Emsworth Medical 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

We looked for evidence 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.

This is the first inspection for this service since its registration with CQC following its move to a new location. This key question has been rated as good.

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.

Reception staff used digital flags within the clinical records system to highlight individual needs. However, reasonable adjustments, such as the need for longer appointment times or access to translation services, were not always consistently documented. This meant some people may have to repeat information each time they contacted the service. The service had access to translation services to support those who required them.

People with a learning disability were identified on the service’s clinical system and invited to attend annual health reviews. A dedicated team was responsible for booking these reviews and ensuring that Health Action Plans were kept up to date. Health Action Plans are personalised documents that outline a person’s health and wellbeing needs, support requirements, and goals to help manage their care effectively.

The latest verifiable data from NHS England showed cervical screening uptake was 75.6% for eligible women aged 24-49 years and 80.1% for those aged 50-64 years. Uptake for the 24-49 years age group was below the national target of 80%. In response, the service told us they held dedicated cervical screening clinics and regularly contacted eligible people to encourage participation.

The service did not always plan and deliver people’s care and treatment with them, including what was important and mattered to them.

During our remote clinical searches, it was identified the monitoring of people with long- term conditions was not always up to date with National Institute for Health and Care Excellence (NICE) guidelines.

Following our feedback, the service acted promptly and provided evidence that all affected people had been contacted and recalled for review. Clinical records we reviewed also demonstrated that, in other cases, care was delivered in line with current guidance. For example, people identified as at risk of diabetes had been appropriately recalled seeing the diabetic nurse following blood test results, in accordance with national recommendations.

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 assess, plan and deliver people’s care, treatment and support. The service worked collaboratively with other providers to ensure continuity of care, including where clinical tasks were delegated.

The service used GP2GP, a digital system provided by NHS England, which enables the secure and efficient transfer of electronic patient records when a person moves between GP services. This helped ensure timely access to accurate and up-to-date clinical information, reducing the risk of delays in care.

The service also worked with the local out-of-hours provider by offering bookable appointment slots and access to a telephone bypass number for urgent queries. Local care homes were supported through regular ward rounds, a dedicated home-visiting team and continuity from named GPs. People referred via NHS 111 had access to designated appointment slots managed by the duty doctor.

Other health and social care providers, such as care homes and community mental health teams, were also given access to a bypass telephone line to ensure timely contact with the service.

The local community health team highlighted occasional uncertainty about whether correspondence sent to the service had been received. They told us they plan to move onto the same clinical system as the service in November, which is intended to improve communication and information sharing.

The service had access to interpreters for appointments via Language Line and could provide leaflets in other languages or easy read leaflets on request. They outlined information relating to reasonable adjustments clearly on their website.

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.

The service supported people to live healthier lives, including those in the last months of life, people at risk of developing long-term conditions and individuals with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including smoking cessation and obesity reduction.

The clinical system used by the service included digital flags to identify people with specific needs, such as carers. These people were signposted to the social prescribing team, who offered access to community-based support groups and wellbeing services.

The service also provided end-of-life care and worked collaboratively with external partners who delivered hospice services. Meetings were held when needed to review people’s care needs and coordinate appropriate support.

The service was accredited as a military veteran-friendly service. Veterans were appropriately coded within the clinical system, which enabled reasonable adjustments such as extended appointment times and prompted annual health checks.

A health monitor machine was available in the waiting room of the service to facilitate self-screening for people when they attended the service.

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 was below national targets for cervical screening for people aged 25–49 years but met targets for those aged 50–64 years. They were aware of the shortfall and had introduced a recall system to encourage attendance for screening appointments. In addition, they met national targets for childhood immunisations and continued to promote uptake by offering a range of appointment times outside dedicated clinics.

Our remote clinical searches highlighted that the service monitored people’s care and treatment, but this was not fully embedded across all long-term conditions. For example, people diagnosed with asthma were reviewed in line with NICE guidelines (National Institute for Health and Care Excellence), whereas those with chronic kidney disease were not always routinely called for annual reviews and monitoring. The service was working to strengthen its process in this area by assigning dedicated teams to manage recalls and monitoring, and leaders explained how this structure was improving the system.

The service did carry out regular audits to improve safety for people using the service. For example, following a Medicines and Healthcare products Regulatory Agency (MHRA) alert, an audit was conducted to review people prescribed quinolones, a type of antibiotic used to treat bacterial infections. Another audit was carried out to identify people with chronic kidney disease and either type 2 diabetes or a certain protein level in their urine who may benefit from being prescribed a medicine called dapagliflozin. This audit identified 128 people, and as a result, 38 people were commenced on dapagliflozin. Repeat annual audit cycles are included in the service’s improvement plans.

The service had also carried out clinical audits, including two-cycle audits where data was reviewed and compared six months apart. One audit focused on identifying people with a serious mental illness. A clinical system search, completed by the service, identified 66 people who were prescribed lithium or antipsychotic medication but had not been appropriately coded. This meant they were not easily identifiable for routine monitoring. While 24 people had been coded correctly, the remaining 66 were subsequently added to relevant monitoring registers, enabling them to be included in appropriate reviews such as care planning, blood pressure monitoring, and blood testing.

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

During our onsite visit, we spoke with a GP who provided women's health services, including the fitting of contraceptive coils. They described the consent process, which included a discussion with the person prior to the procedure and the provision of written information alongside a consent form. While people were encouraged to sign the form, verbal consent was accepted and documented before the procedure commenced.

For people receiving steroid injections, the service used a consent template embedded in the clinical system to ensure consent was appropriately recorded. This supported consistency in documentation and compliance with best practice standards.

Staff understood and applied legislation relating to consent, and capacity and consent were clearly recorded. Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions were appropriate and made in line with relevant legislation. However, there was a lack of evidence to demonstrate that DNACPR forms were reviewed at regular intervals, as there was no record of these being discussed in a person’s records.

During our onsite visit, we reviewed 5 DNACPR records. DNACPR decisions indicate cardiopulmonary resuscitation should not be attempted if a person’s heart or breathing stops. Decision making involved the individual, their appointed power of attorney, and relevant health services where appropriate, and these discussions were documented appropriately. However, one of the 5 records did not include a nurse’s signature, which should have been completed within the hospital setting.

The service acknowledged these issues during the review and confirmed they would arrange an up-to-date discussion with the patient to review the DNACPR decision where appropriate.