Cuckoo Lane 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 that staff involved people in decisions about their care and treatment and provided them advice and support. We assessed all of the quality statements from this key question. At our last assessment we rated this key question as outstanding. At this assessment, the rating has changed to good.

This service scored 83 (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. 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 service had effective systems to identify people with previously undiagnosed conditions. Staff could refer people with social needs, such as those experiencing social isolation or housing difficulties, to a social prescriber.

The service always 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.The service had regular educational events for its patient population. The leaders informed us of an upcoming 6 week drama workshop to help engage patients with learning disabilities. A previous event focused on raising awareness of stress and anxiety among teenagers received positive feedback; of the 25 participants, 12 provided feedback, and all reported that the session was useful.

The leader and manager regularly participated in meetings, workshops, and training sessions within the Primary Care Network (PCN), with the clinical lead being one of the clinical directors for the PCN and the practice manager being manager for the Ealing PCN. Leaders stated this helped them to stay alert to current evidence-based good practice and standards.

In addition, we saw evidence that the service’s nurse led approach led to external recognition and staff and leaders had been involved in educating external agencies on their model. The director delivered presentations to national and international organisations on the development and implementation of a nurse-led practice. This included credible bodies such as World Health Organisation (WHO) as well as being involved in lectures at City University. Leaders informed us the service was the first nurse led practice in the UK, and this was acknowledged by sources such as NHS England, Nursing Times and leaders shared with us recognition with UK news outlets.

Systems were in place to ensure staff were up to date with evidence-based guidance and legislation. The clinical records we reviewed demonstrated that care was provided in line with current guidance. For example, a sample of 5 patient records were looked at for medication reviews, and these were found to be comprehensive. Similarly, no issues were identified in the patient records we reviewed, including those prescribed higher risk medicines (gabapentinoids), cases involving a potential missed diabetes diagnosis and patients with Chronic Kidney Disease (CKD). The service had designated staff who had oversight of patients with specific long term conditions, such as asthma, COPD and diabetes.

The service worked well across teams and other services to support people. They worked with other providers to ensure continuity of care, including where clinical tasks were delegated to external services. 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 had a system of twice daily huddle meetings which encompassed discussions for all staff to address any clinical, and operational matters. Leaders told us this helped to empower, support and engage staff as every member is given an opportunity to speak. We saw evidence of meeting minutes from the huddles, which were shared with the whole team. Staff feedback about the huddles was positive.

There was positive feedback from other healthcare professionals that worked in partnership with the practice. They told us the approach taken by the service supported effective care. They told us staff were very compassionate and committed to providing the best care for all concerned. We saw that the service model to care allowed for clinical staff to be able to support one another. Feedback from a GP who had worked with the service reflected this as the clinician gave an example of when he was running behind and the ANPs were able to assist to care for his patients and minimise delays in care.

In addition, the service has received positive feedback from the North London health protection team for managing paediatric tuberculosis screenings sessions in the community arranged by the health protection team. The staff supported and provided phlebotomy services to external patients. They were praised for handling children and parents with care and professionalism.

The service always supported people to manage their health and wellbeing to fully maximise their independence, choice and control. They supported people to live healthier lives and where possible, reduce their future needs for care and support. Feedback from the National GP Patient Survey found 83% of respondents had enough support from local services and organisations in the last 12 months to help manage their long-term conditions or illness, this was significantly higher than local (65%) and national averages (69%). Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives, patients at risk of developing a long-term condition and those with caring responsibilities. The service supported the patient population to have a better understanding of their own health risks, by providing educational events to support their health and wellbeing. This gave them more information about early signs of ill health and ways to prevent conditions from developing. We saw specific examples where this support had led patients to take up health initiatives that had previously been declined. For example, following a prostate awareness event, leaders informed us this increased screening rates and 20 patients made appointments following this. The service also signposted patients to services that could benefit them.

The service worked closely with the social prescribing link worker to address patients at risk of health inequalities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity. For example, the staff developed and sustained relationships with the local population by hosting a monthly good to talk sessions. Leaders informed us when this was established in 2015, the core aim has remained to strengthen health promotion, improve access, provide support and emotional wellbeing and promote more personalised care. Feedback provided from patients about the most recent sessions showed some patients attended due to interest in the health topics, social connection, and for their wellbeing. Of the 25 patients, 15 provided feedback and 60% rated this as excellent and 40% as good. The service also ensured vulnerable patients were able to partake.

In addition to this the service had established links with the neighbouring church with weekly community coffee mornings with facilitated support group services such as mental health education, social connection, emotional support and early intervention. This attracts around 80-100 people. Although the practice did not provide measurable data for this initiative, leaders informed us this led to improvements in patient wellbeing and health outcomes due to increased early intervention.

The service monitored all people’s care and treatment to continuously improve it. They ensured that outcomes were positive and consistent, and that they met both clinical expectations and the expectations of people themselves. For example, the service had a comprehensive audit schedule covering various clinical and non-clinical areas of the service to drive improvements. They participated in both local and national audit activities. Learning from audits was communicated and shared with staff. From the clinical notes we reviewed, we found that people who used the service experienced positive outcomes as set out in legislation, standards, and evidence-based clinical guidance.

The service met the majority of the national targets for screening and immunisations with the exception of cervical screening for the 25-49 age group which was below the 80% target at 69.6%. Similarly, children aged 5 who had received immunisation for measles, mumps and rubella (MMR) was at 89.6%. The service was taking appropriate steps to encourage uptake by recalling, educating patients and using automated reminders. The nurse also carried out regular searches and formulated data for any patients that declined. Leaders provided information on the MMR audit the service carried out. We saw this information being used to reach out to patients, including when outbreaks occurred in the local area and staff confirmed some patients accepted treatment as a result of this.

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.