Download Factual accuracy comments log for the draft report

Factual accuracy comments log for the draft report
Please fill in all parts of this form and return by email to:
[email protected], or by post to: CQC PMS Inspections, Citygate,
Gallowgate, Newcastle upon Tyne, NE1 4PA
Account Number:
Our reference:
Location name:
Location address:
Page
number
e.g. Pg
10
Heading
e.g. Is the
Service
Safe?
Suggested changes with explanation
e.g. change last sentence from 10 staff to 15
staff
Well-led
Not enough information on our novel appointment system –
as well as appointments through day, we have defined time
for paperwork/admin, deliberately engineered break points to
ensure case discussion and support, home visiting triage,
co-operative approach between duty and visiting doctor to
cope with fluctuations in demand, and duty doctor available
to triage any cases that arrive, the system is ready for 8-8
working should it arrive– we mentioned this in our intro
presentation and on our evidence page
No mention of the fact that we introduced telephone
appointments 3 years ago for advice, reviews, paperwork,
sick notes, results discussion (well before other surgeries),
well received, convenient, effective with low conversion rate
– we mentioned this in our intro presentation and on our
evidence page
No mention of safety built into appointment system (no more
than 9 face to face appointments at any one time, protected
admin time (free from interruption and distraction), cooperative approach between duty and visiting doctor to avoid
one getting swamped with work) – we mentioned this in our
intro presentation and on our evidence page
No mention of specific feature of our home visiting policy
which involves earlier visiting thereby avoiding bulge of
admissions to hospital late afternoon/early evening (this is
entirely in line with CCGs previous winter pressures initiative
to help hospitals cope with surges in demand) ) – we
mentioned this in our intro presentation and on our
evidence page
Our workload management policy was not only shared by
LMC with all Derbyshire practices – it was actually highly
commended (see October 2015 edition of Derbyshire LMC
newsletter), there is no mention of this. The meeting of
February 10, 2016 with clinical director Royal Derby, LMC
and CCG chair, was postponed due to junior doctors strike, it
is now scheduled for May 11, 2016
LMC is also involved in the meeting to discuss workload
management
P24
Well-led
P24
Safe
P14
Effective
P16
Well-led
P24
Well-led
P24
N/a
1-557956698
INS1-561249064
Ivy Grove Surgery
The Ivy Grove Surgery, Steeple Drive, Ripley,
Derbyshire, DE5 3TH
Safe/Effective
No mention anywhere in the report of anything about our
Recall system which has been developed from scratch,
encompasses lab tests, procedures, DMARD monitoring,
QOF recall) – we mentioned this in our intro presentation
CQC
decision CQC
comments
e.g.
or X
explanation
of decision
P14
Safe
P14
Safe
P14
Safe
P14
Safe
P14
Safe
P14/22
Safe/Responsive
P16
Effective
P18
Effective
P18
Effective
P18
Effective
P18
Effective
and on our evidence page
No mention of our defined process for distribution of results
and workflows during leave/sickness) – we mentioned this
in our intro presentation and on our evidence page
No mention of our receptionists following in-house developed
‘RED’ list to ensure emergency patients (e.g. heart attack,
stroke) are appropriately dealt with) – we mentioned this in
our intro presentation and on our evidence page
No mention of our process of ensuring that every patient
seen in office hours and needing a two week cancer referral
actually leave the building with a hospital appointment
(ensures no patients are missed), and those seen out of
office hours receive a phone call with the appointment from
our admin team the next working day) – we mentioned this
in our intro presentation and on our evidence page
No mention of our lone working policy which has a secret ‘I
am in danger’ code so that staff will know to discreetly call
the police) – we mentioned this in our intro presentation
and on our evidence page
No mention of our anticoagulation service. This is an
additional service which not all practices do. We have all
trained staff and lead in this area) – we mentioned this in
our intro presentation and on our evidence page
No mention that we are a registered Yellow Fever Centre
(again an additional service that not all practices do).
Convenient for patients of other practices – we have
provided a travel service for the practice up the road for the
last 3 years as they do not have any trained staff to do it
themselves) – we mentioned this in our intro presentation
and on our evidence page
No direct mention of additional services that we carry out –
dementia screening, care home initiative, admission
avoidance, CCG prescribing quality scheme, CCG winter
pressures initiative etc (again not all practices do this) – we
mentioned this in our intro presentation and on our
evidence page
Under consent to care and treatment, templates written
exclusively for counselling and consent for implants, coils,
injections, i.e., invasive procedures) – we mentioned this in
our intro presentation and on our evidence page
Under improving outcomes for people, no mention of our
involvement in prescribing quality scheme using our unique
alert system for (1) ensuring that patients at risk of acute
kidney injury receive education about this (we met our 12
month target within about 6 weeks of starting this and have
now reached 78% of the at risk group) and (2) deprescribing
medications using a similar alert (met our 12 month target
within 2 weeks) this was so effective that the medicines
management team was interested to learn the technique so
that the process could be shared more widely with other
practices) – we mentioned this in our intro presentation and
on our evidence page
No mention at all of our extensive mail merge document
system, which allows clinicians to generate hard-copy
request and referral forms, which (1) are quick and easy,
saving time in already pressured consultations, (2) form a
contemporaneous record within the patient’s notes and (3)
can be reprinted if lost by patients (happens more often that
you think!) ) – we mentioned this in our intro presentation
and on our evidence page
Although mention is made of our wide ranging system of
alerts, under ‘supporting patients’, no mention is made of our
other alerts which we demonstrated to the inspection team
on the day, e.g., patients who have a ‘do not resuscitate’
order, palliative care traffic light status, if patient is on
admission avoidance or learning disabilities register, whether
P7, P18
Older people
P25
Well-led
P22, P25
Responsive /
Well-led
P24
Well-led
P24
Well-led
P24
Well-led
P24
Well-led
N/a
N/a
P25
Well-led
P18
Effective
DMARD monitoring is overdue or up to date. This are all
custom in-house programmed alerts developed over time
from staff ideas to help improve care) – we mentioned this
in our intro presentation and on our evidence page
Over 75s day is not on March 2016, it will be held on May
18, 2016. Minutes of organisation meetings have been
posted online on our improvements page
Only one description of our newsletter, in that is it ‘regular’!
This is a high quality publication, going for 14 years now,
very popular with our patients, we work with other agencies
to get articles for it (e.g., youth clubs, citizens advice, carers
association), our patient group writes regularly in it, it is
available in PDF format, online and of course paper format
from reception desk. It is regularly within top few hits for
‘patient newsletter’ or ‘patient newsletters’ on google – this is
due to good quality content which people want) – we
mentioned this in our intro presentation and on our
evidence page
No direct mention of our mobile ready/smartphone site.
Again not all practices have such a thing) – we mentioned
this in our intro presentation and on our evidence page
We have held Away Days for 20 years, well before they
became fashionable or the norm
No direct mention of our self-managing team leaders in
reception and nursing (help to plan rotas, determine skill-mix,
involved in interviewing for new staff etc) ) – we mentioned
this in our intro presentation and on our evidence page
No mention of professional rota software, dropboxes (cloud
storage) for collaboration and ensuring documents safe and
available at any time (e.g. business continuity plan) ) – we
mentioned this in our intro presentation and on our
evidence page
No mention of any of our numerous links with outside
agencies (slide 63 of our intro presentation), e.g. Amber
Valley Collective, Sublocality, one of salaried Drs is chair of
the CCG, work with LMC, part of EMIS service users group,
IM&T, Primary Care Development, etc, including Sir Stephen
Moss) – we mentioned this in our intro presentation and on
our evidence page
No mention of loyal staff and longevity of employment (4
employed >25 years, others from school leaving) – we
mentioned this in our intro presentation and on our
evidence page
Under ‘continuous improvement’ as part of our forward
thinking we are looking at other initiatives and aspiring to
more improvements (these were mentioned in the intro
presentation): overarching strategy for housebound patients
and care planning, IT developments (e.g., laptop/iPad on
home visits, texting service), active prescribing review,
aspiring to become a training practice
Inspection team asked for information on the significant
improvements we had made to our IT systems – we provided
comprehensive information on this on our CQC
improvements page
including information on how patient outcomes had improved
as a result. However only two examples were mentioned.
The CQC improvements page documents this all in great
detail, but we are concerned that nothing is mentioned of our
consistent approach to developing the IT Infrastructure over
many years, backed up by evidence of meetings,
presentations, protocols.
There is also insufficient detail on our unique work with EMIS
Web in developing all our own in-house templates, vast
protocols, more on our alerts and why and how they improve
patient outcomes, not only the pop-up alerts already
mentioned, but others such as Acute Kidney Injury Initiative,
Deprescribing initiative (as part of Prescribing Quality
Scheme), in-house customisation of EMIS Web's lightning
bolt function to provide quick and easy access to commonly
used computer entries, templates and protocols enabling
consistent and necessary data entry necessary for QOF and
other work; vast array of mail merge documents developed
in-house, e.g., referral forms, request forms, ranging from
blood forms and X-ray requests; care planning with advice
information sheet; huge variety of searches and reports to
help aid care; developed Recall System from scratch to
enable safe and efficient recall of any patient on QOF
register, those needing repeat blood tests or procedures and
drug monitoring for DMARDs
Our website is unique and custom built, we work to strategy
of providing quick and easy access to information with easy
to remember web address shortcut ivy.gs promoted at every
opportunity, in leaflets, right hand side of prescriptions,
posters, online, we have variety of simple and easy to digest
posters on website to inform patients of services and
appropriate sources of help - example page on website or
see posters e.g., surgery website facilities, minor injuries
unit, telephone appointments, nurses appointments
Newsletter articles series - Day in Life of...(surgery team
member), Make the Most of your GP, Did You Know...?
popular and informative articles to empower patients;
enabling effective use of our services - see example
newsletter with all three series; electronic subscriptions to
newsletter subscription service nearly 200 subscribers;
online services page - centralised page where online
services can be accessed, allows repeat prescription
ordering, viewing of aspects of record, booking and
cancelling of online appointments convenient for patients;
time-saving; medical advice pages to help patients to selfcare or to access appropriate help; unique postcode checker
to allow prospective patients to see if they live within our
practice boundary
No mention of our other IT developments whilst these
innovations are not directly involved in patient care, they free
up time so that our staff can work on other jobs that are
directly related to patient care, including use of dropboxes
(cloud storage) allows collaboration between staff, safe
backup of items (e.g., business continuity plan), remote
access if needed; room rota shared online so that outside
agencies can check availability without having to regularly
trouble management, also management uploads updated
rota directly back online again without needing to trouble IT
lead (i.e., me!); professional rota software used to write
clinician rotas, freeing up time for other job; system-wide
annual leave planner which self-updates with bank holiday
dates and accessible by all staff to allow booking of leave,
calculation of entitlement, totalling of all types of leave, e.g.,
study leave, sickness leave, parental leave etc; management
accounting spreadsheet to enable instant profit/loss,
quarterly review statements, cashflow projection without
having to spend time doing detailed analysis of current
accounting situation; paper-light approach to work, using
EDT (Electronic Document Transfer), OOH notifications
listed on single sheet A4; all policies shared on practice
intranet (Docman Library), with staff views and comments all
audited
P20
Caring
n/a
P17
Effective
P14
Safe
P16, P25
Effective, Wellled
P16
Effective
P14, P16
Safe, Effective
No mention at all of our care co-ordinator and community
matron, who together provide excellent care for elderly
patients and those with long-term conditions – care coordinator contacts every patient on admission avoidance
register who has been discharged from hospital, organises
care, liaises with other agencies, our community matron
carries out home visits autonomously on patients with long
term conditions, polypharmacy, frail and elderly. They are a
crucial and valued part of our team – we mentioned this in
our intro presentation and on our evidence page
No mention of extensive and consistent positive feedback
from patients and others on our messages page
– we mentioned this in our intro presentation
Not enough information on our unique online locum pack,
gives comprehensive insight into how we work, e.g.,
syringe drivers, who does which joint injections, doctors’
interests, layout of building, where toilets are etc, entire
section on emergencies and contact details, e.g.,
safeguarding
No mention that list of safeguarding contacts are all readily
available in each consultation room, reception, also on
template for safeguarding, and finally also in locum pack, so
easily and readily available from multiple sources – we
mentioned this in our intro presentation and on our
evidence page and also demonstrated this on
the day
No mention of staff account of flu clinics – well led, team
event, jovial relaxed atmosphere, all backed up with
efficient protocol – we mentioned this on our evidence
page, also specific flu page on website at flu page for
patients
No mention of our custom in-house programming of EMIS
lightning bolt function that gives quick and easy access
within consultations to most of the important protocols,
templates, procedures, clinical findings, letters, enabling
more efficient working – we mentioned this in our intro
presentation and on our evidence page
No mention at all of our drug monitoring protocols for
DMARDs, QOF conditions, miscellaneous drugs, all backed
up with unique 1 page drug monitoring chart giving all staff
an easy to use reference – this has been used copied by
other practices and commended by our Medicines
Management team – we mentioned this in our intro
presentation and on our evidence page
(Include additional rows if required)
Completed by (name(s))
Michael Wong and Charmagne Stephenson
Position(s)
Registered Manager/CQC lead and Practice Manager
respectively
Date
7/3/16