Lytham Road Surgery

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• 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.

This is the first inspection for this service since its registration with CQC. This key question has been rated as requires improvement.

The service was in breach of legal regulation in relation to safe care and treatment. and governance.

This service scored 50 (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 did not always make sure people’s care and treatment were effective because they did not always check and discuss people’s health, care, wellbeing and communication needs with them.

The practice usually made sure people’s care and treatment was effective by assessing and reviewing their health, care, wellbeing and communication needs with them. However, our clinical searches identified areas where the monitoring of service users’ conditions was not up to date, or it was not apparent their condition had been monitored elsewhere.

Staff did not use digital flags effectively within the care records system to highlight specific individual needs. The use of alerts and flags for vulnerable patients was inconsistent and ineffective. Sometimes their needs were recorded as ‘problems’ in the electronic records and others were flagged in other places within the record. Also, the coding used varied, sometimes persons who were at the end of their lives (EOL) were recorded as gold standard framework (GSF), others as palliative care or sometimes not coded at all. This was similar for risks or vulnerabilities relating to Do not attempt cardio-pulmonary resuscitation (DNACPR), carers, veterans, the homeless, looked after children, children in a household with a child protection record, or domestic violence. It was not possible to obtain accurate lists of patients who fell into these categories.

However, 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. Staff usually checked people’s health, care, and wellbeing needs during health reviews, but carers were not proactively offered health checks. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and wellbeing.

The results of the National GP Patient Survey were slightly below national average. For example, 89% felt the healthcare professional they saw had all the information they needed about them, compared to 92% nationally and 92% locally, and 89% felt their needs were met during their last general practice appointment, compared to 90% nationally and 91% locally.

Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

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

Systems were not always in place to ensure staff were up to date with evidence-based guidance and legislation. Clinical records we saw did not always demonstrate care was provided in line with current guidance, this was seen from the results in clinical searches.

The experience of people who used the service as indicated in the National GP Patient Survey in line with than national and local averages. They showed that 94% of respondents (compared to 93% nationally and locally) stated that during their last appointment they had confidence and trust in the healthcare professional they saw or spoke to.

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 practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. However, their system for overseeing workflow did not ensure all results were dealt with in a timely way, the process for which was changed following the inspection.

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 practice supported national priorities and initiatives to improve the population’s health, including stop smoking and tackling obesity campaigns. Patients were encouraged to attend cancer screening and take up vaccinations offered as part of national programmes. However, the practice was below target for the percentage of persons eligible for cervical cancer screening who were screened adequately within 3.5 years for persons aged 25 to 49 (67.6%, expected rate 80%), but had met the target of within 5.5 years for persons aged 50 to 64 (80.9%, expected rate 80%). They were also below target for childhood vaccinations achieving less than the 90% minimum for 3 out of the 5 childhood vaccinations.

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. Patients who required monitoring did not always have regular checks on their health.

Our clinical searches identified people with hypothyroidism who had not had their thyroid function monitored for 18 months. We examined 5 records and found all of them were overdue monitoring. For 3 of those checked, the last thyroid function test showed their results to be outside the normal range, but no action had been taken. The practice had sent text messages to request monitoring in most cases but continued to regularly prescribe their medicine for periods of 2 months despite overdue checks. We saw that 1 person had been monitored in 2017, 1 in 2020, 2 in 2022 and 1 in 2023. Thyroid stimulating hormone (TSH) should be checked annually when thyroxine is prescribed. This helps to determine if the dose is correct. An incorrect dosage could lead to bone loss or heart problems. Following the inspection the practice located and downloaded blood results for the 2023 case and saved this to the patients’ record. They stated they would follow up the other 40 patients on the search list to ensure their safety and advised us of their intention to implement measures to reduce medicine supply as an incentive to comply with requests.

Medicine reviews we examined in connection with hypothyroidism identified that they did not identify overdue monitoring in 2 cases. 1 was recorded as having been done, but there was no content of the review on record, and another review noted the overdue monitoring but did not follow it up. One medicine review was found to be comprehensive and followed up the issues effectively. We also saw that medicine reviews did not always pick up potential issues, such as the MHRA alert which advises of the contraindication of doses of more than 20mg citalopram and 10mg escitalopram in patients over age 65 years, as it can cause changes in heart rhythms. This was apparent in 3 out of 3 medicine reviews we checked for patients who were being prescribed these medicines in higher than recommended doses.

It was not always evident that the service told people about their rights around consent and respected these when delivering person-centred care and treatment. This was because we found documentation around do not attempt cardiopulmonary resuscitation (DNACPR) decision making, best interests and mental capacity assessments were not clear. Whilst staff appeared to understand legislation relating to capacity and consent, these were not clearly recorded and as such, it was not always apparent that DNACPR decisions were appropriate and made in line with relevant legislation. We reviewed 5 records of persons recorded as having DNACPR status in place and found in 2 of the 5, there was no DNACPR record on file. For these 2 patients it was not clear if indeed a DNACPR was or wasn’t in place as there was conflicting information within the records. Documentation of the mental capacity assessments and best interests decision-making was absent in all 3 patients who were believed to lack capacity.

It was noted that the system by which DNACPRs were recorded on the patient recording system was inconsistent; some were ‘flagged’ under differing codes, and some were recorded in medical history. Furthermore, where DNACPR records were saved was inconsistent, which meant staff had multiple places to check to establish the patients’ status. Staff told us that they did not undertake DNACPR audits and had a system by which the records were reviewed after 12 months of being in place. This meant that any issues would not be picked up until 12 months after being implemented. Following the inspection, the practice undertook a review of all DNACPRs in place to ensure appropriate documentation was in place. They implemented a policy and a plan to implement an annual audit of DNACPRs going forward.