Cavendish Health 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

At our last assessment, we rated this key question as good. At this assessment, the rating remains as good. We assessed all quality statements for this key question and found that the service was providing effective services.Patients were assessed, and care and treatment were delivered in line with current legislation and evidence based guidelines, except for prescribing of lithium and azathioprine (please see medicines optimisation quality statement for more details).Staff worked together and worked well with other organisations to deliver effective care and treatment.

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 had systems and processes in place to identify people’s needs and preferences during the registration process. Leaders and staff told us the service used codes and alerts on the patient’s record to highlight special needs and requirements. Staff told us they checked people’s health, care, wellbeing, and communication needs during health reviews. Systems were in place to identify people with caring responsibilities at registration, opportunistically, and through self-reporting. They held a carers’ register and ensured the information was up to date.

One of the doctors at the practice is a Spin fellow in transgender and nonbinary care, and has provided educational sessions to clinical and non clinical staff at the practice, and federation specific to this population group. The Spin fellow helps patients and staff understand the diversity and equality principles and the practice has developed personal posters, and a dedicated area on the website for patients. As a result, transgender and nonbinary patient care needs and management have improved and the practice shared feedback from these patients. Staff support patients over the age of 18 to change their gender on the patient records, and there is a vulnerable patient list for transgender and nonbinary patients. The practice has a shared care agreement, to continue to monitor patients who have had input from the NHS gender identity clinic. Leaders told us this has helped to highlight inclusivity and not just create awareness for transgender health but also for the LGBTQ community.

The practice mostly planned and delivered evidence-based care and treatment. The practice is a GP training practice, and leaders and staff told us the practice had systems and processes to keep clinicians up to date with current evidence-based practice. The leaders stated they regularly participated in meetings, workshops, and training sessions within the primary care network. In addition, staff had protected time to attend training. One of the GP trainees as part of their training carried out a prescribing assessment audit which ensured she was prescribing according to the latest guidance and her supervisor had oversight of this.

Our search identified that out of 181 people with hypothyroidism prescribed thyroxine in the last year, 11 had not received appropriate blood monitoring. Some of these patients had been followed up prior to the inspection, some patients opted for private healthcare and appropriate action was taken by the practice. In response, the provider submitted an updated monitoring protocol that has been put in place to effectively manage this. The practice held registers for patients with a learning disability and provided annual health checks. There was a register of those patients on end-of-life care who were regularly reviewed and supported to make informed decisions about their future.

Our clinical record searches found some improvements were required for the safe management and monitoring of lithium. These changes have been amended , however this will not affect the rating based on the overall findings. The leaders were responsive and rapidly put systems and processes in place to improve this. The practice held registers for patients with a learning disability and provided annual health checks. We also saw that the practice had set up systems so that patients with complex needs and long-term conditions could have multiple appointments booked in one go; for example, patients could be booked in to see the nurse, GP, and pharmacist in the same visit. Clinical staff used templates when conducting care reviews to support the review of people’s wider health and well-being. There was a register of those patients on end-of-life care who were regularly reviewed and supported to make informed decisions about their future. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

Staff had access to the information they needed to appropriately assess, plan, and deliver people’s care, treatment, and support. The service worked well across teams and services to support people. Management informed us they used appropriate coding when moving children to adult services. There were established pathways for staff to follow to ensure patients’ needs were met.

The practice worked with other services to ensure continuity of care, including where clinical tasks were delegated to other services. The processes in place enabled staff to liaise regularly with community teams such as community nurses, health visitors, and palliative care nurses. Staff told us regular multi-disciplinary team meetings were held with external agencies where vulnerable people, or those receiving end-of-life care were discussed and actions recorded.

The service supported people to manage their health and well-being 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. Patients had access to a social prescriber, which helped them improve their health, well-being, and social welfare by connecting them to community services. Healthy living information was available on the digital information screen in the waiting room and on the practice website.We saw the practice website had links to health and wellbeing information.

Staff supported national priorities and initiatives to improve population health, which included stopping smoking and tackling obesity.Staff gave examples of where people had been positively supported to live healthier lives, which included healthy eating, weight management, and wellbeing talks. Arrangements were in place to offer people with a learning disability and people with a severe mental illness an annual health check. No concerns were raised by those using the service about supporting people to live healthier lives. We found no concerns regarding processes to help support people to live healthier lives.

The service routinely monitored people’s care and treatment to continuously improve it. They ensured that outcomes were positive, consistent, and that they met both clinical expectations and the expectations of people themselves. The practice submitted a range of clinical audits that demonstrated quality improvement such as antimicrobial prescribing.

The practice performed below the national target in 2024 in relation to childhood immunisations and cervical screening. The practice was aware of this and informed us they were actively call-and-recalling patients, they offered a range of appointments including out-of-hours, if patients declined the nurse would follow up with a phone call and staff offered opportunistic immunisations and smears. While the national data was low for the 2024 period, the practice took immediate action to increase the uptake of childhood immunisations and cervical screening. This had a positive impact and the PCN acknowledged the practice’s efforts for the strategies to be shared among other practices in the network. Leaders informed us that service users also opted to go private and or abroad for childhood immunisations and cervical screening, but the practice continues to encourage uptake.

Staff understood and applied legislation relating to consent. Capacity and consent were clearly recorded. The service told people about their rights around consent and respected these when delivering person-centered care and treatment. Clinicians supported patients in making decisions. Where appropriate, they assessed and recorded a patient’s mental capacity to make a decision. We reviewed three patients’ Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decisions and found they were made in line with relevant legislation and were appropriate. Staff had completed mental capacity act training.

Staff who carried out chaperone duties were trained for the role and had received a disclosure and barring (DBS) check. Posters were displayed in the practice informing people this was available to them. There were no concerns were raised by those using the service about consent to care and treatment.