Clifton Medical Centre

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

We looked for evidence that staff involved people in decisions about their care and treatment and provided them advice and support. Staff regularly reviewed people’s care and worked with other services to achieve this.

At our last assessment, we rated this key question as Good. At this assessment, the rating remains the same.

This service scored 67 (out of 100) for this area. Find out what we look at when we assess this area and How we calculate these scores.

The service made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them.

People felt involved in assessments of their needs and felt confident that staff understood their individual and cultural needs. Reception staff were aware of the needs of the local community. Reception staff used digital flags within the care records system to highlight any specific individual needs, such as the requirement for longer appointments or for a translator to be present. Staff checked people’s health, care, and wellbeing needs during health reviews. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing. The provider had effective systems to identify people with previously undiagnosed conditions and identify individuals with caring responsibilities, who were offered an annual review. All patients with a learning disability were invited to attend an annual health assessment.

The practice generally delivered care and treatment in line with legislation and evidence based guidance, however, for some areas we found that monitoring was overdue, despite the practice recalling patients. For example, 5 patients prescribed methotrexate (an immunosuppressant), we found 4 were overdue for monitoring and required retinal screening, although they had been recalled. We found there were 18 patients prescribed a medication for heart failure and reviewed 4 records and found 2 to be overdue for monitoring, despite recall efforts. There were 6 patients who had received 2 or more courses of rescue steroids within the past 12 months. Of the 4 records sampled, 2 had not been followed up within the recommended timeframe. We found 3 patients with diabetes had elevated HbA1c levels (above 75 mmol/mol). Although clinical interventions and safety netting were in place, their reviews were overdue. We reviewed 2 patients with hypothyroidism who have not had thyroid function test monitoring for 18 months and found reviews were in place and they were well controlled. The provider told us of ongoing challenges with delays of 5-6 weeks for patients attending for blood monitoring within secondary care services. This issue had been escalated locally.

Systems were in place to ensure staff were kept up to date with national clinical guidance and best practice through internal systems and team meetings. We found that MHRA alerts demonstrated a proactive approach taken by the practice with relatively low numbers identified through our clinical searches.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care is co-ordinated effectively.

The primary care network (PCN) helped to support the practice by providing links to pharmacists, mental health practitioners and social prescribers. People were able to receive coordinated care between the practice and the primary care network.

Systems were in place to share information about patients electronically with other services. Clinical meetings were held regularly, and practice meetings were in place to ensure all staff were kept up to date with guidance and best practice.

The service supported people to manage their health and wellbeing to maximise their independence, choice and control. The service supported people to live healthier lives and where possible, reduce their future needs for care and support.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives and patients at risk of developing a long-term condition. We found people with caring responsibilities were offered regular health checks and there was regular engagement with community services and referral pathways in place. The practice website detailed information and links for health promotion, health conditions and common health questions. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

The service monitored people’s care and treatment to i ensure outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. However, we found some outcomes lower than national targets. For example, cervical screening uptake at the practice was 66% among patients aged 24–49 and 72% for ages 50–64, falling below the national target of 80%. Breast and bowel screening rates were also lower than national averages. Furthermore, national data indicated that all five indicators for childhood immunisations were below the World Health Organisation’s minimum threshold of 90%, with coverage ranging between 74% and 87%. The practice attributed this to challenges within the patient population, including levels of deprivation and health behaviours that impact engagement with preventative care.

The practice had an established programme of clinical and non-clinical audits and action plans aimed at driving continuous improvement in patient care and operational efficiency.

The service told people about their rights around consent and respected these when delivering person-centred care and treatment.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. Do not attempt cardiopulmonary resuscitation (DNACPR) decisions were appropriate and were made in line with relevant legislation. We sampled some of the records which we noted were undergoing review at the time of our assessment to ensure these were relevant.