The Belgrave 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 in July 2023, we rated this key question as requires improvement.

At this assessment, the rating has changed from requires improvement to good because we found that the issues identified with the effectiveness of patient safety and clinical care at the last assessment had been followed up on and the risks mitigated.

This service scored 71 (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. Feedback from people using the service was positive. People felt involved in any assessment 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. There were digital flags within the care records system to highlight any specific individual needs. Staff checked people’s health, care, and wellbeing needs during health reviews. For example, there were recalls for patients with non-diabetic hyperglycaemia (high blood sugar) to support them to maintain a healthy lifestyle without developing diabetes. Care plans and health check reviews for patients with learning disabilities were completed and documented from our review of the patient records, and there were no concerns found. The practice had relevant healthcare professionals to support people with their needs.

The service planned and delivered people’s care and treatment with them, including what was important and mattered to them. They did this in line with legislation and current evidence-based good practice and standards. Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw demonstrated care was provided in line with current guidance.

The service worked well across teams and services to support people. They made sure people only needed to tell their story once by sharing their assessment of needs when people moved between different services. Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services.

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 focused on identifying risks to patients’ health, including those in the last 12 months of their lives, and those patients at risk of developing a long-term condition. However, patients with caring responsibilities were not proactively offered support other than flu vaccinations and signposting to other relevant support services.

The service did not always routinely monitor people’s care and treatment to continuously improve it. They did not always ensure that outcomes were positive and consistent, or that they met both clinical expectations and the expectations of people themselves. The service did not meet national targets for cervical screening and childhood immunisations. The percentage of women aged 25-49 who had an adequate cervical screening test was 54.3% which was below the 80% national target. The percentage of women aged 50-64 who had an adequate cervical screening test was 63.4% which was below the 80% national target. This was also identified at the last assessment in July 2023.

The service was below the target uptake rates in 3 childhood immunisations. The provider was achieving childhood immunisation uptake rates of 86.4 – 88.9% for children aged 2 and 71.3% for children aged 5. The service was above the minimum immunisation uptake for children aged 1 (97.1%) and met the 90% minimum immunisation uptake target for children aged 2 (MMR category) which was 91.4%. A recall system was in place to engage patients who had not responded to health interventions, providing education on the associated health benefits. This included collaboration with Primary Care Network (PCN) nurses to share learning and identify ways to improve uptake. The impact of this action on the uptake was not yet known. The practice informed CQC that some of the patient population undertook cervical screening privately but this was not added to the national database because of the established protocols that needed to be followed to ensure safe parameters and standards which had contributed to the low uptake data of the cervical screening.

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. However, our review of some DNACPR records showed that a more consistent process of review of the decisions was needed because we found 1 record out of 8 reviewed whose date of decision did not match the date it was authorised.