Practice profile: What "Outstanding" looks like

IT'S hard to say what I was expecting on my visit to Orchard Court Surgery. Certainly not the ordinary one-storey brick building I arrive at by taxi, hidden among almost identical houses in a tightly packed residential area of Darlington.

Inside the waiting room it’s bright and pleasant but again little different from a hundred other GP practices across England – and yet this somehow makes it seem even more extraordinary given that Orchard Court was in May of this year rated "Outstanding" by the Care Quality Commission (CQC).

Sue McMillan, CQC deputy chief inspector of general practice, said: "The care we observed at the practice really was excellent. It sets a high standard that every GP practice should seek to attain."

I have come to meet practice manager Karen Fuat to try and discover what has set Orchard Court apart in the eyes of the regulator – and also to ask how the practice prepared for the ordeal of a CQC inspection.

COMETH THE INSPECTORS

Karen has worked at Orchard Court for over 27 years, joining first as a young receptionist. Today it has a medium-sized list of around 7,700 patients, reasonably distributed over age ranges and with deprivation levels lower than the national average.

The practice is unusual in having seven doctors, all but one of them part-time (making rotas tricky). There are also three practice nurses, a practice assistant, a secretary and no fewer than seven part-time receptionists. Karen also works with a deputy manager.

Certainly her long experience in primary care has been an important factor in the success of the practice. "I know general practice inside and out. I have been there and gone through all the changes," she says.

First hearing that the practice was to be inspected by the CQC was a bit unnerving, admits Karen. "You get notified a fortnight in advance. All of Darlington were told they would be visited – and we were going to be the first. But I didn’t feel scared because I was organised. I think if you weren’t organised it would be a bit of a nightmare."

In fact Karen had been anticipating this day ever since the practice first registered with the CQC. She had read all the information available on the CQC website, highlighting what was required and working through training slides with practice staff.

"Every general practice in England knows that at some stage they are going to be visited by the CQC. You know more or less what they are going to be asking for. You just have to be organised and methodical."

First thing that Monday morning after learning of the inspection Karen began gathering the evidence required by the CQC in advance of the inspection. All of this had to be compiled as email attachments: practice statement of purpose, minutes of PPG (patient participation group) meetings, patient surveys, SEA reports, clinical audits, complaints audits, recruitment and training policies, induction checklists and more.

"I also had to do an essay," says Karen. "They wanted to know evidence and examples of the quality of care provided for six specific population groups."

In preparation she met with her deputy, the GPs and other practice staff and ran through a standard set of key lines of enquiry (KLOEs) which the CQC use to help rate practices. These relate to five key questions – are services safe, effective, caring, responsive and well-led.

INSPECTION DAY

On the appointed day three CQC inspectors arrived at 8:30am. The team comprised a CQC lead inspector, a GP and practice manager. Karen first gave a 30-minute presentation setting out the philosophy at Orchard Court: "we aim to provide accessible high quality healthcare to all patients in a friendly, open, non-judgemental and professional atmosphere." She then explained how this was reflected in the practice culture and its management and approach to patients – and particularly in relation to the five key questions. The inspection team then split up to focus on different aspects of care such as treatment and outcomes, infection control, governance and HR policies.

"The practice manager [inspector] walked around the waiting room looking at all our posters, seeing if they were relevant," says Karen. "She talked to patients, interviewed my healthcare assistant. She then interviewed a member of our PPG."

This was followed after lunch by a three hour meeting in which the inspector asked Karen to run through all the practice policies and procedures. "She basically sat in my office and asked can I have a look at this and a look at that. And I had everything to hand."

The visit finished later that day with a meeting in which the inspectors provided some immediate feedback to the senior practice team. In the case of Orchard Court it was almost all positive. Says Karen: "It was great to get feedback. We all work hard and it helps to be told once in a while that you are doing a good job."

We weren’t really expecting Outstanding. We know we are good. We always aim to be very good but we didn’t expect to be Outstanding.

THE REPORT

Twelve weeks later when the CQC published its report Karen was both shocked and delighted. "We weren’t really expecting Outstanding. We know we are good. We always aim to be very good but we didn’t expect to be Outstanding."

She shows me her copy of the report which bristles with multi-coloured stickies. "I went through it with a fine-tooth comb as you can see." The report found the practice Outstanding in four categories: safe, caring, responsive and well-led, and it was rated Good in providing effective services. Orchard Court also demonstrated "elements of outstanding practice" across six main population groups: older people; people with long term conditions; families, children and young people; working age people; vulnerable people and people experiencing poor mental health.

Among some of the highlights the inspectors praised the practice for its "open culture" in which safety concerns raised by staff and patients were integral to learning and improvement. "People here do feel comfortable about raising issues," says Karen. She puts this down in part to an egalitarian spirit among staff. "I am the manager but I don’t think I’m any more special. We are all on an equal level – doctors, nurses, cleaners. I can’t do their job and they can’t do mine."

The inspectors also cited specific safety initiatives such as a "buddy system" in which when one GP is away from the practice another takes responsibility for their letters, results and queries, and actions them.

The report also praised the "patient-centred culture" at the practice, stating: "We found many positive examples to demonstrate how patients’ lives were enhanced through the caring and supportive actions of staff." These included a scheme to support diabetic Muslim patients during Ramadan and another dealing with recently bereaved patients and families in which a GP makes contact and a condolence card is sent.

"I think absolutely everyone in this building goes over and above what we are asked to do," says Karen.

The inspectors were also impressed with the rapid and flexible appointment system at Orchard Court – and how the practice coordinates their appointments to reduce the number of times a patient has to attend. Karen explains: "If someone is seen by a GP who then wants some blood tests. They don’t go to the desk and make another appointment. The patient will have the blood test done right then by an HCA. Our GPs don’t want an 80-year-old lady having to come back the next day."

Many more examples of outstanding care at Orchard Court can be found in the full inspection report.

It is evident that much of the success at Orchard Court is down to good teamwork and the leadership provided by Karen and her partners. The report commented: "The cohesiveness shown amongst the whole team was remarkable…There was a high level of constructive engagement with staff and a high level of staff satisfaction."

Karen was pleased that this was so evident in the inspection. "I am very close to my staff. They never need an appointment to see me. My door is always open."

So what is her advice for other practices contemplating their turn with the CQC?

"You know at some stage they are coming. They have been coming for the last two years," she says. "Start getting organised now. It’s not going to take that long – and all the information is there on the website."

Jim Killgore is an associate editor of MDDUS Practice Manager

Image: Simon Ryder