Evergreen Practice

On this page

• Overview
• Assessing needs
• Delivering evidence-based care and treatment
• How staff, teams and services work together
• Supporting people to live healthier lives
• Monitoring and improving outcomes
• Consent to care and treatment

During the assessment we reviewed policies, spoke with staff, and undertook observations while on site. We found the following: • There were clear examples of how the practice had supported patients with communication needs to maximise the effectiveness of their care and treatment. • Results of the GP Patient Survey indicated patients felt involved in their care and treatment and were confident in the healthcare provided by professionals they saw or spoke with. • Staff confirmed they followed evidence-based guidance when planning care and treatment for patients. • We found no evidence of missed diagnosis for diabetes or chronic kidney disease stages 3, 4 or 5.

This service scored 75 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The practice explained it offered double appointments to patients with a learning disability to ensure they were able to support the patient to maximise their health and well-being. We heard an example of how a member of the nursing team had identified a patient with a learning disability who was non-verbal and was encouraged to communicate their consent to a procedure, such as phlebotomy, by squeezing a ball. We found there was a monthly multi-disciplinary team meeting to review patients receiving end of life care. There was also a locality cluster meeting every six weeks to assess patients in the community, which was attended by health visitors, social services, the community mental health team and district nurses. These meetings helped the practice to be involved in care planning for patients that were vulnerable and needed additional support.

We asked the provider to place a link on their website to our Give Feedback on Care process so we could hear of patients’ experiences of care. We received 24 pieces of feedback during the assessment period and of these submissions, 22 were positive and 2 were negative. There were 5 pieces of positive feedback which specifically praised individual clinicians about the quality of the care and treatment they had provided and the difference the patients felt it had made to them. We also reviewed the results of the GP Patient Survey (GPPS) and found the percentage of patients who stated that during their last GP appointment they had been involved in decisions about their care and treatment as much as they wanted to be, was 93%, compared to a national average of 90.3%

Our remote clinical searches reviewed the care and treatment of patients with the following long-term conditions: asthma, chronic kidney disease stages 3 – 5, hypothyroidism and diabetes. We found 11 patients had been prescribed 2 or more courses of rescue steroids in response to exacerbations of their asthma. Our GP specialist advisor sampled the records of 5 patients and found patients were issued emergency steroid cards when required. However, in one patient’s record we found they had been assessed by telephone consultation and there was no documentation to record the clinician’s assessment of the patient and whether face to face follow up was required. Our review of patients with chronic kidney disease stages 3 to 5 found 1 patient that was overdue monitoring tests, however, our GP specialist advisor reviewed the patients record and found no concerns with the care provided. The practice used advanced analytical tools which included local population health data and identified patients with moderate or severe frailty. This helped the practice to plan and assess patients’ needs.

Our remote clinical searches identify patients potentially overdue routine monitoring within the required timescales. Our searches indicated the practice had 141 patients with hypothyroidism (hypothyroidism is a condition which means the thyroid gland is underactive and does not produce enough hormones). Monitoring tests check whether the amount of hormones produced by the thyroid are within the normal range and determine how it should be treated. Our search identified 5 patients and our GP specialist advisor reviewed all of these patients’ clinical records. We found 1 patient had not been invited for monitoring tests recently and the other 4 had only been recalled within the month preceding our assessment. We identified 34 patients with diabetes who had a HbA1c result greater than 75mmol/l at their last monitoring appointment (HbA1c is the average blood glucose (sugar) levels for the last 2-3 months and is used to give an indication of how well controlled a patient’s diabetes is). We reviewed 5 records and found 3 patients had received appropriate follow up and annual reviews, however 2 patient’s records required further review by the practice. We highlighted these patients to the practice who immediately reviewed them and found 1 patient was being monitored in secondary care and the other had stopped taking the medication so did not require monitoring. Our remote clinical searches included a review of patients taking a disease-modifying anti rheumatic drug (DMARD). These medicines are used to treat autoimmune conditions and require regular monitoring to ensure that complications are identified early. The searches identified 3 of 13 patients prescribed a DMARD had not had monitoring tests in the required timescale. Our GP specialist advisor reviewed the 3 patients’ records and found all were being monitored in secondary care but the practice did not have complete patient records to ensure patients’ were prescribed to safely and their health was optimised.

We did not look at How staff, teams and services work together during this assessment. The score for this quality statement is based on the previous rating for Effective.

We did not look at Supporting people to live healthier lives during this assessment. The score for this quality statement is based on the previous rating for Effective.

Our remote clinical searches included a search for any patients with a potential missed diagnosis of diabetes and chronic kidney disease stages 3, 4 or 5 and the searches did not identify any potential missed diagnoses. We also reviewed patients taking medicines to treat raised blood pressure (hypertension), heart failure and some patients with chronic kidney disease. Our remote searches identified 351 patients who were prescribed these medicines and indicated 29 were overdue required monitoring. Our GP specialist advisor reviewed a sample of 5 of those patients and found no concerns with the monitoring for 3 patients. 1 patient was overdue their review and needed their condition coding in their record and another patients needed a blood test which the practice arranged once we made them aware. The practice confirmed it would review the remaining patients identified by the searches as potentially overdue monitoring. We found limited evidence of a programme of clinical audit activity within the practice. An audit provided by the practice in relation to patients taking direct oral anticoagulants (DOACs) included 2 audit cycles. The audit showed that after the second cycle, less patients were overdue monitoring tests as per national guidance but it provided limited detail about how this had been achieved. Another audit focusing on patients taking sodium valproate and of childbearing age, identified a patient not taking a highly effective contraceptive but did not detail next steps or confirm another cycle of audit would be repeated.

We did not look at Consent to care and treatment during this assessment. The score for this quality statement is based on the previous rating for Effective.