Primary Care 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, we rated this key question as Inadequate. At this assessment, the rating has changed to Good.

The service was previously in breach of legal regulation in relation to:

• People with long term conditions were not receiving the appropriate reviews.

At the last inspection we found that the management of patients with long term conditions needed improving, patients’ needs were not always assessed and care and treatment was not always delivered in line with current legislation and evidence-based guidelines. We also found there was limited clinical oversight and a lack of supervision.

At this inspection, we found that improvements had been made, however these required further strengthening to ensure all people’s needs were assessed and health conditions were monitored to improve the outcomes for people.

Patients received care and treatment that supported them to live healthier lives including being supported to undertake national screening programmes and vaccinations. The majority of patients who required monitoring underwent regular checks on their health.

Multi-disciplinary meetings were held where the needs of patients with complex conditions or those approaching the end of life could be discussed, reviewed and planned for. The supporting documents and alerts where people had undergone an assessment for ‘Do not attempt cardiopulmonary resuscitation’ were available on the patient record system.

This service scored 62 (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.

During the remote clinical review, we found patients with long term conditions were not being assessed appropriately. We carried out a clinical search to identify people who had potentially been missed as having diabetes. The search identified 3 people. We reviewed each clinical record and found 2 people had not been informed of their diagnosis and had not had an annual review. Following the clinical review, we spoke with one of the GP partners who confirmed that all patients identified were being reviewed.

All requests for appointments were triaged by the duty doctor who prioritised patients who reported symptoms that could be considered a clinical emergency. Patients were told when they needed to seek further help and what to do if their condition deteriorated.

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 and the provider 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.

We found the provider held registers which were reviewed to prioritise care for their most clinically vulnerable patients. For example, we reviewed a sample of patients with a Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) record to consider whether the DNACPR had been prepared and found this had been reviewed and agreed appropriately.

Systems were in place to identify individuals with caring responsibilities, who were offered an annual review. All patients with a learning disability were invited to attend an annual health assessment.

There were appropriate referral pathways to make sure that patients’ needs were addressed. We spoke with staff who were able to describe the process for coding of correspondence and care and treatment records for people.

Staff we spoke with were aware of the workflow and clinical staff were able to demonstrate how the practice provided further education and support to patients. We found that staff had the appropriate skills and training to carry out reviews where appropriate.

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

At the last inspection we found the systems in place to monitor people’s health conditions were ineffective and needed strengthening to ensure all patients received the appropriate care and treatment. At this assessment we found improvements had been made, but further improvements were required to ensure all patients received the appropriate care and treatment. We carried out a review of people with long term conditions and found 294 patients had been prescribed 2 or more steroids due to an exacerbation of asthma. We reviewed a random sample of 5 clinical records and found people had not been assessed at the time of prescribing the steroids or after in line with evidence-based guidance. A further clinical review showed 4 people with hypothyroidism had not received the appropriate monitoring in the past 18 months. We reviewed each clinical record and found no evidence to demonstrate that the patient’s health needs were being managed.

Leaders told us they had reviewed the systems in line with good practice standards and were reviewing quality improvement through audits and checking care is consistently provided in line with 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 told us that they had access to the information they need to appropriately assess, plan and deliver people’s care, treatment and support and they had enough information to plan and refer people and receive subsequent results and information following referral.

There were systems and processes in place to enable information to be shared between the provider and services to ensure continuity of care. Regular meetings were held with multi-disciplinary teams to ensure care is co-ordinated effectively.

The PCNhelped to support the practice by providing links to pharmacists, dieticians, mental health practitioners and social prescribers. People were able to receive co-ordinated care between the practice and the primary care network.

Systems were in place to share information about patients electronically with other services. Clinical meetings were held monthly and practice meetings had been re-established to ensure all staff were kept up to date with guidance and best practice.

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.

At the last inspection we were unable to gain assurances that the practice had effective systems in place to identify carers and people had access to appropriate health assessments and checks. At this assessment we found processes had been strengthened to support people to live healthier lives. There were flags on patients records who were vulnerable and required ongoing monitoring and recalls in place to review patients and educate them to manage their health needs. There was regular engagement with community services and referral pathways in place. The practice website detailed information and links for health promotion, health conditions and common health questions.

Staff focussed on identifying risks to patients’ health, including those in the last 12 months of their lives and those with caring responsibilities. Staff supported national priorities and initiatives to improve population health, including stopping smoking and tackling obesity.

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.

We identified some people with long term conditions had not received the appropriate monitoring, however the people we had identified during the clinical searches were discussed with the clinical team and following the assessment we received evidence to demonstrate that the provider had taken action to review each patient and reviews had been organised. The practice had recently employed a practice nurse to support the delivery of long-term condition monitoring.

The provider was performing below the national average for cervical screening targets. To increase uptake the provider had tried Saturday clinics and had also trialled phoning the patient before their appointment as a reminder, however at the time of the assessment these had not been continued. The practice continued to strengthen systems and had processes in place to recall patients and implement flagging procedures aimed at promoting opportunistic uptake.

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

We saw evidence that consent was obtained for patients so that they understand their rights around consent to the care and treatment they are offered. The national GP patient survey demonstrated that 84% of patients were involved as much as they wanted to be in decisions about their care and treatment during their last general practice appointment, this was slightly below the local average of 89% and the national average of 91%

. At the last inspection, we found that Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) required strengthening to ensure DNACPR’s was coded appropriately on the clinical record. At this assessment, we found that the practice had strengthened their processes for consent to care and treatment in line with legislation and guidance

All staff had completed training on mental capacity and understood legislation when considering consent and decision making.