety. For example, reportedincidents and national patient safety alerts as well ascomments and complaints received from patients. The staffwe spoke with were aware of their responsibilities to raiseconcerns, and knew how to report incidents and nearmisses.

We reviewed safety records, incident reports and notes ofmeetings where these were discussed for the last 12months. This showed the practice had managed theseconsistently over time and so could show evidence of asafe track record over the long term. Significant eventreports covered a range of issues including concerns aboutpossible child abuse, medicine errors, diagnostic delaysand problems with the telephone system.

Learning and improvement from safety incidentsThe practice had a system in place for reporting, recordingand monitoring significant events, incidents and accidents.There were records of significant events that had occurredduring the last 12 months and we were able to reviewthese. A dedicated meeting was held monthly to reviewsignificant events including actions and learning. There wasevidence that the practice had learned from these and thatthe findings were shared with relevant staff. Staff, includingreceptionists, administrators and nursing staff, knew howto raise an issue for consideration at the meetings and theyfelt encouraged to do so.

Staff used incident forms on the practice intranet and sentcompleted forms to the practice manager. We saw thesystem in place to track incidents to ensure they weremonitored and managed in a timely manner. We reviewed32 reports of significant events that had been identifiedand recorded in the previous 12 months. The practiceencouraged reporting of significant events and usedlearning to improved patient safety. There were norecurrent themes identified in the significant events. Wefound they had been completed by GPs, nursing staff andadministration staff on a range of incidents includingprescribing, clinical decision making and poorcommunication with other providers.

National patient safety alerts were disseminated by thepractice manager to practice staff. Nursing staff we spokewith confirmed they received alerts and took theappropriate action.

Reliable safety systems and processes includingsafeguardingSystems were in place to safeguard children and adults. Adesignated GP partner was the practice lead forsafeguarding children. Safeguarding policies andprocedures consistent with the local clinicalcommissioning group (CCG) and Local Authority guidelineswere in place to protect children and vulnerable adults.

Safeguarding information, including local authoritycontacts, were accessible on the practice intranet. Staffdemonstrated an understanding of safeguarding childrenand vulnerable adults and the potential signs to indicate aperson may be at risk. All staff had received training insafeguarding children. All GPs had level three safeguardingchildren training. At the previous inspection we found therewas a lack of staff training on safeguarding adults. Thepractice had taken action and provided staff with adultsafeguarding training and a named GP lead for adultsafeguarding was identified. Staff were able give examplesof where they had raised concerns about patients’ safety inand outside the practice. There was a system to highlightvulnerable patients on the practice’s electronic recordsystem.

There was a notice displayed behind the reception desk toremind and prompt patients to request a chaperone ifdesired. (A chaperone is a person who acts as a safeguardand witness for a patient and health care professionalduring a medical examination or procedure). All nursingstaff, including health care assistants, had been trained tobe a chaperone. Reception staff would act as a chaperoneif nursing staff were not available. Receptionists had alsoundertaken training and understood their responsibilitieswhen acting as chaperones, including where to stand to beable to observe the examination. Staff who undertookchaperone duties had disclosure and barring service (DBS)checks in place.

Medicines managementWe checked medicines kept in the treatment rooms andmedicine refrigerators and found they were stored securelyand were only accessible to authorised staff. There was aclear policy for ensuring that medicines were kept at therequired temperatures, which described the action to take

Are services safe?

Good –––


in the event of a potential failure. However, we found staffdid not consistently follow this policy. We found sixoccasions when the temperature was out of range and noexplanation had been recorded or action taken.

Processes were in place to check medicines were withintheir expiry date and suitable for use. All the medicines wechecked were within their expiry dates. Expired andunwanted medicines were disposed of in line with wasteregulations.

The practice prescribing lead reviewed monthly prescribingdate provided by the CCG and performance was discussedat monthly meetings. This showed the practice prescribingin all areas compared favourably with the CCG average.

The nurses and the health care assistant administeredvaccines using directions that had been produced in linewith legal requirements and national guidance. We sawup-to-date copies of both sets of directions and evidencethat nurses and the health care assistant had receivedappropriate training to administer vaccines. A member ofthe nursing staff was qualified as an independentprescriber and she received regular supervision andsupport in her role as well as updates in the specific clinicalareas of expertise for which she prescribed.

There was a system in place for the management of highrisk medicines, which included regular monitoring in linewith national guidance. Appropriate action was takenbased on the results. We saw the practice had carried out anumber of audits to monitor checks were carried out whenthese medicines were prescribed. For example, regularblood tests were taken and issues communicated to theNHS Trust hospital if appropriate.

All prescriptions were reviewed and signed by a GP beforethey were given to the patient. Blank computer forms werestored securely, however, the recording of these blankforms was not in accordance with national guidance asthese were not tracked through the practice.

The practice held stocks of controlled drugs (medicinesthat require extra checks and special storage arrangementsbecause of their potential for misuse) and had in placestandard procedures that set out how they were managed.However, these did not include the disposal process. Staffdemonstrated they were aware of how to handle CDs. Forexample, controlled drugs were stored in a controlleddrugs cupboard and access to them was restricted and thekeys held securely.

Practice staff undertook regular audits of controlled drugprescribing to look for unusual products, quantities, dose,formulations and strength. Staff were aware of how to raiseconcerns around controlled drugs with the controlleddrugs accountable officer in their area.

Dispensing staff at the practice were aware prescriptionsshould be signed before being dispensed. If prescriptionswere not signed before they were dispensed, staff wereable to demonstrate that these were risk assessed and aprocess was followed to minimise risk. We saw that thisprocess was working in practice.

The practice had a system in place to assess the quality ofthe dispensing process and had signed up to theDispensing Services Quality Scheme, which rewardspractices for providing high quality services to patients oftheir dispensary. The GP lead for dispensing analysed thereported dispensing errors. They supported dispensarystaff to review the dispensary procedures to improve safetyand reduce risks.

Records showed that all members of staff involved in thedispensing process had received appropriate training andtheir competence was checked regularly.

The practice had established a prescription home deliveryservice for elderly patients and those patients who couldnot attend the practice due to illness or mobility issues.

Cleanliness and infection controlWe observed the premises were clean and tidy. We sawthere were cleaning schedules in place and cleaningrecords were kept. Patients we spoke with told us theyalways found the practice clean and had no concernsabout cleanliness or infection control. Daily cleaningschedules were followed and monitored. We saw evidencethat when issues were identified they were raised with thecontractor.

Systems were in place to reduce the risks of spread ofinfection. A designated member of staff was the practiceinfection control lead person. They demonstrated a goodunderstanding of their role. All staff had received training ininfection control and were aware of infection controlpractices. For example, we observed staff used personalprotective equipment such as gloves and saw that theydisposed of clinical waste safely.

The practice infection control lead carried out fortnightlyinfection control audits. Our review of the last audit

Are services safe?

Good –––


showed improvements had been carried out, for example,wall mounted couch rolls were installed and foot operatedbins. There was also a plan to replace carpets and softfurnishings with hard floors and washable materials asneeded.

EquipmentStaff we spoke with told us they had sufficient equipmentto enable them to carry out diagnostic examinations,assessments and treatments. They told us that allequipment was tested and maintained regularly and wesaw equipment maintenance logs and other records thatconfirmed this. All portable electrical equipment wasroutinely tested and displayed stickers indicating the lasttesting date. A planned maintenance and testing schedulewas followed. Regular checks on the premises andequipment were in place to ensure they were fit to use. Forexample, service checks on gas, electricity and fireequipment were all up to date. We saw evidence of testingof relevant equipment; for example, ECG machine andpremises alarm.

Staffing and recruitmentRecords we reviewed contained evidence that appropriaterecruitment checks had been undertaken prior toemployment. For example, proof of identification,references, qualifications, registration with the appropriateprofessional body and criminal records checks through theDisclosure and Barring Service (DBS). The practice had arecruitment policy that set out the standards it followedwhen recruiting clinical and non-clinical staff.

Staff told us about the arrangements for planning andmonitoring the number of staff and mix of staff needed tomeet patients’ needs. We saw there was a rota system inplace for all the different staffing groups to ensure thatenough staff were on duty. There was also an arrangementin place for members of staff, including nursing andadministrative staff, to cover each other’s annual leave.

Staff told us there were usually enough staff to maintainthe smooth running of the practice and there were alwaysenough staff on duty to keep patients safe.

The majority of practice staff worked part time whichallowed for some flexibility in the way the practice wasmanaged. For example, staff were available to work

overtime if needed and available for annual leave andsickness absence cover. A bank of regular GP locums wasused to ensure familiarity with practice procedures and adegree of continuity of care for patients.

There were recruitment and selection processes in place.Staff described the recruitment process which followedbest practice guidelines. We reviewed a sample of ten fileswhich confirmed the required pre-employmentinformation had been sought. These included all therequired information including a curriculum vitae orapplication form, one or two references, occupationalhealth check, photographic identity and professionalregistration check. The practice had made improvementswith regards to obtaining Disclosure and Barring Service(DBS) checks for all staff working at the practice or theycarried out a DBS risk assessment to record a DBS checkwas not needed. For example, in the case of reception staffwho did not carry out chaperone duties.

Monitoring safety and responding to riskThe 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 were told issues and risks were discussed at GPpartners’ meetings and within team meetings. For example,staff cover during busy times, issues with the phone systemand patient appointments. Meeting notes showeddiscussions took place and actions were agreed to improvethe situation.

The practice had considered the risks of delivering theservice to patients and staff and had implemented systemsto reduce risks. We observed the practice was organisedand tidy. We saw the provider had carried out a range ofrisk assessments reviewing environmental and personalrisks, to ensure the health and safety of patients, visitorsand staff members. For example, in relation to staffing,premises, fire and environmental issues such as inclementweather.

Are services safe?

Good –––


Arrangements to deal with emergencies and majorincidentsThe practice had arrangements in place to manageemergencies. Records showed that all staff had receivedtraining in basic life support. Emergency equipment wasavailable including access to oxygen and an automatedexternal defibrillator (used to attempt to restart a person’sheart in an emergency). When we asked members of staff,they all knew the location of this equipment and recordsconfirmed that it was checked regularly.

Emergency medicines were available in a secure area of thepractice and all staff knew of their location. These included

those for the treatment of cardiac arrest, anaphylaxis andhypoglycaemia. Processes were also in place to checkwhether emergency medicines were within their expirydate and suitable for use.

A business continuity plan was in place to deal with a rangeof emergencies that may impact on the daily operation ofthe practice. Each risk was rated and mitigating actionsrecorded to reduce and manage the risk. Risks identifiedincluded power failure, adverse weather, unplannedsickness and access to the building. The document alsocontained relevant contact details for staff to refer to. Forexample, contact details of essential suppliers.

Are services safe?

Good –––


Our findingsEffective needs assessmentThe GPs and nursing staff we spoke with could clearlyoutline the rationale for their approaches to treatment.They were familiar with current best practice guidance, andaccessed guidelines from the National Institute for Healthand Care Excellence (NICE) and from local commissioners.We saw notes of practice meetings where new guidelineswere disseminated, the implications for the practice’sperformance and patients were discussed and requiredactions agreed. The staff we spoke with and the evidencewe reviewed confirmed that these actions were designed toensure that each patient received support to achieve thebest health outcome for them. We found from ourdiscussions with the GPs and nurses that staff completedthorough assessments of patients’ needs in line with NICEguidelines, and these were reviewed when appropriate.

The GPs told us they led in specialist clinical areas such asdiabetes and dermatology. GPs we spoke with were veryopen about asking for and providing colleagues withadvice and support. GPs told us this supported all staff tocontinually review and discuss new best practice guidelinesas part of their daily meetings and in their weekly clinicalmeetings.

We reviewed prescribing data from the local clinicalcommissioning group (CCG). Wallingford Medical Practicefully participated in all the elements of the local prescribingincentive scheme 2013/

14. It achieved two out of three areas of the schemeincluding a reduction in antimicrobial prescribing.

The practice identified 269 patients with complex needswho were at greater risk of admission to hospital. This wasmore than 2% of the practice registered list size. Thepractice ensured all these patients had a care plan in placeand priority access to a GP via a dedicated phone line.

CCG data showed the practice was in the lower one third ofreferrals for all major specialities except for ear nose andthroat (ENT). Where referral rates were higher thanexpected the practice carried out an audit to identify ifimprovements were needed and we saw an example of thisfor ENT referrals.

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 outcomesfor peopleStaff across the practice had key roles in monitoring andimproving outcomes for patients. These roles includeddata input, scheduling clinical reviews, and managing childprotection alerts and medicines management. Theinformation staff collected was then collated by thepractice manager and deputy practice manager to supportthe practice to carry out clinical audits. Daily searches werecarried out on the disease registers of patients with longterm conditions. These identified patients who had notattended for regular reviews and they were followed upwith recall appointments to encourage attendance.

One of the GP trainers led on clinical audit. Monthly clinicalmeetings were held to discuss audit findings. The practiceshowed us seven clinical audits that had been undertakenin the previous 12 months. Three of these were completedaudits where the practice was able to demonstrate thechanges resulting since the initial audit. A wide range ofclinical audits in a rolling audit programme had beenundertaken which showed practice was measured againstcurrent best evidence and demonstrated adherence tocurrent guidelines to monitor changes in practice andoutcomes for patients. For example, one audit looked atblood test results for patients with gout. Recommendationswere made to review patients with gout in line withaccepted guidelines and re-audit in 12 months. Anotheraudit was an annual audit of dispensing errors to identify ifthere were common trends. Other examples includedaudits to confirm that the GPs who undertook minorsurgical procedures were doing so in line with theirregistration and NICE guidance. Clinical audits were oftenlinked to medicines management information, safety alertsor as a result of information from the quality and outcomesframework (QOF). QOF is a national performancemeasurement tool. For example, we saw an audit regardingthe prescribing of high risk drugs which required regularblood tests to monitor patient safety and effectiveness.

The practice had consistently achieved 100% in the clinicaldomain of the Quality and Outcomes Framework (QOF)since 2006 and 100% overall for the last two years. The

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

Good –––


practice was on track to achieve the same this year (2014/15). The QOF is part of the General Medical Services (GMS)contract for general practices. It is a voluntary incentivescheme which rewards practices for how well they care forpatients. The practice maintained and managed patientswith a range of long term conditions in line with bestevidence based practice.

The practice also used the information collected for theQOF and performance against national screeningprogrammes to monitor outcomes for patients. Thepractice had identified 531 diabetic patients and providedsix monthly reviews for all its diabetic patients as theyconsidered annual reviews to be insufficient to adequatelymonitor their condition. The majority of patients with longterm conditions had received annual reviews of theircondition: 93% of patients with chronic obstructivepulmonary disease (lung disease), 72% of patients withasthma and 100% patients with heart failure. Eighty percent of patients with dementia had an annual review in theprevious year. GPs worked with the community mentalhealth team to develop care plans for patients with severemental health conditions. This practice was not an outlierfor any QOF (or other national) clinical targets.

The team was making use of clinical audit tools, clinicalsupervision and staff meetings to assess the performanceand support their GPs and nursing staff. Daily clinicalmeetings were held where GP trainees and trainersdiscussed issues and agreed a course of action forindividual patients. This was supplemented by weeklytutorials for GP trainees. The staff we spoke with discussedhow, as a group, they reflected on the outcomes beingachieved and areas where this could be improved. Staffspoke positively about the culture in the practice aroundaudit and quality improvement; this was facilitated by daily‘coffee morning’ meetings and formal weekly clinicalmeetings.

There was a protocol for repeat prescribing which was inline with national guidance. In line with this, staff regularlychecked that patients receiving repeat prescriptions hadbeen reviewed by the GP. They also checked that all routinehealth checks were completed for long-term conditionssuch as diabetes and that the latest prescribing guidancewas being used. The IT system flagged up relevantmedicines alerts when the GP was prescribing medicines.We saw an example of an audit carried out as a result of anew alert of a potential drug interaction to review all

patients prescribed the drug and ensure safe and effectiveprescribing. The evidence we saw confirmed that the GPshad oversight and a good understanding of best treatmentfor each patient’s needs.

Effective staffingPractice staffing included medical, nursing, managerial andadministrative staff. We reviewed staff training records andsaw that all staff were up to date with attending mandatorycourses such as annual basic life support. We noted a goodskill mix among the doctors with two GPs with a specialinterest in diabetes and one with a diploma indermatology. All GPs were up to date with their yearlycontinuing professional development requirements and alleither have been revalidated or had a date for revalidation.(Every GP is appraised annually, and undertakes a fullerassessment called revalidation every five years. Only whenrevalidation has been confirmed by the General MedicalCouncil can the GP continue to practise and remain on theperformers list with NHS England).

All staff undertook annual appraisals that identifiedlearning needs from which action plans were documented.Our interviews with staff confirmed that the practice wasproactive in providing training and funding for relevantcourses, for example diploma in dermatology for one of theGPs. As the practice was a training practice, doctors whowere training to be qualified as GPs were allocatedextended appointments and had access to a senior GPthroughout the day for support. We received positivefeedback from the trainees we spoke with.

Practice nurses were expected to perform defined dutiesand were able to demonstrate they were trained to fulfilthese duties. For example, on administration of vaccines,cervical cytology and contraceptive implant devices. Thosewith extended roles, for example in diabetes and asthmawere also able to demonstrate that they had appropriatetraining to fulfil these roles.

Staff files we reviewed showed that where poorperformance had been identified appropriate action hadbeen taken to manage this.

Working with colleagues and other servicesThe practice worked with other service providers to meetpatients’ needs and manage complex cases. It receivedblood test results, x-ray results, and letters from the localhospital including discharge summaries, out-of-hours GPservices and the 111 service, both electronically and by


Good –––


post. The practice had a policy outlining theresponsibilities of all relevant staff in passing on, readingand acting on any issues arising from communications withother care providers on the day they were received. The GPwho saw these documents and results was responsible forthe action required. All staff we spoke with understoodtheir roles and felt the system in place worked well.

The practice was commissioned for the new enhancedservice and had a process in place to follow up patientsdischarged from hospital. (Enhanced services require anenhanced level of service provision above what is normallyrequired under the core GP contract).

The practice held monthly multidisciplinary team meetingsto discuss the needs of complex patients, for example,those with end of life care needs or children on the at riskregister. These meetings were attended by district nurses,social workers, palliative care nurses and decisions aboutcare planning were documented in a shared care record.Discussion of palliative care patients followed the GoldStandards Framework for end of life care. The GoldStandards Framework is a systematic evidence basedapproach. It is designed to assist healthcare professionalsto optimise care for all patients approaching the end of life.

The practice operated a GP buddy system which ensuredall correspondence and results were managed in a timelymanner to optimise patient care. The GP buddy systemensured all essential duties, for example, checking testresults and signing prescriptions were completed when aGP was on leave.

Information sharingThe practice used several electronic systems tocommunicate with other providers. For example, there wasa shared system with the local GP out-of-hours provider toenable patient data to be shared in a secure and timelymanner. Electronic systems were also in place for makingreferrals, the practice used the Choose and Book system.(The Choose and Book system enables patients to choosewhich hospital they will be seen in and to book their ownoutpatient appointments in discussion with their chosenhospital).

The practice registration information included a leaflet onelectronic patient records. The practice used the electronicSummary Care Record and planned to offer patients access

to their electronic GP record by 31 March 2015. (SummaryCare Records provide faster access to key clinicalinformation for healthcare staff treating patients in anemergency or out of normal hours).

The practice had systems to provide staff with theinformation they needed. Staff used an electronic patientrecord to coordinate, document and manage patients’care. All staff were fully trained on the system, andcommented positively about the system’s safety and easeof use. This software enabled scanned papercommunications, such as those from hospital, to be savedin the system for future reference.

Consent to care and treatmentWe found that GPs were aware of the Mental Capacity Act2005, the Children Acts 1989 and 2004 and their duties infulfilling it. All the clinical staff we spoke with understoodthe key parts of the legislation and were able to describehow they implemented it in their practice. GPs and nurseswere aware of what action to take if they judged a patientlacked capacity to give their consent. They told us theyrecorded best interest decisions, consulted carers withlegal authority to make healthcare decisions and soughtspecialist advice if needed. One of the GPs told us theyinvolved patients and families in discussions beforecompletion of the do not attempt cardiopulmonaryresuscitation form.

Patients with a learning disability and those with dementiawere supported to make decisions through the use of careplans, which they were involved in agreeing. These careplans were reviewed annually (or more frequently ifchanges in clinical circumstances dictated it) and had asection stating the patient’s preferences for treatment anddecisions. All those patients had a care plan in place. Wheninterviewed, staff gave examples of how a patient’s bestinterests were taken into account if a patient did not havecapacity to make a decision. All clinical staff demonstrateda clear understanding of Gillick competencies. (These helpclinicians to identify children aged under 16 who have thelegal capacity to consent to medical examination andtreatment).

There was a practice policy for documenting consent forspecific interventions. For example, for all minor surgicalprocedures, a patient’s verbal consent was documented in


Good –––


the electronic patient notes with a record of the relevantrisks, benefits and complications of the procedure. Wewere shown an audit that confirmed the consent processfor minor surgery had been followed in 100% of cases.

Health promotion and preventionThe practice was aware of the local area health prioritiesand more specifically in relation to their practicepopulation.

It was practice policy to offer a health check with the healthcare assistant or practice nurse to all new patientsregistering with the practice. The GP was informed of allhealth concerns detected and these were followed up in atimely way. We noted a culture among the GPs to use theircontact with patients to help maintain or improve mental,physical health and wellbeing. For example, by offeringopportunistic chlamydia screening to patients aged 18-25and offering smoking cessation advice to smokers.

The practice also offered NHS Health Checks to all itspatients aged 40 to 75 years. Practice data showed that1720 patients had a health check since the initiative startedin 2011. A GP told us how patients were followed uppromptly if they had risk factors for disease identified at thehealth check and how they scheduled furtherinvestigations.

The practice had numerous ways of identifying patientswho needed additional support, and it was pro-active inoffering additional help. For example, the practice kept aregister of all patients with a learning disability and 51 outof 84 patients had an annual review of their condition so farthis year and 100% last year. The practice had alsoidentified the smoking status of 90% of patients over theage of 16 and 99% had been offered smoking cessationadvice.

The practice’s performance for cervical smear uptake was83%, which was above average for the CCG area. Patientswho did not attend for screening were followed up by thepractice.

The practice offered a full range of immunisations forchildren, travel vaccines and flu vaccinations in line withcurrent national guidance. Last year’s performance for childimmunisations was comparable to the CCG average for allage groups. The practice had a clear policy for following upnon-attenders by the GP. The practice achieved 74% fluvaccine uptake in over 65 year olds in the previous year.

A range of information was available on the TV screen inthe reception area and on the practice website, aimed atpatients for health promotion and self-care.


Good –––


Our findingsRespect, dignity, compassion and empathyWe reviewed the most recent data available for the practiceon patient satisfaction. The most recent national GP surveydata (January 2015), based on a good response rate of 123surveys (47%) indicated very good satisfaction. Thepractice achieved above the clinical commissioning group(CCG) average in a number of areas. For example, 91% ofrespondents rated their overall experience of the surgery asgood and 86% would recommend the surgery. Theproportion of patients who stated staff were good attreating them with care and concern was 91% for doctorsand 86% for nurses. Patients were also satisfied with thegood listening skills of both GPs and nurses.

We spoke with 12 patients during the inspection. They werea mix of patients, male and female, parents with youngchildren and older patients. All but one of the patients wespoke with had been with the practice for over five years.We also spoke with two representatives of the Wallingfordpatients in partnership PIP) group. All the patients wespoke with were extremely positive about the care andtreatment they received. They told us staff providedcompassionate care.

We received 28 comments cards from patients. All thecomments were positive and referred to the kindness andconsideration of GPs, nurses and reception staff. Nonegative comments were recorded.

Staff and patients told us that all consultations andtreatments were carried out in the privacy of a consultingroom. 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 saw that staff were careful to follow the practice’sconfidentiality policy when discussing patients’ treatmentsso that confidential information was kept private. Thepractice reception desk was directly in front of the waitingarea; a small room was located adjacent to the receptiondesk to provide privacy if needed.

All staff had received training on information governanceand signed a confidentiality agreement at the start of their

employment. Staff had a good understanding ofconfidentiality and how it applied to their working practice.For example, during the inspection we witnessednumerous caring and compassionate interactions betweenstaff and patients which demonstrated how staff treatedpatients with dignity and respect.

Care planning and involvement in decisions aboutcare and treatmentThe patient survey information we reviewed showedpatients responded positively to questions about theirinvolvement in planning and making decisions about theircare and treatment and generally rated the practice well inthese areas. For example, data from the national patientsurvey showed 82% of practice respondents said the GPsand nurses were good at involving them in decisions abouttheir care and 86% said GPs were good at explaining testsand treatment, compared to 87% for nurses, respectively.Both these results were above average compared to theCCG area.

Patients we spoke with 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.

Staff told us that translation services were available forpatients who did not have English as a first language.However, staff confirmed the facility was very rarely used asthe majority of patients could speak English.

Patients preferred methods of communication wasrecorded and the practice sought the patients consentbefore messages were left on answerphones.

GPs and nurses were aware of what action to take if theyjudged a patient lacked capacity to give their consent. Theytold us they recorded best interest decisions, consultedcarers with legal authority to make healthcare decisionsand sought specialist advice if needed. One of the GPs toldus they involved patients and families in discussions beforecompletion of the do not attempt cardiopulmonaryresuscitation form.

Are services caring?

Good –––


Patient/carer support to cope emotionally withcare and treatmentThe patients we spoke with on the day of our inspectionindicated patients were very positive about the emotionalsupport provided by the practice. Bereaved patients werecontacted by their named GP to offer support.

A list of palliative and vulnerable patients was updateddaily. Staff were aware of patients or recently bereavedfamilies so they could manage calls sensitively and refer tothe GP if needed. A counsellor was offered to bereavedfamilies for support.

Notices in the patient waiting room and patient websitealso told people how to access a number of support groupsand organisations. Information on the TV screen in thewaiting area included support groups for depression andbereavement. The practice’s computer system alerted GPsif a patient was also a carer. We were shown the writteninformation available for carers to ensure they understoodthe various avenues of support available to them.

Are services caring?

Good –––


Our findingsResponding to and meeting people’s needsWe found the practice was responsive to patients’ 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 in the way services were delivered. Wewere told the practice purchased a car from its own fundsto provide a prescription home delivery service for patientswho were unable to attend the practice due to illness ormobility issues. We saw the practice had installed floorlevel wash basins in all the treatment rooms. Practicenurses told us this facilitated the care of patients whorequired leg and foot ulcer dressings.

A daily phlebotomy (the process of taking blood frompatients) service was offered and this began at 8am threedays a week for patients who required certain blood tests.The practice offered a dispensing service for patients wholived more than a mile from a pharmacy, for theirconvenience.

The practice offered a number of services including an earsuction service, a full travel clinic service and was alsoaccredited as a yellow fever centre.

A small number of patients with a learning disability anddiabetes had been supported to manage their conditions.The practice nurses taught the patients’ carers toadminister insulin to the patients. This contributed tomaintaining the patients’ independence and impacted ontheir quality of life.

The practice valued the role of their patient participationgroup (PPG) or as they preferred to call it patients inpartnership (PIP). The PIP is a forum for patients of thepractice to share their experience and engage in improvingthe service for all patients. We reviewed the feedback fromthe 2014 annual survey. The majority of feedback waspositive and suggested improvements included changes tothe appointment system and the car park facilities. Both ofwhich were under review by the practice. For example, thepractice was raising awareness of the appointment systemand was also in discussions with the estate departmentregarding the car park. The IT manager had a role in

supporting patients to use the on line appointment service,they did this by telephone or face to face meetings. Over100 patients had been enabled to use the on line systemthrough this support.

Tackling inequity and promoting equalityThe practice has a higher proportion of patients over theage of 40 years compared to the local Oxfordshire ClinicalCommissioning Group (CCG) and national average and alower proportion in the 15-34 year age group. The practiceserves a population which is significantly more affluentthan the national average. Life expectancy for males andfemales is higher than the national average. The practicepopulation of patients identified from non-white ethnicgroups was 2.5%.

The practice had access to online and telephonetranslation services. However, staff confirmed the facilitywas very rarely used as the majority of patients could speakEnglish.

The practice maintained a register of all patients with alearning disability. One hundred per cent of patients on theregister had annual reviews of their condition in 2013/14and 51 out of 84 patients had an annual review of theircondition so far this year.

The patient areas of the practice were all located on theground floor of the premises. The low reception desk hadbeen designed to accommodate the needs of patients inwheelchairs. We saw that the waiting area was largeenough to accommodate patients with wheelchairs andprams and allowed for easy access to the treatment andconsultation rooms. Accessible toilet facilities wereavailable for all patients attending the practice includingbaby changing facilities.

Access to the serviceAppointments were available from 8am to 6.30pm daily.Extended surgery hours were provided by a surgery onSaturdays 8am to 12.30pm. This access was particularlyuseful to patients with work commitments.

Comprehensive information was available to patientsabout appointments on the practice website. This includedhow to arrange urgent appointments and home visits andhow to book appointments through the website. Therewere also arrangements to ensure patients received urgentmedical assistance when the practice was closed. If

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

Good –––


patients called the practice when it was closed, ananswerphone message gave the telephone number theyshould ring depending on the circumstances. Informationon the out-of-hours service was provided to patients.

The practice operated a flexible appointment system whichinvolved a duty GP, to ensure all patients who needed to beseen the same day were accommodated. Longerappointments were available for people who needed themand those with long-term conditions. Named GPs visitedfive nursing homes weekly. Patients on the ‘unplannedadmission’ register had a dedicated priority line forappointments or to speak to a GP.

Patients were satisfied with the appointments system.Three patients commented they had noticed animprovement in obtaining appointments in recent months.They confirmed that they could see a doctor on the sameday if they needed to and they could see another doctor ifthere was a wait to see the doctor of their choice.Comments received from patients showed that patients inurgent need of treatment had often been able to makeappointments on the same day of contacting the practice.On the day we visited, patients told us they were able toobtain urgent and routine appointments when needed andour review of the appointment system record confirmedthis.

Data from the national patient survey showed the practicecould improve on access to appointments: 50% of

respondents said they found it easy to get through to thissurgery by phone compared to the local average of 85%.76% of respondents find the receptionists at this surgeryhelpful compared to 87% and 73% of respondents describetheir experience of making an appointment as goodcompared to 80%.

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

We saw that information was available to help patientsunderstand the complaints system in the practice leafletand website. Patients we spoke with were aware of theprocess to follow if they wished to make a complaint. Noneof the patients we spoke with had ever needed to make acomplaint about the practice.

We looked at the complaints received since April 2014. Wefound they were appropriately handled and dealt with in atimely way. The practice showed openness andtransparency in dealing with the compliant. Threecomplaints had been reviewed at the ‘significant eventmeetings’ and learning shared. No complaint had beenescalated to the Ombudsman.

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

Good –––


Our findingsVision and strategyWe spoke with 13 members of staff and they all expressedpride in working at the practice. They told us they aimed toprovide high quality care and promote good outcomes forpatients. All staff shared the practice objectives to deliverhigh quality person centred care. The practice website andnew patient leaflet included the practice aim to ‘Treat allour patients promptly, courteously and in completeconfidence’. The practice engaged with the localcommunity through a regular feature in the localWallingford magazine which was delivered to allhouseholds in Wallingford. The senior partner was the chairof the local learning disability charity and this was a priorityarea for the practice.

GP trainees were very positive about the teaching andtraining ethos at the practice. A number of past GP traineeshad often applied for partner and associate vacancy whenthey arose. The practice worked on succession planningwith both GPs and the practice management team tomaintain the smooth running of the practice and its futuredevelopment. The practice was planning to extend itspremises to include more consulting rooms to meet theincreasing demand for its services.

The practice worked collaboratively with the local clinicalcommissioning group (CCG) to develop services andidentify priority areas.

Governance arrangementsThe 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 seven of these policies and procedures and moststaff had completed a cover sheet to confirm that they hadread the policy and when. All seven policies andprocedures we looked were up to date.

There was a clear leadership structure with namedmembers of staff in lead roles. For example, the seniorpartner was the lead for safeguarding adults and there wasa lead nurse for infection control. Other partners had leadroles in finance, training, child protection and prescribing.We spoke with 13 members of staff and they were all clearabout their own roles and responsibilities. They all told usthey felt valued, well supported and knew who to go to inthe practice with any concerns.

The practice used the Quality and Outcomes Framework(QOF) to measure its performance. The QOF data for thispractice showed it consistently achieved 100% in theclinical domain and 100% in total for the previous twoyears. We saw that QOF data was regularly discussed atmonthly team meetings and action plans were produced tomaintain or improve outcomes.

The practice had an ongoing programme of clinical auditswhich it used to monitor quality and systems to identifywhere action should be taken. For example, referralpatterns where the practice or an individual GP wasidentified as an outlier.

The practice had carried out a range of risk assessmentsreviewing environmental and personal risks, to ensure thehealth and safety of patients, visitors and staff members.The practice had a service continuity plan in place in caseof emergency. Relevant contact numbers for staff andresources were recorded in the plan. These were to be usedin the event of an incident that effected the operation ofthe service to ensure, where possible, alternative provisioncould be made and patients were appropriately informed.

The practice had arrangements for identifying, recordingand managing risks. We saw risks were regularly discussedat team meetings and updated in a timely way. Riskassessments had been carried out where risks wereidentified and action plans had been produced andimplemented.

The practice had a monthly schedule of meetings. Theseincluded business/ partners meetings, nursing, dispensarymeetings and administration meetings. We looked at notesfrom the last two meetings and found that performance,quality and risks had been discussed.

Arrangements were in place to ensure staff were clearabout their responsibilities and were familiar with practiceprocedures. An annual practice meeting schedule was inplace which covered administration meetings, clinicalmeetings and business meetings. The meetings supportedstaff and ensured they were kept up to date with changesto practice systems. Staff told us they were comfortable toraise issues and concerns when they arose and wereconfident they would be dealt with constructively.

Every morning an informal clinical meeting was held whichGPs and nurses told us they found very valuable indiscussing day to day clinical issues and obtaining supportfrom colleagues.

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

Good –––


The practice regularly reviewed its policies and proceduresand implemented changes as a result of learning fromserious events.

Leadership, openness and transparencyWe saw from minutes that team meetings were heldregularly, at least monthly. Staff told us that there was anopen culture within the practice and they had theopportunity and were happy to raise issues at teammeetings.

The practice management team were responsible forhuman resource policies and procedures. We reviewed anumber of policies, for example, recruitment,confidentiality and whistleblowing, which were in place tosupport staff. We were shown the electronic staff handbookthat was available to all staff, which included sections onequality and harassment and bullying at work. Staff wespoke with knew where to find these policies if required.

All staff spoke about a desire to provide high quality,patient centred care. The practice benefited fromdedicated long serving staff. Staff described a supportiveand inclusive environment where individual roles werevalued. The GPs in the practice emphasised a strong focuson education and learning for all staff.

Practice seeks and acts on feedback from itspatients, the public and staffThe Wallingford Medical Practice PIP consisted of eight coremembers. We spoke with two representatives of the PIP.They were very enthusiastic about their roles and werecommitted to working with the practice to improveservices. PIP representatives also participated in externalevents such as a carers conference and nationalassociation for patient participation. The PIP held emailaddresses of approximately half of all its registered patientsand used this method of communication. It was alsomindful of patients who did not have internet access andused the local monthly Wallingford magazine tocommunicate messages to patients and the public.

The practice and PIP were proud of the practice open dayheld in April 2014. This had been publicised in the localpress and featured competitions, talks by practice staff andlocal voluntary groups. One hundred and twenty peopleattended the open day. Another open day was planned forSummer of 2015 and expected to be an annual event goingforward The PIP report from 2014 indicated that the groupmainly consisted of older patients. However, they had an

extended virtual group of 180 patients whose views werealso sought. We reviewed the 2014 annual report andreviewed the annual survey results. We were told the surveyresponse was significantly higher than in previous years;1099 responses. The majority of feedback was positive andsuggested improvements included changes to theappointment system and the car park facilities. Both ofwhich were under review by the practice. For example, thepractice was raising awareness of the appointment systemand in discussions with the estate department regardingthe car park. The PIP regularly contributed to the localWallingford magazine which was distributed to allhouseholds in Wallingford and included ‘News from PIP’.

The practice engaged with staff informally and formallythrough staff meetings, appraisals and discussions. Stafftold us they would not hesitate to give feedback anddiscuss any concerns or issues with colleagues andmanagement. Staff gave examples of when they had raisedconcerns if they felt it necessary. Staff told us they feltinvolved and engaged in the practice to improve outcomesfor both staff and patients.

The practice had a whistleblowing policy which wasavailable to all staff in the staff handbook and electronicallyon any computer within the practice. Staff we spoke withwere aware of the policy.

Staff told us they felt valued as part of the practice team.There were opportunities for formal and informalcommunication for staff, to ensure issues were raised andmanaged appropriately. An annual meeting schedule wasin place which included significant event meetings, clinicalmeetings and practice business meetings. The practicewelcomed feedback from the public, via a suggestion boxin the reception area and the NHS choices website. Thepractice had recently introduced the NHS Friends andFamily test.

Management lead through learning andimprovementStaff told us that the practice supported them to maintaintheir clinical professional development through trainingand mentoring. Staff told us that the practice was verysupportive of training.

The practice had made improvements in the opportunitiesfor training and training record keeping for all staff. Staff


Good –––


said they had mandatory training updates. For example, ininfection control, child safeguarding and basic life support.Nursing and dispensary staff reported they were supportedand had received appropriate training.

All the GPs mentioned the practice’s focus on educationand all staff said they had opportunities for development.All staff had been appraised in the last year. Staff told usthey felt the appraisal was a meaningful process andidentified areas for future personal development.

The practice had completed reviews of significant eventsand other incidents and shared with staff at team meetingsto ensure the practice improved outcomes for patients.


Good –––


Dr A R Vernon and PartnersRatingsOverall rating for this serviceAre services safe?Are services effective?Are services caring?Are services responsive to people’s needs?Are services well-led?

ContentsSummary of this inspectionDetailed findings from this inspection

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

The five questions we ask and what we foundAre services safe?Are services effective?Are services caring?

Summary of findingsAre services responsive to people’s needs?Are services well-led?The six population groups and what we foundOlder peoplePeople with long term conditions

Summary of findingsFamilies, children and young peopleWorking age people (including those recently retired and students)People whose circumstances may make them vulnerablePeople experiencing poor mental health (including people with dementia)What people who use the service sayAreas for improvementAction the service SHOULD take to improve

Outstanding practice

Summary of findingsDr A R Vernon and PartnersOur inspection teamBackground to Dr A R Vernon and PartnersWhy we carried out this inspectionHow we carried out this inspectionOur findingsSafe track recordLearning and improvement from safety incidentsReliable safety systems and processes including safeguardingMedicines management

Are services safe?Cleanliness and infection controlEquipmentStaffing and recruitmentMonitoring safety and responding to riskArrangements to deal with emergencies and major incidentsOur findingsEffective needs assessmentManagement, monitoring and improving outcomes for people

Are services effective?Effective staffingWorking with colleagues and other servicesInformation sharingConsent to care and treatmentHealth promotion and preventionOur findingsRespect, dignity, compassion and empathyCare planning and involvement in decisions about care and treatment

Are services caring?Patient/carer support to cope emotionally with care and treatmentOur findingsResponding to and meeting people’s needsTackling inequity and promoting equalityAccess to the service

Are services responsive to people’s needs?Listening and learning from concerns and complaintsOur findingsVision and strategyGovernance arrangements

Are services well-led?Leadership, openness and transparencyPractice seeks and acts on feedback from its patients, the public and staffManagement lead through learning and improvement

Dr A R Vernon and Partners NewApproachComprehensive Report … · 2020. 4. 1. · • Thepatientparticipationgroup,knownasthe Wallingfordpatientsinpartnership(PIP)worked...

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